Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial.

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

A survey of prelicensure pain curricula in health science faculties in Canadian universities.

OBJECTIVE: The present exploratory, descriptive study aimed to determine the designated time for mandatory pain content in curricula of major Canadian universities for students in health science and veterinary programs before being licensed. METHOD: Major Canadian university sites (n=10) were chosen where health science faculties included at least medicine (n=10) and nursing (n=10); many also included dentistry (n=8), pharmacy (n=7), physical therapy (n=8) and/or occupational therapy (n=6). These disciplines provide the largest number of students entering the workforce but are not the only ones contributing to the health professional team. Veterinary programs (n=4) were also surveyed as a comparison. The Pain Education Survey, developed from previous research and piloted, was used to determine total mandatory pain hours. RESULTS: The majority of health science programs (67.5%) were unable to specify designated hours for pain. Only 32.5% respondents could identify specific hours allotted for pain course content and/or additional clinical conferences. The average total time per discipline across all years varied from 13 h to 41 h (range 0 h to 109 h). All veterinary respondents identified mandatory designated pain content time (mean 87 h, range 27 h to 200 h). The proportion allotted to the eight content categories varied, but time was least for pain misbeliefs, assessment and monitoring/follow-up planning. CONCLUSIONS: Only one-third of the present sample could identify time designated for teaching mandatory pain content. Two-thirds reported 'integrated' content that was not quantifiable or able to be determined, which may suggest it is not a priority at that site. Many expressed a need for pain-related curriculum resources.

Painful neuropathic disorders: an analysis of the Régie de l'Assurance Maladie du Québec database.

BACKGROUND/OBJECTIVE: Painful neuropathic disorders (PNDs) refer to neurological disorders involving nerves in which pain is a predominant symptom. In most cases, PNDs involve the peripheral nerves. Treatment of PNDs is likely to use large health care resources. However, little is known about the economic burden of PNDs in Canada. METHOD: The present study was performed using data from a random sample of patients covered by the Régie de l'Assurance Maladie du Quebec drug plan. Subjects with a diagnosis of a peripheral PND were identified. Comorbidities, pain-related medication use and resource utilization were compared between PND patients and control patients without PNDs matched for age and sex in a 1:1 ratio. RESULTS: A total of 4912 patients with PNDs were identified. A higher level of comorbidities was found in the PND group (Von Korff chronic disease score 3.91 versus 2.54; P<0.001). The proportion of users of pain-related medications was significantly higher in the PND cohort than in the control group (chi-squared; P<0.001). The average annual number of physician visits was also significantly higher in the PND group than in the control group (14.7 versus 6.4; P<0.001). From a health ministry perspective, costs of health care resources were significantly higher in the PND group (4,163 dollars versus 1,846 dollars; P<0.001). The proportion of potentially inappropriate medications was 34% among those 65 years of age or older. CONCLUSIONS: PNDs are associated with a higher level of comorbidities, higher medical resources utilization and higher health care costs than non-PND conditions.

Do depression and anxiety profiles over time predict persistent post-surgical pain? A study in cardiac surgery patients.

BACKGROUND: Rates of depression and anxiety in cardiac surgery patients are higher than in the general population. The development of persistent post-surgical pain (PPSP) in this population is also concerning. The objectives of this study were to (1) identify anxiety and depression trajectories of cardiac surgery patients over a 2-year period; (2) examine demographic and clinical characteristics associated with trajectory memberships and (3) determine if anxiety and/or depression trajectories predict PPSP. METHODS: A total of 1071 patients completed questionnaires before cardiac surgery and 7 days, 3, 6, 12 and 24 months thereafter. Models were run using growth mixture modelling. RESULTS: Both anxiety and depression models yielded a 3-trajectory solution. A minority of patients (< 10%) had unremitted major depression, almost one-third of patients had remitted minor depression and the remaining patients had no depression over the 2-year period. < 10% of patients had unremitted elevated anxiety, almost 40% of patients had unremitted mild anxiety symptoms, whereas half of patients did not experience anxiety over the same time period. Patients with unremitted elevated anxiety were more likely to report PPSP; the association between depression and PPSP was not significant. CONCLUSIONS: The results' novelty lies in the identification of a homogeneous patient subgroup presenting with unremitted elevated anxiety which predicted the presence of PPSP up to 2 years following cardiac surgery. Unlike anxiety, depression subgroups were not predictive of PPSP status. SIGNIFICANCE: This article presents the relationship between anxiety and depression profiles over 2 years in cardiac surgery patients and persistent post-surgical pain. These results suggest the importance of evaluating how early identification and treatment of high-risk patients could prevent PPSP. These results provide potential detection and prevention avenues of chronic pain for high-risk patients based on their anxiety trajectory.

Development and Implementation of a Registry of Patients Attending Multidisciplinary Pain Treatment Clinics: The Quebec Pain Registry.

The Quebec Pain Registry (QPR) is a large research database of patients suffering from various chronic pain (CP) syndromes who were referred to one of five tertiary care centres in the province of Quebec (Canada). Patients were monitored using common demographics, identical clinical descriptors, and uniform validated outcomes. This paper describes the development, implementation, and research potential of the QPR. Between 2008 and 2013, 6902 patients were enrolled in the QPR, and data were collected prior to their first visit at the pain clinic and six months later. More than 90% of them (mean age ± SD: 52.76 ± 4.60, females: 59.1%) consented that their QPR data be used for research purposes. The results suggest that, compared to patients with serious chronic medical disorders, CP patients referred to tertiary care clinics are more severely impaired in multiple domains including emotional and physical functioning. The QPR is also a powerful and comprehensive tool for conducting research in a "real-world" context with 27 observational studies and satellite research projects which have been completed or are underway. It contains data on the clinical evolution of thousands of patients and provides the opportunity of answering important research questions on various aspects of CP (or specific pain syndromes) and its management.

Analgesia produced by injection of lidocaine into the lateral hypothalamus.

The local anesthetic lidocaine was injected into the lateral hypothalamus (LH) of awake, freely moving rats immediately prior to pain testing with either the formalin or the foot-flick test. Regional anesthesia of the LH resulted in a significant bilateral reduction of pain scores in the formalin test but had no effect in the foot-flick test. The decreased pain in the formalin test was not due to the diffusion of lidocaine into areas surrounding the LH or other possible artifacts. The results provide further evidence of hypothalamic involvement in pain perception and indicate that different neural systems subserve different types of pain.

Prevalence and characteristics of chronic sensory problems in burn patients.

Problems of pain and paresthesia in the healed wounds of burn patients are an understudied and poorly documented phenomenon. This descriptive study was designed to examine the prevalence and characteristics of these chronic sensory problems 1 year or more postburn. Four hundred and thirty patients were sent questionnaires which assessed the frequency and intensity of the problems, influencing factors and impact on patients' lives. These problems were assessed by rating scales (visual analogue and categorical scales) and the McGill Pain Questionnaire (MPQ). The response rate was 67%. Over one-third of the participants (36.4%) complained of pain while the prevalence of paresthetic sensations was 71.2%. More than half of the symptomatic patients experienced sensory problems every week sufficient to interfere with daily living. No relationships were found between these sensory problems and the patients' age or sex, burn etiology, or length of time elapsed since injury. Burn severity was related to the frequency of the problems. Discussion emphasizes the need for adequate treatment of these problems and suggests further research issues.

A visual analogue thermometer for measuring pain intensity.

A new instrument for measuring pain intensity--the visual analogue thermometer (VAT)--was developed to overcome limitations and disadvantages of the conventional visual analogue scale (VAS). Two studies were performed to assess the validity and utility of the VAT as compared to conventional pain instruments whose psychometric qualities are scientifically recognized. The first study was carried out with a group of 65 chronic pain patients who provided pain intensity ratings using the VAT, a standard VAS, and the McGill Pain Questionnaire. A second set of measures was obtained from a group of 243 adult healthy volunteers who quantified the intensity of a set of descriptive pain terms with the VAT, a numerical scale (NUM), and a VAS. The results of both studies support the concurrent validity of the VAT as a pain measure. When assessing changes in pain levels, the VAT was able to distinguish between different pain intensities, confirming the construct validity of the instrument. No major difference emerged in the relative sensitivity of the VAT compared to the standard VAS, both scales yielding comparable pain estimates. In contrast, the NUM scale tended to produce higher pain ratings. Regardless of the pain scale used, the results showed unequal differences between descriptive pain terms that are commonly considered equidistant on an ordinal scale. No major problem was noticed in subjects' understanding or using either the VAT, VAS, or NUM scales. When questioned about pain scale preference, a substantial number of participants preferred the VAT to the standard VAS as a means of rating pain intensity. In view of the results obtained in the present studies, it is concluded that the VAT is a valid accurate, and clinically useful tool for measuring pain. Its design makes it suitable and effective for clinical use and as an outcome measure in clinical trials.

Pain and paresthesia in patients with healed burns: an exploratory study.

The present study was designed to examine the prevalence and characteristics of painful and paresthetic sensations in a group of patients with healed burns. Adult patients who had been hospitalized for burn injuries during a 7-yr period were contacted and given a structured interview that included a series of questions about their present condition. Patients' medical charts were reviewed to obtain relevant demographic and medical information. The results show that abnormal sensations in healed burns are frequently reported as long as several years after the injury. Of 104 patients interviewed 1 yr or more after a burn injury, 82% reported paresthetic sensations such as tingling, stiffness, cold sensations, and numbness; and 35% complained of pain in the scarred tissue. The prevalence of these sensations was not related to age, sex, or etiology of the burns, but was associated with burn size and skin grafting. The theoretical and clinical implications of these results are discussed with particular emphasis on the need to pursue research on the long-term adverse effects of burn injuries.

Successful use of methadone in the treatment of chronic neuropathic pain arising from burn injuries: a case-study.

Methadone is used increasingly as a second-line opioid in the management of cancer pain refractory to conventional opioids. Recent case studies suggest that its use as an analgesic could be extended to non-cancer pain, especially neuropathic pain. The present case study reports, for the first time, the efficacy of methadone in a burn patient experiencing neuropathic pain in his healed wounds. The patient sustained extensive (55% total body surface area) chemical burns and developed chronic burning sensations, particularly in the lower limbs where skin grafting had been performed. Conventional pharmacotherapies against neuropathic pain were attempted to control pain for over 5 years. The agents used included long- and short-acting opioids, amitriptyline, clonazepam, and gabapentin, but they all failed to relieve the pain. When methadone (5 mg every 12 h) was introduced, it significantly alleviated the patient's pain within a few days of administration. The patient has now been taking methadone (15 mg every 12 h) for 10 months and reports that the opioid caused 70% pain relief and a 55% amelioration in his quality of life. Although these results are based on a case report, they suggest that a switch to methadone might be useful in some burn patients who have developed chronic neuropathic pain unrelieved by conventional pharmacotherapies. Methadone, however, needs to be titrated with vigilance and thus should be administered by a physician experienced with its use in the treatment of chronic pain.

Visual analogue thermometer: a valid and useful instrument for measuring pain in burned patients.

This study assessed the psychometric qualities of a new pain rating instrument--the visual analogue thermometer (VAT)--which was developed to measure pain in burned patients. The validity and utility of the VAT was assessed and compared with a conventional numeric (NUM) and adjective pain scale (ADJ) with a group of 103 burned patients and 51 nurses. Analyses of the results support the concurrent and construct validity of the VAT as a pain measure. Furthermore, the VAT gave more sensitive and precise pain measures than the ADJ and/or NUM scales. No major difference between the three scales emerged in the patients' preference. The same was true for the nurses' evaluation except for those who had more clinical experience with the VAT and who tended to prefer this scale for its accuracy and ease of utilization. The VAT appears to be a valid, sensitive and clinically useful tool to measure pain in burned patients. A systematic pain assessment procedure which can be easily implemented in burn care facilities is presented.

Patient-controlled analgesia: a double-blind study in burn patients.

A double-blind controlled study was performed to assess the efficacy and safety of patient-controlled analgesia in burn patients. This method was compared with conventional analgesic therapy consisting of intermittent intravenous morphine injections. Twenty-four adult patients hospitalised for burn injuries participated in the study. The McGill Pain Questionnaire, visual analogue scales and verbal-numeric scales were administered at regular intervals to measure various components of the patients' pain experience, degree of pain relief, anxiety levels, adverse side effects and overall treatment efficacy. Although statistical significance was found in only one measure, the results suggested better pain control in patients who were administered morphine by patient-controlled analgesia as compared with intermittent injections. Analysis of the side effects showed no difference between the groups. The amount of morphine administered over the trial period was also similar for the two groups but considerable interpatient variability was seen. Although further research is needed to determine the conditions for optimal use of patient-controlled analgesia, it is concluded that it is a safe, effective and improved method for controlling pain in selected burn patients.

Severity and impact of pain after day-surgery.

PURPOSE: To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction. METHODS: Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0-10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods. RESULTS: Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain > or = 4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects. CONCLUSION: The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.

An economic evaluation of pain therapy after hysterectomy. Patient-controlled analgesia versus regular intramuscular opioid therapy.

OBJECTIVES: To assess the economics of patient-controlled analgesia (PCA) treatment versus regular intramuscular (i.m.) injections of opioid analgesia for pain management after hysterectomy. METHODS: Cost-minimization analysis was used based on the comparable pain control results achieved in the two treatment groups. Observations were taken of treatment-related events with personnel (mostly nursing) time implications during the trial. Times were then associated with these events in an independent study of personnel activity. Costs were linked by using average wage rates for the various personnel for the Montreal area during the time of the study. Drug and material costs were hospital acquisition costs for all items. The cost of the PCA pump itself was not included in the analysis. Several analyses were performed to test the sensitivity of the results to various assumptions. RESULTS: The results for total costs of the two therapies generally showed PCA to be more costly than regular i.m. injections despite no costs of the pump being included in the analyses. These results were robust with respect to changes in assumptions. Even when intentionally biasing the analysis against i.m. therapy, it was difficult to obtain results that favored PCA. CONCLUSIONS: Based upon the institutions and assumptions in this analysis, PCA offers no cost advantages over regular i.m. therapy in the pain management after hysterectomy. Regular i.m. injections provided less costly analgesia.

Long-term adjustment in burn victims: a matched-control study.

BACKGROUND: To date, there is little information about how severely burned patients compare to unburned healthy individuals in terms of psychological profile and quality of life. As part of a larger study on the sensory consequences of burns, we assessed psychological functioning and quality of life in burned patients and unburned healthy control subjects. We also examined whether burn patients experiencing pain and/or paresthetic sensations (i.e. symptomatic patients) present a profile that is different from those who are asymptomatic. METHODS: Forty-nine burned patients (% total body surface area = 34 59 % +/- 13.40; 82% males/18% females) were evaluated 63 59 +/- 28.1 months post-burn. They were matched with 49 unburned healthy volunteers on age, sex, and education level. All subjects were administered the Symptom Checklist 90-Revised (SCL-90-R) to assess psychological functioning and the 36-item Short-Form Health Survey (SF-36) to assess quality of life. RESULTS: Approximately 25% of the burn patients presented clinically-significant psychological disturbances compared to 12% in the control group. Burn patients enjoyed a quality of life comparable to that of the control subjects, although they perceived some deterioration in their general health. More symptomatic than asymptomatic patients suffered from clinically-relevant somatization and obsessive-compulsive disturbances. CONCLUSIONS: Severely burned patients adjust relatively well, although some develop clinically-significant psychological disturbances such as somatization and phobic anxiety. Burn patients experiencing abnormal sensations in their healed wounds (i.e. symptomatic patients) do not suffer from maladjustment to a greater extent than their asymptomatic counterparts, although more symptomatic patients experience somatization and obsessive-compulsive behaviours.

The pain of burns: characteristics and correlates.

This study examined the characteristics of pain experienced by burned patients. Sources of inter-individual variations were also studied and the interrelationships between anxiety, depression, and pain were investigated. Forty-two adult patients hospitalized for burn injuries participated in the study. The McGill Pain Questionnaire and a visual analogue scale were employed to measure the pain experienced at rest and during therapeutic procedures. Anxiety and depression levels were assessed with the Spielberger State Anxiety Inventory, the Beck Depression Inventory, and visual analogue scales. The results showed that the pain varies greatly from patient to patient and undergoes wide fluctuations over time in each patient. The greatest pain is usually experienced during therapeutic procedures, the patients reporting significantly more pain on these occasions than at rest. Variations in pain severity were not related to socio-demographic characteristics of the patients, the length of time elapsed since the injury, or the quantity of analgesics administered. The extent of the burns was a significant predictor of pain but only in the first week after the injury. High levels of anxiety or depression were not necessarily associated with higher pain scores during therapeutic procedures but the patients who were more anxious or depressed tended to report more pain when at rest. These results are discussed in relation to pain management strategies, with particular emphasis on the need for the analgesic therapy to be highly individualized and frequently adjusted.

Pharmacokinetics of morphine and its glucuronidated metabolites in burn injuries.

OBJECTIVE: To investigate the effects of major thermal burn injury and continuous intravenous morphine infusion on the disposition of morphine and its glucuronidated metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) once a week for three weeks. CASE SUMMARIES: Five patients with major first-, second-, or third-degree burn injuries received long-term intravenous morphine infusion. The required dose varied greatly (from 4 to 39.5 mg/h). The steady-state concentrations of morphine, M3G, and M6G ranged from 20 to 452, 29 to 3436, and 20 to 1240 mumol/L, respectively. The systemic clearance (Cls) of morphine ranged from 14.8 to 40.3 mL/min/kg and did not change over time. The ratios of M6G and M3G to morphine were not affected by dose, even with the wide variation of intravenous dosage. Morphine kinetics appeared to be first-order. Mean recovery of morphine, M3G, and M6G in urine was 1.7 +/- 1.0%, 42.0 +/- 16.8%, and 11.8 +/- 3.2%, respectively, and renal clearance ranged from 8 to 64, 26 to 325, and 59 to 589 mL/min, respectively. Mean pain intensity ratings at rest remained low and stable (0.7 +/- 0.9 on day 7, 0.4 +/- 0.3 on day 14, 0 +/- 0 on day 21). DISCUSSION: To our knowledge, this is the first published report describing morphine, M3G, and M6G disposition in patients with major thermal burn injury. The Cls of morphine is similar to that observed in other patient populations and healthy subjects, suggesting that the presence of major burn injuries or a continuous morphine infusion over a three-week period may not contribute significantly to the variability among individuals. In these cases, the renal clearance of morphine and its glucuronides was within the range of values reported for other populations of patients and healthy subjects. Recovery of morphine and its glucuronides in urine was also similar to that in healthy individuals. CONCLUSIONS: These cases suggest that the effects of major burn injuries and of long-term intravenous infusion of morphine did not seem to modify morphine, M3G, and M6G disposition. Among patients with burn injuries, the severity of burns of duration of administration are not a cause of nonlinear kinetic of morphine or of morphine resistance. The morphine infusion rate was substantially variable and not directly related to its clearance, suggesting that monitoring of morphine should be focused on the clinical response.

Comparison between patient-controlled analgesia and intramuscular meperidine after thoracotomy.

A prospective randomized controlled study was performed to assess the efficacy and safety of patient-controlled analgesia (PCA) in patients undergoing thoracotomy. This method was compared with a conventional pain management technique consisting of regularly scheduled im injections of analgesics. Forty adult patients were randomly assigned to receive intravenous PCA or im meperidine treatment over a 48-hr period after surgery. Care was taken to optimize analgesia in patients of both groups. The McGill Pain Questionnaire, visual analogue and verbal-numeric scales were administered at regular intervals to measure various components of the patients' pain experience, degree of pain relief, adverse side effects and overall treatment efficacy. Functional recovery after surgery was also examined. The results showed good and comparable analgesia with both pain-control methods. However, a greater number of patients receiving im injections required dosage adjustments than in the PCA group. Patients' and nurses' evaluations of overall treatment efficacy also favoured PCA treatment. There were no major group differences in the side effect profile. Recovery pattern was also comparable in the two groups except for the length of hospitalisation. There were fewer long-stay patients in the PCA than in the im group. Meperidine intake was similar in both groups but considerable interpatient variation was seen. In conclusion, PCA is a safe, effective and individualized treatment method for controlling pain after thoracotomy. There appears to be some clinical advantages of PCA over im dosing regimens for analgesia after thoracotomy.

Muscle strength in individuals with healed burns.

OBJECTIVE: To quantify the long-term effects of burns on muscle strength and to investigate the impact of the initial severity of the trauma on muscle strength. DESIGN: Cross-sectional study comparing individuals with healed burns to nonburned control individuals matched for age, gender, body mass index, and physical activity level. SETTING: Subjects were selected from the data bank of a burn center of a large Montreal teaching hospital and tested in a university laboratory. PATIENTS: Thirty subjects (mean age, 36.3 +/- 11.5 yrs) with second- and third-degree burns covering 15% to 75% of total body surface area (TBSA) (mean, 35.5% +/- 15.9%) were evaluated more than 1 year after discharge (mean, 37.3 +/- 20.4 months; range, 15 to 92 months). Thirty unburned subjects were recruited from the community at large. MAIN OUTCOME MEASURE: Maximal torque, work, and power developed by the elbow and knee flexors and extensors. RESULTS: Subjects with burns of > 30% of TBSA produced significantly less torque, work, and power in the quadriceps than control subjects (15.2% to 20.5% depending on velocity [p < .05]). The ability to develop muscle power at the elbow was also compromised in the severely burned subjects (19.2% in extension and 18.7% in flexion [p = .07]) at the faster velocities. No differences were observed between controls and patients with small burn injuries (TBSA of < 30%). CONCLUSION: Patients who had severe burns (TBSA of > 30%) had weaker muscles even years after the trauma, suggesting either an inability to fully recover or insufficient rehabilitation.