Chronic Pain Syndrome: Nursing Assessment and Intervention

Chronic pain is a major health problem in the United States. People with chronic pain syndrome are a subgroup of patients with chronic pain who experience high levels of pain, functional impairment, and depression. Because chronic pain syndrome is a complex multidimensional health problem, nurses must use their expert knowledge and skills in pain management and in rehabilitation nursing to help patients improve their health status and quality of life. This article discusses the nursing assessment and management of chronic pain syndrome as well as an assessment tool that the author has helped develop.     

An Analysis of the Role of Mental Health in a Randomized Trial of a Walking Intervention for Black Veterans With Chronic Pain

Black patients and those with co-occurring mental health disorders are disproportionately affected by chronic pain, but few interventions target these populations. This is a secondary analysis of a randomized trial of a walking-focused proactive counseling intervention for Black Veterans with chronic musculoskeletal pain (ACTION). The primary aim was to examine intervention effectiveness among Veterans with an electronic health record-documented mental health diagnosis [depressive disorder, anxiety disorder, substance use disorder, post-traumatic stress disorder or serious mental illness (n = 205)] and those without a diagnosis (n = 175). About 380 Black Veterans receiving care at the Atlanta VA Health Care System were enrolled from 2016 to 2019 and randomized to the intervention or usual care (UC) (1:1). The intervention featured 6 telephone coaching sessions over 8–14 weeks to encourage walking. Participants with a mental health disorder were more likely to complete all counseling sessions (56% vs 38%) and reported improvements in global perceptions of pain and pain intensity/interference (secondary outcomes) at 3-months vs UC. Among participants without a mental health disorder, the intervention was associated with an improvement in pain-related disability at 6-months (primary outcome). Black chronic pain patients with co-occurring mental health disorders may require more intensive treatment to affect improvement in pain-related disability.PerspectiveThis study examines the effectiveness of a walking intervention for chronic pain among Black Veterans with a mental health disorder. These patients were more engaged with the intervention than those without a mental health disorder. However, they did not experience reductions in pain-related disability, suggesting more intensive treatment is needed.     

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm

BackgroundConducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions.PurposeThe aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm.Design & MethodsThe Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice.ResultsThe majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments.ConclusionsThe use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms “assume pain present” and “assume pain managed,” and to also improve the overall feasibility and effectiveness of the algorithm.     

Assessment of Mental Health Literacy among Perinatal Hispanic Adolescents

According to the United States (U.S.) Census Bureau, Hispanics are the fastest growing ethnic minority in the U.S. As such, Hispanic females have the highest birth rate (35 per 1000) among adolescents between the ages of 15 and 19 years. Despite high fertility rates, there is limited mental health information among Hispanic adolescents during the perinatal period. Perinatal depression is a major concern as it poses health risks for both the mother and infant. Adverse outcomes such as preterm birth, low infant birth weight, and poor maternal-infant attachment may result from perinatal depression. However, less than half of Hispanic adolescent mothers who experience perinatal depression receive treatment. Previous research identified low mental health literacy (MHL) as one of the primary reasons for the limited use of mental health services among ethnic minorities. This study assessed the MHL of pregnant and postpartum Hispanic adolescents (n = 30) using a modified MHL scale. Implications for nursing practice are discussed to help improve mental health outcomes among pregnant and postpartum Hispanic adolescents.     

Cognitive Biases in Children and Adolescents With Chronic Pain: A Review of Findings and a Call for Developmental Research

Cognitive biases that emphasize bodily harm, injury, and illness could play a role in the maintenance of chronic pain by facilitating fear and avoidance. Whereas extensive research has established attention, interpretation, and memory biases in adults with chronic pain, far less is known about these same biases in children and adolescents with pain. Studying cognitive biases in attention, interpretation, and memory in relation to pain occurring in youth is important because youth is a time when pain can first become chronic, and when relationships between cognitive biases and pain outcomes emerge and stabilize. Thus, youth potentially offers a time window for the prevention of chronic pain problems. In this article, we summarize the growing corpus of data that have measured cognitive biases in relation to pediatric pain. We conclude that although biases in attention, interpretation, and memory characterize children and adolescents with varying pain experiences, questions regarding the direction, magnitude, nature, and role of these biases remain. We call for independent extension of cognitive bias research in children and adolescents, using well powered longitudinal studies with wide age ranges and psychometrically sound experimental measures to clarify these findings and any developmental trends in the links between cognitive biases and pain outcomes.

Chronic Pain and High Impact Chronic Pain in Children and Adolescents: A Cross-Sectional Study

The aims of this study were to: 1) estimate the prevalence of chronic pain (CP) and high impact chronic pain (HICP) in a community sample of children and adolescents; and 2) compare groups (those without CP, those with CP but no HICP, and those with HICP) with respect to demographic variables, pain variables, and physical, psychological, and school-related function. One thousand one hundred and fifteen children and adolescents participated (56% girls; age: ߂ = 11.67; SD = 2.47; range = 8–18 years). The prevalence of CP and HICP was 46% and 5%, respectively, and was higher in girls and increased with age. Participants with HICP reported greater pain intensity and higher pain frequency than those with CP but no HICP. In addition, participants with HICP reported lower mobility, greater fatigue, worst sleep quality, more anxiety and depression symptoms, worst cognitive function, missing more school days, and worse perceived school performance. HICP is a prevalent condition in children and adolescents and is associated with many negative consequences. Stakeholders must be aware of this and ensure that treatment programs are available to reduce the individual and societal impact of HICP in young individuals.PerspectiveThis article provides information on CP and HICP prevalence and impact in children and adolescents. By better understanding the nature and score of these conditions, we will be able to develop more effective early interventions to help this population and thereby reduce their long-term negative impact.     

Development and Validation of an Evidence-Based Breathing Exercise Intervention Protocol for Chronic Pain Management in Breast Cancer Survivors

BackgroundBreathing exercise has been utilized as a promising approach to pain management in cancer survivors. However, the development process of the breathing exercise intervention protocol was rarely reported.AimTo develop an evidence-based breathing exercise intervention protocol for chronic pain management in breast cancer survivors and to provide a detailed account of the intervention development process.MethodsThe study design was guided by the Medical Research Council Framework for Developing and Evaluating Complex Intervention. The breathing exercise intervention development process adopted phase one of the Medical Research Council Framework for Developing and Evaluating Complex Intervention framework. The content validity index was applied to determine the consensus of the appropriateness of the breathing exercise intervention protocol among the panel experts.ResultsThe preliminary breathing exercise intervention protocol was developed based on fight-or-flight theory and vagus nerve theory, and the best available research evidence identified from seven systematic reviews, three clinical trials, and four practice recommendations. The breathing exercise intervention was designed as slow deep pursed-lip breathing with a time ratio of inspiration to expiration 1:2-3. The intensity of the breathing exercise was determined as 3 to 5 sessions a day, 5 minutes per session, for 4 weeks. The content validity of the breathing exercise intervention protocol was excellent as consensus was achieved among all panel experts with both the item-level and scale-level CVIs reaching 1.0.ConclusionsThis study developed an evidence-based breathing exercise intervention protocol for chronic pain management in breast cancer survivors. The protocol is well-supported by the relevant theories, research evidence, practice recommendations, and experts’ consensus.     

The ACTTION-American Pain Society Pain Taxonomy (AAPT): An Evidence-Based and Multidimensional Approach to Classifying Chronic Pain Conditions

Current approaches to classification of chronic pain conditions suffer from the absence of a systematically implemented and evidence-based taxonomy. Moreover, existing diagnostic approaches typically fail to incorporate available knowledge regarding the biopsychosocial mechanisms contributing to pain conditions. To address these gaps, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration and the American Pain Society (APS) have joined together to develop an evidence-based chronic pain classification system called the ACTTION-APS Pain Taxonomy. This paper describes the outcome of an ACTTION-APS consensus meeting, at which experts agreed on a structure for this new taxonomy of chronic pain conditions. Several major issues around which discussion revolved are presented and summarized, and the structure of the taxonomy is presented. ACTTION-APS Pain Taxonomy will include the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. In coming months, expert working groups will apply this taxonomy to clusters of chronic pain conditions, thereby developing a set of diagnostic criteria that have been consistently and systematically implemented across nearly all common chronic pain conditions. It is anticipated that the availability of this evidence-based and mechanistic approach to pain classification will be of substantial benefit to chronic pain research and treatment.PerspectiveThe ACTTION-APS Pain Taxonomy is an evidence-based chronic pain classification system designed to classify chronic pain along the following dimensions: 1) core diagnostic criteria; 2) common features; 3) common medical comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.     

Adult Cancer Pain: An Evidence-Based Update

Cancer often produces excruciating pain, which sends waves reverberating through the person's body, mind, spirit, and social interactions diminishing their quality of life and that of those closest to them. This updated review will summarize the latest research exploring the biologic mechanisms, psychosocial impact, and evidence-based approaches to treating cancer pain. Persons with cancer should not live or die with needless pain because of the detrimental effects it has on longevity and quality of life. This review intends to inform nurses of evidence-informed best practices they can use to prevent avoidable suffering that results from cancer pain.     

卫生技术评估与循证医学

随着人口增长、年龄老化、新技术和新药物的应用、人类健康需求层次的提高,使全世界都面临着严峻的挑战：有限卫生资源与无限增长的卫生需求之间的矛盾。本文通过简要介绍卫生技术、卫生技术评估的基本概念,国际上卫生技术评估的产生背景、现况、评估的范畴和特点及评估结果对卫生技术合理应用的影响,国内卫生技术应用和评估的现状、存在问题,说明中我国建立具有权威性的卫生技术评估机构的必要性;同时阐述了循证医学与卫生技术     

Relaxation and Imagery for Chronic,Nonmalignant Pain: Effects on Pain Symptoms,Quality of Life,and Mental Health

Nonpharmacologic treatments are being increasingly adopted as alternative or primary approaches to chronic pain management. We present results of a pilot study examining the effect of a 6-week combined abbreviated progressive relaxation technique (APRT) and guided imagery (GI) intervention for the management of chronic pain (N = 19) and, using power analysis, explore recommended sample sizes for future clinical trials. Results indicated consistent and clinically significant trends of improvement on pain (McGill Pain Questionnaire, visual analog scale), mental health (Depression Anxiety and Stress Scale), all domains of quality of life (RAND-36 Health Survey), and sleep for the treatment group only. Owing to inadequate power in this study, these results were not statistically significant. Methodologic concerns, along with suggestions for an improved intervention protocol, are discussed. It is concluded that there is strong preliminary evidence for the efficacy of APRT and GI as an adjunct to conventional treatment options for chronic pain.     

An Evidence-Based Guideline on Pain Assessment in Nursing Homes For Residents and Informal Caregivers

BackgroundNursing home residents are often affected by pain. Pain assessment aims to determine pain intensity and quality. An evidence-based guideline on pain assessment in nursing homes was developed to support residents and informal caregivers in archiving an adequate pain assessment prerequisite to pain treatment.AimThe residents’ guideline presents key recommendations that is comprehensible and accessible to residents and informal carers.DesignWe conducted a content analysis.Setting/SubjectsTherefore, all recommendations of an evidence-based guideline for pain assessment in nursing home were evaluated on relevance for supporting residents’ decision-making process.MethodsTwo researchers conducted the content analysis independently and as a result, 29 recommendations could be included. In addition, representatives of a support-group organization for patients with pain validated the derived recommendations.ResultsThe present residents’ guideline of pain assessment consists of nine thematic categories, written in laymen’s terms to enable older persons to make informed choices and optimizing their own pain management process.ConclusionsThe Guideline is available in print format and ready for implementation to enhance the effects on maintaining the physical and psychological well-being and optimal care of older adults in Nursing Homes.     

Barriers and Facilitators of Evidence-Based Psychotherapies for Chronic Pain in Adults: A Systematic Review

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) have demonstrated effectiveness for improving outcomes in chronic pain. These evidence-based psychotherapies (EBPs) remain underutilized in clinical practice, however. To identify research gaps and next steps for improving uptake of EBPs, we conducted a systematic review of patient-, provider-, and system-level barriers and facilitators of their use for chronic pain. We searched MEDLINE, Embase, PsycINFO, and CINAHL databases from inception through September 2022. Prespecified eligibility criteria included outpatient treatment of adults with chronic pain; examination of barriers and facilitators and/or evaluation of implementation strategies; conducted in the United States (US), United Kingdom (UK), Ireland, Canada or Australia; and publication in English. Two reviewers independently assessed eligibility and rated quality. We conducted a qualitative synthesis of results using a best-fit framework approach building upon domains of the Consolidated Framework for Implementation Research (CFIR). We identified 34 eligible studies (33 moderate or high quality), most (n = 28) of which addressed patient-level factors. Shared barriers across EBPs included variable patient buy-in to therapy rationale and competing responsibilities for patients; shared facilitators included positive group or patient-therapist dynamics. Most studies examining ACT and all examining MBSR assessed only group formats. No studies compared barriers, facilitators, or implementation strategies of group CBT to individual CBT, or of telehealth to in-person EBPs. Conceptual mismatches of patient knowledge and beliefs with therapy principles were largely analyzed qualitatively, and studies did not explore how these mismatches were addressed to support engagement. Future research on EBPs for chronic pain in real-world practice settings is needed to explore provider and system-level barriers and facilitators, heterogeneity of effects and uptake, and both effects and uptake of EBPs delivered in various formats, including group vs individual therapy and telehealth or asynchronous digital approaches.PerspectiveThis systematic review synthesizes evidence on barriers and facilitators to uptake of cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based stress reduction for chronic pain. Findings can guide future implementation work to increase availability and use of evidence-based psychotherapies for treatment of chronic pain.RegistrationPROSPERO number CRD42021252038