Pain assessment in chronic pancreatitis: A comparative review of methods

BackgroundPatients with chronic pancreatitis (CP) frequently report chronic abdominal pain that adversely impacts their quality of life. Assessment of pain in CP is required for clinical management and clinical studies. International consensus guidelines recognized a lack of specific and validated pain assessment tools for CP. Therefore, the aim of this systematic review is to identify and compare all clinical studies that assessed pain in the context of a treatment for pain in CP.MethodsA systematic literature search was performed in PubMed, Cochrane Library and Ovid MEDLINE. The search identified all intervention studies for pain in CP and the pain assessment tools used based on pre-defined inclusion and exclusion criteria.ResultsOf 341 articles identified, 137 studies were included. Pain assessment tools were both general and CP-specific. The latter were used in only 22 (16%) studies. Despite recommendations the aspects of pain assessed were limited and variable between tools. Validation of these tools in CP patients was limited to quality of life measures. None of the pain assessment tools evaluated duration of pain and postprandial pain.ConclusionsThere are no published pain assessment tools for CP that includes all relevant aspects of pain. There is the need to develop a comprehensive and validated pain assessment tool for patients with CP to standardised pain assessment, identify likely underlying pain mechanisms, help select appropriate treatments, report outcomes from interventions, improve clinical communication and aid the allocation of patients to clinical trials.     

Nonanesthetic Effects of Ketamine: A Review Article

Ketamine is considered a dissociative anesthetic medication, and it is commonly administered by a parenteral route. It works mainly by blocking the N-methyl-D-aspartate receptor. It inhibits the voltage-gated Na and K channels and serotonin and dopamine reuptake; also, it affects specific receptors, such as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, kainate, and aminobutyric acid A receptors. Ketamine appears to have particular mechanisms that are potentially involved during analgesic induction, including enhancing of descending inhibition and antiinflammatory effects. More recently, it has been shown that ketamine has potential in clinical practice for the management of chronic pain, cognitive function, depression, acute brain injury, and disorders of the immune system.     

Non-Pharmacological Approaches to Pain Management in Residential Aged Care: a Pre-Post-Test Study

Objectives: The project aimed to evaluate a pain management program (PMP) using non-pharmacological approaches at five residential aged care facilities (RACFs) in Australia.

Methods: The PMP involved a physiotherapist implementing four sessions per week of treatments (massage therapy, TENS, exercises and stretching, or combinations of these). Ninety-five participants were recruited (average age, 83 years; SD = 7.6; 38% men, 62% women; 56% with dementia). Sessions lasted approximately 10 minutes, and residents’ levels of pain were recorded using a 5-point scale before and after each treatment. The intervention period for each participant was the first consecutive 8 weeks in which they received the intervention.

Results: Data analyses showed: (1) a small but statistically significant decrease in the number of as required (PRN) medications; and (2) a decrease in average pain ratings from pre-session to post-session from 2.4 (some to moderate pain) to 1.1 (a little pain). Notably, residents with dementia received lower pain ratings than those without.

Conclusions: Non-pharmacological approaches to pain in residential care settings are effective, especially when two or more are combined. Staff working in residential care settings should rely on best practice to recognise pain in residents with dementia.

Clinical Implications: Non-pharmacological interventions may be effective in reducing pain and reliance on PRN medications in residential care settings, especially when two or more are used. Staff working in residential aged care settings should be provided with training in pain assessment and management, with particular attention to residents with dementia.     

More Than a Pain in the Neck: How Discussing Chronic Pain Affects Hypertension Medication Intensification

BACKGROUND  A difficult to manage comorbid condition, like chronic pain, could adversely affect the delivery of recommended care for other serious health problems, such as hypertension. OBJECTIVE  We examined whether addressing pain at a primary care visit acts as a competing demand in decisions to intensify blood pressure (BP) medications for diabetic patients with an elevated BP. DESIGN  Prospective cohort study. Participants: 1,169 diabetic patients with a BP ≥140/90 prior to a primary care provider (PCP) visit were enrolled. MEASUREMENTS  After the visit, PCPs provided information about the top three issues discussed and whether hypertension medications were intensified or reasons for not intensifying. We used multi-level logistic regression to assess whether discussing pain during the visit decreased the likelihood of BP medication intensification. We calculated predicted probabilities of medication intensification by whether pain was discussed. RESULTS  PCPs discussed pain during 222 (20%) of the visits. Visit BP did not differ between patients with whom pain was and was not discussed. BP medications were intensified during 44% of the visits. The predicted probability of BP medication intensification when pain was discussed was significantly lower than when pain was not discussed (35% vs. 46%, p = 0.02). CONCLUSIONS  Discussing pain at a primary care visit competed with the intensification of BP medication. This finding is concerning given that controlling blood pressure may be the most important factor in decreasing long-term complications for patients with diabetes. Better care management models for complex patients are needed to ensure that both pain and other chronic conditions are adequately addressed.     

Pain patterns in chronic pancreatitis and chronic primary pain

BackgroundAbdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator.AimsThis cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes.MethodsPatients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics.ResultsCompared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent.ConclusionsWithin CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.     

Pain and chronic pancreatitis: A complex interplay of multiple mechanisms

Despite multiple theories on the pathogenesis of pain in chronic pancreatitis,no uniform and consistently successful treatment strategy exists and abdominal pain still remains the dominating symptom for most patients and a major challenge for clinicians.Traditional theories focussed on a mechanical cause of pain related to anatomical changes and evidence of increased ductal and interstitial pressures.These observations form the basis for surgical and endoscopic drainage procedures,but the outcome is variable and often unsatisfactory.This underscores the fact that other factors must contribute to pathogenesis of pain,and has shifted the focus towards a more complex neurobiological understanding of pain generation.Amongst other explanations for pain,experimental and human studies have provided evidence that pain perception at the peripheral level and central pain processing of the nociceptive information is altered in patients with chronic pancreatitis,and resembles that seen in neuropathic and chronic pain disorders.However,pain due to e.g.,complications to the disease and adverse effects to treatment must not be overlooked as an additional source of pain.This review outlines the current theories on pain generation in chronic pancreatitis which is crucial in order to understand the complexity and limitations of current therapeutic approaches.Furthermore,it may also serve as an inspiration for further research and development of methods that can evaluate the relative contribution and interplay of different pain mechanisms in the individual patients,before they are subjected to more or less empirical treatment.     

Pain Management Programmes for Non‐English‐Speaking Black and Minority Ethnic Groups With Long‐Term or Chronic Pain

Increasing ethnic diversity in the UK means that there is a growing need for National Health Service care to be delivered to non‐English‐speaking patients. The aims of the present systematic review were to: (1) better understand the outcomes of chronic pain management programmes (PMPs) for ethnic minority and non‐English‐speaking patients and (2) explore the perspectives on and experiences of chronic pain for these groups. A systematic review identified 26 papers meeting the inclusion criteria; no papers reported on the outcomes of PMPs delivered in the UK. Of the papers obtained, four reported on PMPs conducted outside the UK; eight reported on ethnic differences in patients seeking support from pain management services in America; and the remaining papers included literature reviews, an experimental pain study, a collaborative enquiry, and a survey of patient and clinician ratings of pain. The findings indicate a lack of research into UK‐based pain management for ethnic minorities and non‐English‐speaking patients. The literature suggests that effective PMPs must be tailored to meet cultural experiences of pain and beliefs about pain management. There is a need for further research to explore these cultural beliefs in non‐English‐speaking groups in the UK. Culturally sensitive evaluations of interpreted PMPs with long‐term follow‐up are needed to assess the effectiveness of current provision. Copyright © 2015 John Wiley & Sons, Ltd.     

Using Focus Groups in Gerontological Research

Focus groups may be successfully used in gerontological research as exploratory or confirmatory research tools. Results from a national applied gerontological project on oral health and the elderly from the U.S. Centers for Disease Control, which utilized a focus group process in survey development, are presetented. Findings indicate that focus groups offer rich possibilities for combining qualitative and quantitative approaches to strengthen gerontological designs for preliminary investigations, instrument design, and government policymaking.     

Pain coping strategies in children with juvenile primary fibromyalgia syndrome: Correlation with pain,physical function,and psychological distress

Objectives . The purpose of this study was twofold: (1) to describe the coping strategies used by children with juvenile primary fibromyalgia syndrome (JPFS), and (2) to examine how pain coping relates to measures of pain, disability/function, psychological distress, and pain behavior. Methods . Sixteen children with JPFS completed the Child Version of the Coping Strategies Questionnaire (CSQ-C), the visual analog scale for pain, the McGill Pain Questionnaire, the Fibromyalgia Impact Questionnaire modified for children, the Arthritis Impact Measurement Scales 2, and the Symptom Checklist-90-Revised. Subjects also underwent pain behavior observation. Pearson's product moment correlations were conducted to examine the relationship of coping to measures of pain and disability. Results . The Pain Control and Rational Thinking composite factor score on the CSQ-C correlated with measures of pain severity, functional disability, and psychological distress. Results supported the internal reliability of the CSQ-C in assessing pain coping. Conclusions . These results suggest that the CSQ-C may provide a reliable measure for assessing variations in pain coping in JPFS patients. Behavioral interventions aimed at increasing the perception of pain control may be beneficial in treating JPFS.     

Pain in thalassaemia: the effects of age on pain frequency and severity

Pain is not a symptom generally associated with thalassaemia. However, providers have noted increasing patient reports of pain, creating an impetus for this prospective, observational assessment of pain in thalassaemia patients. The primary study goals were to assess pain prevalence, severity, location, and potential risk factors. This was a multicentre, prospective study of thalassaemia patients receiving care at 12 Thalassaemia Clinical Research Network sites. Pain was assessed using the Brief Pain Inventory. Two hundred and fifty‐two thalassaemia patients ranging in age from 12 to 71 years (mean 28·8) were enrolled. Sixty‐four per cent reported experiencing pain during the last 4 weeks, 22% of whom reported pain on a daily basis. Ordinal regression analysis of pain ratings demonstrated significant (P < 0·001) correlation of increased age with increased pain, irrespective of diagnosis, transfusion status, gender, bone density, chelator type or iron overload. Eighty‐one per cent reported having pain for 1 year or longer and 31% reported pain for five or more years. Pain is a major cause of morbidity and an unrecognized problem for patients with thalassaemia. Age is the strongest predictor of frequency and severity. Little else is known about the aetiology and predictors of this pain syndrome.     

Pain/Depression Dyad: A Key to a Better Understanding and Treatment of Functional Somatic Syndromes

Functional somatic syndromes include some of the most common and frustrating illnesses seen by primary care physicians and medical specialists. An extensive literature search of the 2 best characterized functional somatic syndromes, fibromyalgia and irritable bowel syndrome, reveals the overlap of these 2 disorders and their close relationship to depression. New pathophysiologic studies have shown that there are similar central nervous system changes in fibromyalgia, irritable bowel syndrome, and depression. These clinical and biologic similarities are consistent with the observations that the effective management of fibromyalgia and irritable bowel syndrome is comparable to that of depression.