多学科协作癌痛整合门诊的实施与管理

目的 探讨专科医院多学科协作癌痛整合门诊的运营管理模式，为解决“看病难”问题提供参考。方法 同济大学附属上海市肺科医院于2013年起构建癌痛整合门诊一站式多学科协作诊疗模式，由肺内科医师、麻醉师、临床药师、疼痛专科护士兼国家二级心理咨询师组成，通过绿色通道实现癌痛问题的快速检查、诊断及解决；并建立个人档案，登记“疼痛筛查表”，由疼痛专科护士每周电话随访实施疼痛跟踪管理和延续护理。通过调查2018-2021年就诊于癌痛整合门诊的308例患者，了解其就医体验并评价癌痛门诊实施效果。结果 患者就医体验总体满意度为96.4%；认为一次性达到就医目的者占88.3%、认为诊治及时合理者占87.3%、认为居家康复护理指导及时者占78.6%;53.9%的患者认为门诊费用价格适中。结论 与目前分科精细化的诊疗模式相比，多学科癌痛整合门诊为患者提供了一站式的便捷快速诊疗服务，可有效解决看病难的问题，提升了患者的就医满意度，值得临床推广。     

Pain causes in 200 patients referred to a multidisciplinary cancer pain clinic

Causes of pain were analysed in 200 patients referred to a specialized cancer pain clinic. Pain caused by tumour growth was found in 158 patients, pain secondary to cancer or its treatment in 116 patients and pain unrelated to cancer in 33 patients. Visceral involvement (74 cases), bone metastases (68 cases), soft tissue invasion (56 cases) and nerve/plexus pressure or infiltration (39 cases) were the most frequent causes of pain due to tumour growth. Myogenic pain (68 cases) was the most frequent cause of secondary pain. The patients presented with a multitude of different combinations of causes of pain, the majority having at least two separate causes. Since pain treatment in cancer patients should be determined by its aetiology, a detailed analysis of the pain condition in each patient should form the basis for a rational therapy.     

Sex differences in experimental and clinical pain sensitivity for patients with shoulder pain

Previous research demonstrates that men and women differ in the way that they perceive and process pain. Much of this work has been done in healthy adults with a lack of consensus in clinical pain populations. The purpose of this study was to investigate how men and women with shoulder pain differ in their experience of experimental and clinical pain and whether psychological processes differentially affect these responses. Fifty‐nine consecutive subjects (24 women, 35 men) seeking operative treatment for shoulder pain were enrolled in this study. Subjects completed self report questionnaires to assess clinical pain, catastrophizing, anxiety and depression and underwent a series of experimental pain tests consisting of pressure pain, thermal pain (threshold and tolerance), and thermal temporal summation. Results indicated that women experienced greater clinical pain and enhanced sensitivity to pressure pain. Age did not affect the observed sex differences. There were no sex differences in psychological association with experimental and clinical pain in this cohort. The relationship between clinical and experimental pressure pain was stronger in women as compared to men. These findings offer insight into the interactions between biological and psychosocial influences of pain and how these interactions vary by sex.     

Sex-based differences in pain distribution in a cohort of patients with persistent post-traumatic neck pain

Objectives: To analyze a cohort of 745 consecutive patients referred to a regional specialist clinic for evaluation of post-traumatic neck pain during a five-year period.

Methods: A cross-sectional observational study of baseline assessments performed by multi-professional rehabilitation teams according to a standardized checklist.

Results: The cohort contained nearly twice as many females as males (64% versus 36%). The type of injury did not differ between sexes. Of the entire cohort, 38% were diagnosed with widespread pain, 50% with regional pain, and 12% with local pain. The pain distribution among the females was 43% widespread, 48% regional, and 9% local, and corresponding figures among males were 29%, 53%, and 18%. Longer time between trauma and assessment did not affect pain distribution among the men, but a tendency towards more widespread pain was observed among the women.

Discussion: The importance of "female sex" as risk factor for the development of persistent pain after neck trauma needs to be discussed further. The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls for both multidisciplinary assessments and treatment strategies. The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.

• Implications for rehabilitation

• Patients suffering from pain and disability after neck trauma constitute a significant proportion of patients with persistent pain.

• The importance of the risk factor “female sex" should be further discussed in the development of persistent pain after neck trauma.

• The high frequency of regional and widespread pain among patients with persistent neck pain after trauma calls both for multidisciplinary assessments and treatment strategies.

• The relationships between different pain distribution patterns, disability, activity, and psychological factors need to be studied further.

     

An assessment of methods used to evaluate the adequacy of cancer pain management

This paper assesses different methods of evaluating pain management. We used the established methods of pain prevalence measurement and the Pain Management Index (PMI) to compare pain management between two groups who might be expected to have different outcomes. We also developed and used a method to assess how quickly pain was controlled for each group (time to pain control). We compared a group of cancer patients (n = 712) managed by general practitioners in the community (Community Group) and a group of patients (n = 152) treated in a Specialist Palliative Care Unit (Hospice Group) using all methods. The time to pain control method identified a significant difference between the two groups (P < 0.01 log rank test), with the Hospice Group achieving pain control significantly faster. By contrast, neither the pain prevalence method nor the PMI could detect any difference (P = 0.11 Wilcoxon test). The established methods of pain prevalence measurement and PMI are limited by their inability to measure pain over time and to assess prescribers' response to changing pain. Dynamic methods that evaluate changes in prescribing and pain levels over time must be developed in order to accurately assess pain management.     

Long-term effectiveness of a patient and family pain education program on overcoming barriers to management of cancer pain

The purpose of this research was to investigate the effectiveness of a patient and family pain education program on reducing cancer patients' and their families' barriers to (i.e., concerns or misconceptions about) cancer pain management, on increasing patients' adherence to a prescribed analgesic regimen, and on decreasing pain intensity and pain interference with daily life. An experimental and longitudinal design was used. The experimental group consisted of 31 pairs of cancer outpatients and their family carers, while the control group consisted of 30 patient-family pairs (N=122). Patients and their family carers in the experimental group simultaneously received a pain management education program. Both groups had pretest data collection and after-test follow-ups on the second and fourth weeks at the outpatient clinics. Comparisons between those two groups were made using the Generalized Estimating Equations (GEE) method. Results revealed that at both the second and fourth weeks, patients and family carers in the experimental group showed a significantly greater reduction in barrier scores than did patients and family carers in the control group. At the second and fourth weeks, patients in the experimental group reported significantly better adherence to a scheduled analgesic regimen than did patients in the control group. In the fourth week, patients in the experimental group reported significantly lower levels of worst pain intensity and pain interference than did patients in the control group. This research provides evidence of the effectiveness of a patient and family pain education program.     

Personal and professional pain experiences and pain management knowledge among Greek nurses

The purpose of this exploratory study was to describe Greek registered nurses' personal and professional pain experiences and to examine the relationship with their pain management knowledge. Forty-six Greek nurses provided written responses to open-ended questions about their personal and professional experiences with pain and beliefs about suffering. Reporting a personal pain experience was associated with describing a positive professional pain experience, Phi=0.44, p < 0.03. The nurses vividly described their personal and professional pain experiences. One nurse wrote " em leader I begged to lose consciousness, in order not to feel". These compelling accounts might motivate nurses to strengthen their understanding of pain management.     

癌痛护理策略团队模式管理在中重度癌痛患者中的运用

目的探讨癌痛护理策略团队模式管理对中重度癌痛患者疼痛程度及生命质量的影响。方法选择2019年8月—2020年8月医院肿瘤科收治的120例癌症患者为研究对象,按照组间基本资料具有可比性的原则分为对照组和观察组,每组60例。对照组患者进行癌痛常规护理干预指导,观察组患者在此基础上建立癌痛护理策略团队进行疼痛护理管理,比较两组患者疼痛控制效果、癌症患者生存质量测定量表(EORCT QLQ-C30)评分。结果干预前,两组患者各项疼痛控制指标评分和各领域生命质量评分比较差异均无统计学意义(P>0.05);干预后观察组患者疼痛程度、疼痛影响和疼痛信念维度评分均低于对照组,疼痛控制满意度评分高于对照组,差异均有统计学意义(P<0.05);干预后观察组患者功能领域各维度评分和总生命质量评分高于对照组,症状领域评分低于对照组,差异均有统计学意义(P<0.05)。结论通过建立癌痛护理策略团队对中重度癌痛患者进行疼痛护理,可缓解患者疼痛,改善患者疼痛结局,提升患者生命质量。     

How chronic pain patients cope with pain: Relation to treatment outcome in a multidisciplinary pain clinic

One hundred male and 100 female chronic pain patients in a multidisciplinary pain clinic completed a 34-item Pain Coping Questionnaire (PCQ). Factor analysis identified four pain coping factors: self-management, helplessness, social support, and medical remedies. Multiple-regression analyses were conducted to determine the relation between PCQ factors and measures of adjustment at admission to the pain program as well as admission to discharge changes in adjustment measures. The following concepts relevant to coping with chronic pain were defined: cognitive strategies, self-efficacy, helplessness, catastrophizing, and cognitive distortion. Suggestions were made for integrating these concepts in the development of scales for assessing strategies for coping with chronic pain.     

Patients referred to a pain management clinic: beliefs, expectations and priorities

AIM: This paper is a report of a study to explore patients' pain-beliefs and emotions at the point of referral to a pain clinic, their expectations of the clinic and their priorities for improvement in aspects of their lives affected by pain. BACKGROUND: Chronic pain is a common experience and, although the percentage of people with pain referred to pain clinics is increasing, they often experience complex journeys through the healthcare system. Patients' beliefs about pain have been shown to influence their experience of pain and treatment outcomes, with a focus on the organic cause of pain reported. METHODS: Three focus groups were convened with 18 participants. Ten statements about pain were distributed to each participant and ranked according to their priorities. The data were collected in 2002-2003. FINDINGS: The participants' beliefs were dominated by the search for a firm diagnosis and cure. Participants held three main beliefs; that the cause of the pain must be established; that other people do not believe in the pain of a person without a firm diagnosis; and that painkillers are a way of 'fobbing you off'. Participants had little knowledge and few concrete expectations of the pain clinic. Their main priorities for improvement were 'less pain', 'some pain free times', and being able to do more 'everyday things'. CONCLUSION: Staff delivering pain management services must understand patients' beliefs and expectations and explain their own perspectives in order to provide a sound basis for working together.     

Sex differences in experimental pain among healthy children: A systematic review and meta-analysis

Sex differences in response to experimental pain are commonly reported in systematic reviews in the adult literature. The objective of the present research was to conduct a systematic review and meta-analysis of sex differences in healthy children’s responses to experimental pain (eg, cold pressor, heat pain, pressure pain) and, where possible, to conduct analyses separately for children and adolescents. A search was conducted of electronic databases for published papers in English of empirical research using experimental pain tasks to examine pain-related outcomes in healthy boys and girls between 0 and 18 years of age. Eighty articles were eligible for inclusion and were coded to extract information relevant to sex differences. The systematic review indicated that, across different experimental pain tasks, the majority of studies reported no significant differences between boys and girls on pain-related outcomes. However, the meta-analysis of available combined data found that girls reported significantly higher cold pressor pain intensity compared to boys in studies where the mean age of participants was greater than 12 years. Additionally, a meta-analysis of heat pain found that boys had significantly higher tolerance than girls overall, and boys had significantly higher heat pain threshold than girls in studies where the mean age of participants was 12 years or younger. These findings suggest that developmental stage may be relevant for understanding sex differences in pain.     

Gender differences in outcomes of a multimodal pain management program

Although gender differences in pain and analgesia are well known, it still remains unclear whether men and women vary in response to multimodal pain treatment. This study was conducted to investigate whether men and women exhibited different outcomes after an intensive multimodal pain treatment program. The daily outpatient program consisted of individual treatment as well as group therapy, with a total amount of therapy of 117.5 h per patient. Overall, 496 patients (254 women) completed the multimodal program. Pretreatment parameters for pain, disability due to pain, pain duration, and pain chronicity stage, as well as age or psychiatric comorbidities, did not differ between genders. The average pain, measured with a Numeric Rating Scale, decreased after treatment of −1.54 (±1.96) with a large effect size (ES) of .911 for the total sample. However, there were considerable differences in the benefit for women (−1.83 ± 2.12; ES 1.045) compared with men (−1.23 ± 1.74; ES .758). Consistently, women (ES .694) improved more in pain-related disabilities in daily life than men (ES .436). These distinctions are not due to differences in pain duration, received medication, psychiatric comorbidities, pain chronicity stage, or application for a disability pension. Therefore, gender differences not only refer to chronic pain prevalence, pain perception, or experimental pain measurement, but also seem to have a clinically relevant impact on the response to pain therapy.     

Sex differences in perceptions of pain coping strategy usage

Sex differences are generally found in the perception and experience of pain, with women reporting more intense and frequent pain than men. One reason why such differences may occur has been linked to socially-acquired gender-role expectations associated with pain. Although there is evidence that men and women report using different pain coping strategies, we do not know the extent to which gender-specific expectations are associated with pain-related coping. The current study sought to examine this in more detail by administering a standard pain coping measures on three separate occasions, but with different instructions. Hundred and twenty two participants (57 male, 65 female) were asked to complete the coping measure as themselves, then again as they would expect the typical man and the typical woman to complete it. Results indicated that there were no significant differences between men and women in their own self-reported usage of pain coping strategies. However, there was general evidence to suggest that there are differences in stereotypical views of how men and women are thought to cope with pain. Furthermore, sex differences were also found in how participants viewed their own coping behaviours in comparison to that of the typical man and typical woman. These results confirm that alongside pain, men and women hold different gender-specific expectations with respect to certain pain coping strategies. Future research is required to examine whether these different coping expectations influence an individuals own choice of strategy, and whether this in turn affects actual pain experiences.     

Sex differences in cardiac and autonomic response to clinical and experimental pain in LBP patients.

Rehabilitation professionals are currently using heart rate (HR) in order to assess the sincerity of effort in certain evaluations. It has been shown that a relation exists between HR and pain but no study has measured cardiac response during both clinical and experimental pain among a patient population using an intra-subject design. Thirty patients with low back pain (LBP) participated in this study including 16 men. Clinical pain was induced by applying a postero-anterior pressure (PA) on a painful lumbar segment for 15 and 30s in order to reproduce the patient's typical LBP at an intensity ranging between 50 and 70/100. Experimental pain was induced with a 15s thermal stimulus at a temperature which reproduced the same pain intensity as the 15s PA. For both reproduced clinical pain durations, we observed a rise in HR ranging between 8.5% and 12.67%. However, unlike men, women's cardiac response failed to show a constant rise in HR during the 30s PA. For all subjects, the rise in HR was much lower during the experimental pain condition (p<0.001), reaching only 5%. On the other hand, galvanic skin responses were significantly higher during the experimental pain condition (p<0.001). During this same condition, women also had a greater rise in galvanic skin responses than men (p=0.04). Finally, a significant correlation was found between both types of pain. These results suggest that pain induced during a clinical evaluation will produce a significant HR augmentation. However, heart rate variability analysis showed greater sympathetic cardiac regulation for men. The sex differences observed in this study call for caution when interpreting HR during pain assessment.     

Psychological and behavioural predictors of pain management outcomes in patients with cancer

Scand J Caring Sci; 2010; 24; 781–790
Psychological and behavioural predictors of pain management outcomes in patients with cancer To better understand the phenomenon of patient‐related barriers to cancer pain management and address them more effectively in interventional studies, a theoretical model related to psychological aspects of pain experience and pain‐related behaviours was elaborated. The aim of the study was to analyse the impact of patient‐related barriers on cancer pain management outcomes following this model. Thirty‐three patients responded to the Brief Pain Inventory Pain scale, the Danish Barriers Questionnaire II (DBQ‐II), the Hospital Anxiety and Depression scale (HADS), the Danish version of Patient Perceived Involvement in Care Scale measuring the quality of patient‐physician pain communication, and the Danish version of Medication Adherence Report Scale (DMARS‐4). Statistical analysis was performed with SPSS 16.00. The results of the multivariable linear regression analyses showed that pain intensity was explained by patients’ emotional distress (symptoms of anxiety and depression) and that pain relief was explained by cognitive barriers. In conclusion, interventions in emotional distress and patients’ concerns may supposedly result in better cancer pain management outcomes.     

The effectiveness of a multidisciplinary pain management programme managing chronic pain

The aim of this study was to develop and evaluate the effects of a multidisciplinary pain management programme on coping, health-related quality of life and pain intensity. Seventy-six outpatients suffering from chronic pain completed this eight-week programme with the primary aims to increase coping, as measured by the Ways of Coping Checklist, and health-related quality of life, as measured by the Short Form-36 Health Survey. Therapeutic dialogues and education, combined with physical activity, were given in order to increase understanding of and attention to non-medical factors that might affect pain perception. The programme was active, time-limited and structured on the basis of multidisciplinary pain management programmes based on a cognitive-behavioural approach. The findings suggest that this programme has the potential to improve coping skills and health-related quality of life. Additionally, pain intensity, as measured by the Visual Analogue Scale, was reduced. Age and disability were revealed as the prominent predictors of change after treatment. The differences in this sample indicated that the drop-outs tended to be older and reported more health problems, although these findings were non-significant. Clinical and research implications are discussed.     

个体化疼痛管理对癌痛患者生活质量的影响与效果评价

目的探讨疼痛管理对提高疼痛患者生活质量的效果,为完善疼痛管理方案提供依据。方法选取2014年3月至2015年3月肿瘤科疼痛患者80例分为对照组40例,观察组40例。对照组实施常规疼痛治疗与护理,观察组在常规治疗护理基础上实施个体化疼痛管理,比较两组患者住院期间的疼痛状况、生活质量。结果观察组患者入院14d疼痛状况、生活质量明显优于对照组,差异有统计学意义(P0.05)。结论对癌症疼痛患者实施疼痛管理,能够改善疼痛患者的疼痛状况,提高疼痛患者的生活质量,值得临床推广。     

Sex differences among treatment clients with cocaine-related problems

Background: In a sample of treatment clients with cocaine-related problems, the present study examined sex differences in measures across six key domains, including socio-demographics, mental health, substance use, physical health, sexual health and psychosocial health.

Methods: Data were utilized from a cross-sectional study of treatment clients in Ontario and British Columbia, Canada (N?=?417). t-Tests were used to examine sex differences in continuous measures, while Fisher’s exact tests were used for dichotomous measures. A Bonferroni correction was applied to adjust for multiple comparisons. For measures that were significant in these tests, multivariable analyses were also conducted.

Results: Females were found to be more likely than males to have lower personal and household incomes, report membership in sexual minority groups and engage in high risk sexual behaviors, including trading sex for money, trading sex for drugs and having sex when they did not want to. Males were more likely than females to report higher sexual compulsion scores and have paid for sex.

Conclusion: Overall, the health-related needs of treatment clients with cocaine-related problems appear to differ by sex, especially in relation to sexual health. As such, setting of treatment priorities by treatment providers should reflect these important differences.     

建立多学科随访管理体系 加强出院患者癌痛管理

癌痛严重影响患者的生活质量,癌痛患者出院后更需要得到规范化镇痛治疗和护理,才能达到无痛生存,提高生活质量的目的。因此,我院通过摸索建立了以肿瘤科为主导,配合宁养院访视、多学科团队支持的多学科随访管理体系,通过电话随访、短信咨询、居家访视和网络互动等方式,帮助出院的癌痛患者进行疼痛管理,并给予心理支持和帮助,不仅缓解了患者的焦虑情绪,提高了生活质量,同时也提高了随访率。