The prevalence of episodic pain in cancer: a survey of hospice patients on admission

Pain that varies with time, referred to here as episodic pain, is a commonly encountered but under-investigated clinical problem. Previous studies of cancer patients have found that a significant proportion of their pains are episodic. To establish the prevalence and characteristics of episodic pains in hospice in-patients we assessed 245 consecutive admissions to four hospices in Yorkshire. The admitting doctor completed a questionnaire, detailing the characteristics of all pains experienced by the patient in the previous 24 h. Two hundred and forty-two questionnaires were entered into the study. One hundred and thirty-two patients reported pain in the preceding 24 h, of these 93% had at least one episodic pain. In total, 228 pains were described, of which 211 were episodic with a wide variation in their temporal characteristics, intensities and limitation. One hundred and fifty-two episodic pains had a precipitating factor; movement and weight bearing being the most frequent precipitants. One hundred and sixty-eight episodic pains had a relieving factor, medication improving 54%. Ninety-five pains were related to the malignancy and 47 to concurrent illness. The study confirms that episodic pain is extremely common in cancer patients referred for in-patient hospice care and highlights the need for further evaluation of its management.     

Psychosocial impact of headache and comorbidity with other pains among Swedish school adolescents

BACKGROUND: The psychosocial impact of headache combined with other pains has previously been insufficiently investigated. OBJECTIVE: The present study examined the prevalence of headache, its comorbidity with other pains and psychosocial impact among adolescents. METHODS: 793 adolescents in a sample recruited from 8 schools in the middle of Sweden were assessed. RESULTS: Forty-five percent of the adolescents reported ongoing pain during assessment and more than half of the adolescents reported at least one frequent pain during the previous 6 months. The most common pain among girls was headache (42%), but for boys muscle pain (32%) was most prevalent. Number of pains and perceived pain disability were also higher among girls than boys. One-third of the headache sufferers had headache only, while one-third reported one other frequent pain and the others had at least two other frequent pains. Overall, adolescents with frequent headaches had higher levels of anxiety or depressive symptoms, in addition to functional disability and usage of analgesic medication. Frequent headache sufferers reported more problems in everyday life areas than those with infrequent headaches. CONCLUSIONS: It is recommended that adolescents suffering from recurrent headaches routinely should be asked about the presence of other pains, anxiety and depressive symptoms, medication usage, in addition to psychosocial consequences in their everyday life activities. Longitudinal research is also needed to delineate causal relationships between psychosocial factors and recurrent pains, in particular regarding possible sex differences.     

Breakthrough pain: definition, prevalence and characteristics.

In the cancer population, the term breakthrough pain typically refers to a transitory flare of pain in the setting of chronic pain managed with opioid drugs. The prevalence and characteristics of this phenomenon have not been defined, and its impact on patient care is unknown. We developed operational definitions for breakthrough pain and its major characteristics, and applied these in a prospective survey of patients with cancer pain. Data were collected during a 3 month period from consecutive patients who reported moderate pain or less for more than 12 h daily and stable opioid dosing for a minimum of 2 consecutive days. Of 63 patients surveyed, 41 (64%) reported breakthrough pain, transient flares of severe or excruciating pain. Fifty-one different pains were described (median 4 pains/day; range 1-3600). Pain characteristics were extremely varied. Twenty-two (43%) pains were paroxysmal in onset; the remainder were more gradual. The duration varied from seconds to hours (median/range: 30 min/1-240 min), and 21 (41%) were both paroxysmal and brief (lancinating pain). Fifteen (29%) of the pains were related to the fixed opioid dose, occurring solely at the end of the dosing interval. Twenty-eight (55%) of the pains were precipitated; of these, 22 were caused by an action of the patient (incident pain), and 6 were associated with a non-volitional precipitant, such as flatulence. The pathophysiology of the pain was believed to be somatic in 17 (33%), visceral in 10 (20%), neuropathic in 14 (27%), and mixed in 10 (20%). Pain was related to the tumor in 42 (82%), the effects of therapy in 7 (14%), and neither in 2 (4%). Diverse interventions were employed to manage these pains, with variable efficacy. These data clarify the spectrum of breakthrough pains and indicate their importance in cancer pain management.     

Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice

A prospective survey was undertaken to determine the prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. Of 414 consecutive admissions, 33 patients were confused or too unwell to take part and 136 were pain-free. The remaining 245 reported 404 pains (range 1-5 per patient); of these patients, 218 (89%) had breakthrough pain and identified 361 pains (range 1-5 per patient). Breakthrough pain was classified as somatic (46%) visceral (30%), neuropathic (10%) or mixed etiology (16%). Thirty-eight percent of pains were severe or excruciating. The average number of daily breakthrough pain episodes was 4 [corrected] (range 1-14); 49% occurred suddenly. Most (59%) were unpredictable, and 72% lasted less than 30 minutes. Seventy-five percent of patients were dissatisfied with their pain control. Breakthrough pain is common among patients admitted to our hospice. It is frequent, short lasting, often unpredictable and not necessarily related to chronic pain making treatment difficult.     

Prevalence and characteristics of breakthrough pain in opioid-treated patients with chronic noncancer pain.

Breakthrough pain is well-characterized in cancer patients but not in patients with chronic noncancer pain. We recruited 228 patients with diverse types of chronic noncancer pain from 9 pain programs and administered a telephone questionnaire with a breakthrough pain assessment algorithm originally designed for cancer patients. All patients had controlled baseline pain, and 168 (74%) experienced severe to excruciating breakthrough pain. Among those with breakthrough pain, the most common syndrome was low back pain (52%), and the underlying pathophysiology was variably characterized as somatic (38%), neuropathic (18%), visceral (4%), or mixed (40%). A total of 189 different types of breakthrough pain were reported. The median number of episodes per day was 2 (range, <1 to 12). Median time to maximum intensity was 10 minutes (range, 0 to 180 minutes). Median duration of the breakthrough pain was 60 minutes (range, 1 to 720 minutes). Patients identified a precipitant for 69% of pains, and 92% of these were activity-related. Onset could never be predicted for 45% of pains and only sometimes predicted for 31% of pains. Breakthrough pain is highly prevalent and varied in this population. Further studies are warranted to clarify whether the clinical impact and therapeutic challenges posed by this phenomenon are comparable to the cancer population. PERSPECTIVE: This article presents results from a survey that demonstrates that breakthrough pain is highly prevalent and varied in opioid-treated patients with chronic noncancer pain. These findings will assist clinicians in assessing and managing this type of pain.     

Schmerzbehandlung bei Karzinompatienten

Freedom from cancer pain is one of the four priorities of the WHO Cancer Control Programme. Every day 3.5 million people are suffering from cancer pain, and most do not receive adequate relief. A lack of training in cancer pain management at most nursing and medical schools is the principal reason for this, coupled with limited availability of oral strong opioids in many countries. Education is the key to progress in cancer pain management. Health workers must appreciate that: 1. Attention must be paid to all aspects of suffering -physical, psychological, social and spiritual. 2. In advanced cancer, most patients with pain have multiple pain. 3. Pain experienced in carcinoma is not always caused by the tumour. 4. There is more to pain management than the use of analgesics. 5. In the case of opioid-responsive pains, analgesics should be administered by mouth according to a regular time-schedule and with dose increments. 6. Adjuvant medication is generally necessary. 7. Opioid-resistant pains require other forms of treatment. 8. Pain is the physiological antagonist to the central depressant effects of opioids. 9. Opioid tolerance is not a problem in practice. 10. Psychological dependence does not occur in patients receiving opioids for pain relief. 11. Patients receiving analgesics must be carefully monitored. 12. Teamwork is necessary for good results.     

Phantom limb, phantom pain and stump pain in amputees during the first 6 months following limb amputation

The incidence and clinical picture of non-painful and painful phantom limb sensations as well as stump pain was studied in 58 patients 8 days and 6 months after limb amputation. The incidence of non-painful phantom limb, phantom pain and stump pain 8 days after surgery was 84, 72 and 57%, respectively. Six months after amputation the corresponding figures were 90, 67 and 22%, respectively. Kinaesthetic sensations (feeling of length, volume or other spatial sensation of the affected limb) were present in 85% of the patients with phantom limb both immediately after surgery and 6 months later. However, 30% noticed a clear shortening of the phantom during the follow-up period; this was usually among patients with no phantom pain. Phantom pain was significantly more frequent in patients with pain in the limb the day before amputation than in those without preoperative limb pain. Of the 67% having some phantom pain at the latest interview 50% reported that pains were decreasing. Four patients (8%), however, reported that phantom pains were worse 6 months after amputation than originally. During the follow-up period the localization of phantom pains shifted from a proximal and distal distribution to a more distal localization. While knifelike, sticking phantom pains were most common immediately after surgery, squeezing or burning types of phantom pain were usually reported later in the course. Possible mechanisms for the present findings either in periphery, spinal cord or in the brain are discussed.     

Prevalence and characteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice.

A prospective survey was undertaken to determine the prevalence and characteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice. Of the 78 admissions surveyed, 10 patients were confused or too unwell to take part and 25 were pain-free. The remaining 43 reported 86 pains (range 1-6 per patient); of these patients, 27 (63%) had breakthrough pain and identified 52 pains (range 1-5 per patient). Breakthrough pain was classified as somatic (46%) visceral (14%), neuropathic (25%) or mixed aetiology (15%); 60% of pains were severe or excruciating. The mean number of daily breakthrough pain episodes was five (range 1-13), 54% of which occurred suddenly. Most pains (56%) were unpredictable; 75% lasted less than 30 min. These findings suggest that breakthrough pain is common in patients with non-malignant terminal disease; it is frequent, short lasting and often unpredictable, thus making treatment difficult.     

Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review

Pain in cancer patients remains common and is often associated with insufficient prescribing of targeted analgesia. An explanation for undertreatment could be the failure to identify neuropathic pain mechanisms, which require additional prescribing strategies. We wanted to identify the prevalence of neuropathic mechanisms in patients with cancer pain to highlight the need for detailed assessment and to support the development of an international classification system for cancer pain. We searched for studies that included adult and teenage patients (age above 12 years), with active cancer and who reported pain, and in which a clinical assessment of their pain had been made. We found 22 eligible studies that reported on 13,683 patients. Clinical assessment methods varied, and only 14 studies reported confirmatory testing for either sensory abnormality or diagnostic lesion to corroborate a diagnosis of neuropathic pain. We calculated that the prevalence of patients with neuropathic pain (95% confidence interval) varied from a conservative estimate of 19% (9.4% to 28.4%) to a liberal estimate of 39.1% (28.9% to 49.5%) when patients with mixed pain were included. The prevalence of pain with a neuropathic mechanism (95% confidence interval) ranged from a conservative estimate of 18.7% (15.3% to 22.1%) to a liberal estimate of 21.4% (15.2% to 27.6%) of all recorded cancer pains. The proportion of pain caused by cancer treatment was higher in neuropathic pain compared with all types of cancer pain. A standardised approach or taxonomy used for assessing neuropathic pain in patients with cancer is needed to improve treatment outcomes.     

中医情志护理对消化道恶性肿瘤患者疼痛的干预效果

目的观察中医情志护理在缓解消化道恶性肿瘤患者疼痛中的作用,以探索一种安全、高效的缓解疼痛的中医护理方法。方法选择2011年1-6月上海中医药大学附属普陀医院收治的消化道恶性肿瘤患者50例,予以中医情志护理,并在实施前后予以疼痛强度量表的评估。结果实施中医情志护理后患者疼痛次数明显减少,疼痛强度、平均疼痛程度、严重程度、轻微程度以及目前疼痛程度均明显减轻,差异有统计学意义(P<0.05)。结论中医情志护理能有效缓解消化道恶性肿瘤患者的疼痛,提高其生活质量,有较为广泛的推广应用前景。     

Pediatrics (79)

Pain children: a common experience. (Erasmus University Rotterdam, Rotterdam, The Netherlands) Pain 2000;87:51–57. This study analyzed the prevalence of pain in Dutch children from 0 to 18 years of age. A random sample of 1300 children 0–3 years of age was taken from the register of population in Rotterdam, The Netherlands. In the Rotterdam area, 27 primary schools and 14 secondary schools were selected to obtain a representative sample of 5336 children from 4–18 years of age. Depending on the age of the child, a questionnaire was either mailed to the parents (0–3 years) or distributed at school (4–18 years). Of 6636 children surveyed, 5424 (82%) responded; response rates ranged from 64% to 92%, depending on the subject age and who completed the questionnaire. Of the respondents, 54% had experienced pain within the previous 3 months. Overall, a quarter of the respondents reported chronic pain (recurrent or continuous pain for more than 3 months). The prevalence of chronic pain increased with age, and was significantly higher in girls (P < 0.001). In girls, a marked increase occurred in reporting chronic pain between 12 and 14 years of age. The most common types of pain in children were limb pain, headache, and abdominal pain. Half of the respondents who had reported pain reported to have multiple pain, and one‐third of the chronic pain sufferers experienced frequent and intense pain. These multiple pains and severe pains were more often reported by girls (P < 0.001). The intensity of pain was higher in the case of chronic pain (P < 0.001) and multiple pains (P < 0.001), and for chronic pain the intensity was higher for girls (P < 0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow‐up investigations documenting the various bio‐psycho‐social factors related to this pain.     

308例胸痛患者冠状动脉造影结果分析

目的：探讨行冠状动脉造影的住院胸痛患者中冠心病的患病率及冠心病患者冠状动脉病变的特点.方法：对因胸痛在我院心内科接受冠状动脉造影的连续308例患者的造影结果进行分析.结果：308例胸痛患者中130例诊断为冠心病,患病率42.21%.其中60岁及以上的老年人占66.16%,男性患病率明显高于女性（P＜0.01）.病变血管以LAD最为常见,占40.31%.分叉病变占非完全闭塞性病变患者的44.12%.完全闭塞性病变患者28例,其中一支血管闭塞的患者23例,两支5例.单支、双支和3支血管病变分别为64例、41例和25例,分别占冠心病患者的49.23%、31.54%和19.23%.冠状动脉最狭窄病变狭窄程度越重,其两支及多支血管病变以及合并左主干病变的发生率越高.101例（77.69%）冠心病患者需要行血运重建治疗.结论：冠心病是行冠状动脉造影的住院胸痛患者中首要病因.大多数冠心病患者需要行血运重建治疗.对住院胸痛患者,尤其对具有冠心病易患因素的老年男性应常规行冠状动脉造影.     

Reproducing a cancer patient's pain on physical examination: bedside provocative maneuvers

While various aspects of the physical examination in pain patients have been validated, the value of screening maneuvers that reproduce a cancer patient's pain on physical examination has been less well defined. The purpose of this prospective case series is to better characterize the role of bedside provocative maneuvers as part of the comprehensive evaluation of cancer pain patients. Fifty consecutive patients referred to an ambulatory cancer pain clinic were evaluated; they described a total of 89 discrete pains. All or much of the pain that brought each patient to medical attention was reproduced by a provocative maneuver in 47 (94%) patients; 79 of 89 (89%) pains were elicited at the bedside. Pains that were not reproducible with any provocative maneuver included paroxysmal spells of pain, neuropathic pain, and steady headache. On the basis of the history, physical examination, and both positive and negative provocative maneuvers, all pains were characterizable as somatic, visceral, neuropathic, or mixed, and a pathophysiological basis for the pain was inferred in 85 of 89 (95%) pains. On the basis of this preliminary report, we conclude that provocative bedside maneuvers are usually able to reproduce a cancer patient's pain. They help to better characterize the pain and identify the pain sensitive structure, and should be a routine part of the comprehensive assessment of cancer pain patients. Further research is needed to validate the diagnostic role of standardized pain-provoking maneuvers in a variety of clinical situations.     

Emotional/behavioural, social correlates and one-year predictors of frequent pains among early adolescents: influences of pain characteristics.

In a one-year longitudinal study, emotional/behavioural correlates and predictors of four common pain complaints (headaches, stomach, back and limb pain), were examined in a representative school sample of 2360 adolescents aged 12- to 15-years. At first assessment, 18.3% reported being bothered by a frequent pain (at least once a week) and 40% of the pain sufferers had two or more pain locations, more commonly reported by girls. Subjects having any of the four frequent pains reported having fewer friends and were more often absent from school. Frequency and number of reported pains among adolescents were positively related to levels of internalising and externalising problems. These latter problems were consistently and significantly higher among adolescents with frequent back and limb pains, however, when coexistence of another frequent pain was controlled, differences were small. Number of pains at the one-year follow-up was significantly predicted by frequent back pain and headache, depressive symptoms scores, somatic complaints (other than pain), number of friends and reduced leisure time activities during the follow-up period. Frequent back pain and depressive symptoms also predicted multiple frequent pains (vs single frequent pain) at the follow-up as did recent parental divorce. It is concluded that various emotional and behavioural problems, and which are commonly regarded as being specifically related to pain type or location among adolescents, depend rather on frequency and coexistence of multiple frequent pains. Assessment of adolescents with frequent and multiple pains should, therefore, include broad screening of internalising as well as externalising problems as well as various aspects of impairment.     

Pain in children and adolescents: a common experience

Little is known about the epidemiology of pain in children. We studied the prevalence of pain in Dutch children aged from 0 to 18 years in the open population, and the relationship with age, gender and pain parameters. A random sample of 1300 children aged 0-3 years was taken from the register of population in Rotterdam, The Netherlands. In the Rotterdam area, 27 primary schools and 14 secondary schools were selected to obtain a representative sample of 5336 children aged 4-18 years. Depending on the age of the child, a questionnaire was either mailed to the parents (0-3 years) or distributed at school (4-18 years). Of 6636 children surveyed, 5424 (82%) responded; response rates ranged from 64 to 92%, depending on the subject age and who completed the questionnaire. Of the respondents, 54% had experienced pain within the previous 3 months. Overall, a quarter of the respondents reported chronic pain (recurrent or continuous pain for more than 3 months). The prevalence of chronic pain increased with age, and was significantly higher for girls (P<0.001). In girls, a marked increase occurred in reporting chronic pain between 12 and 14 years of age. The most common types of pain in children were limb pain, headache and abdominal pain. Half of the respondents who had experienced pain reported to have multiple pain, and one-third of the chronic pain sufferers experienced frequent and intense pain. These multiple pains and severe pains were more often reported by girls (P<0.001). The intensity of pain was higher in the case of chronic pain (P<0. 001) and multiple pains (P<0.001), and for chronic pain the intensity was higher for girls (P<0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow-up investigations documenting the various bio-psycho-social factors related to this pain.     

Pain syndromes and etiologies in ambulatory AIDS patients

Ambulatory AIDS patients participating in a quality of life study were recruited for an assessment of pain syndromes. Of 274 patients with pain, 151 (55%) consented to the assessment which included a clinical interview, neurologic examination, and review of medical records. The number, type, and etiology of pains were evaluated in terms of risk factors, age, sex, CD4+ lymphocyte count, and performance status. The average number of pains per patient was 2.7 (range, 1–7), yielding a total of 405 pains. The most common pain diagnoses were headache (46% of patients; 17% of all pains), joint pain (31% of patients; 12% of pains), pain due to polyneuropathy (28% of patients; 10% of pains), and muscle pain (27% of patients; 12% of pains). Pathophysiology was inferred for all pain syndromes (except for headache), 45% of pain syndromes were somatic in nature, 15% were visceral, 19% were neuropathic, and 4% were unknown, psychogenic, or idiopathic; 17% of pains were classified as headache, hence pathophysiology could not be determined. Pain resulted from diverse etiologies, including the direct effects of HIV/AIDS-related conditions (30%) pre-existing unrelated conditions (24%), and therapies for HIV/AIDS and related conditions (4%). The latter category, pain related to HIV therapies, occurred in 11% of patients. In 37% of the pains, the etiology could not be determined from the information available. In univariate analyses, lower CD4+ cell counts were significantly associated with polyneuropathy (P<0.05) and headache (P<0.05), and female gender was significantly associated with the presence of headache (P<0.05) and radiculopathy (P<0.001). These data confirm the diversity of pain syndromes in AIDS patients, clarify the prevalence of common pain types, and suggest associations between specific patient characteristics and pain syndromes. The large proportion of patients who could not be given a diagnosis underscores the need for a careful diagnostic evaluation of pain in this population.     

门诊及住院急慢性疼痛患者疼痛情况调查分析

目的 调查门诊患疼痛发生情况及住院疼痛患控制状况。方法 对5404例门诊挂号患采用询问法确定其有无疼痛症状；另采取问卷法的形式调查了256例有急笥或慢性疼痛的住院患的疼痛程度、受疼痛困扰情况，对疼痛知识的了解及其止痛需求。结果 40％的门诊患有疼痛证状，而住院的急慢性疼痛患中虽部分采取了一定止痛措施，但仍有相当数量的人受到了疼痛的困扰，并且由于疼痛知识的缺乏，很多患盲目忍耐疼痛造成痛楚。提示 必须对患及家属进行疼痛知识的宣教，规范急慢性疼痛的诊疗、护理方案，以有效控制疼痛，减少患不必要的痛苗，提高护理质量。     

癌症患者的疼痛管理与人文关怀

大多数癌症患者都遭遇不同程度的疼痛,癌痛管理已成为癌症护理的重要部分。疼痛的正确、持续评估及妥当的干预对于提高患者的生活质量至关重要,同时在疼痛管理中,应突出以患者为中心的思想,体现人文关怀。