Hypnosis for cancer care: over 200 years young.

Answer questions and earn CME/CNE Hypnosis has been used to provide psychological and physical comfort to individuals diagnosed with cancer for nearly 200 years. The goals of this review are: 1) to describe hypnosis and its components and to dispel misconceptions; 2) to provide an overview of hypnosis as a cancer prevention and control technique (covering its use in weight management, smoking cessation, as an adjunct to diagnostic and treatment procedures, survivorship, and metastatic disease); and 3) to discuss future research directions. Overall, the literature supports the benefits of hypnosis for improving quality of life during the course of cancer and its treatment. However, a great deal more work needs to be done to explore the use of hypnosis in survivorship, to understand the mediators and moderators of hypnosis interventions, and to develop effective dissemination strategies.

Determinants for Meaningful Clinical Improvement of Pain and Health-Related Quality of Life After Spinal Cord Stimulation for Chronic Intractable Pain.

OBJECTIVES: Previous studies demonstrated significant improvement in mean pain scores and quality of life (QOL) scales in patients with chronic pain who underwent spinal cord stimulation (SCS). However, the number of individuals who experience relevant improvements in QOL, termed the meaningful clinical improvement (MCI), is not known. The present study investigated changes in pain measurements based on MCI after SCS. MATERIALS AND METHODS: Thirty-four patients with chronic intractable pain completed scales of pain (visual analogue scale [VAS]), QOL (SF-36), and psychological dimensions during a 22-month follow-up period (mean). Patient-centered MCI of the VAS and SF-36 domain scores were determined based on the MacNab criteria of surgical global effectiveness. Independent presurgical predictors for MCI in the VAS and SF-36 domains were analyzed using multiple binary logistic regression. RESULTS: There was significant improvement of pain and QOL after the SCS (p < 0.00001). Twenty-three patients (67.6%) reached an MCI of pain, and 16 (47.7%)-23 (67.7%) reported an MCI of QOL. Predictors of MCI included ≥80% paresthesia coverage of the painful area, lower levels of anxiety and catastrophizing symptoms, shorter pain duration, female gender and no use of opioids before surgery. MCI of pain and QOL was observed in 50%-70% of patients with chronic pain after SCS. CONCLUSIONS: The identification of determinants for MCI is a challenge to improve the accuracy of prognostic models in SCS for patients with chronic pain. Our results, if confirmed in other populations with a larger sample size, have implications for patients with chronic pain who are candidates for SCS treatment.

Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication?

STUDY OBJECTIVE: We assess the efficacy of a simple pain titration protocol of 1-mg increments of intravenous hydromorphone, given at fixed intervals, driven solely by patient response to a yes/no question. METHODS: This was a prospective interventional cohort study of nonelderly adults with acute severe pain defined as requiring intravenous opioids in the judgment of the attending emergency physician. All patients received 1 mg intravenous hydromorphone and 30 minutes later were asked, "Do you want more pain medication?" Patients responding yes received an additional 1 mg of intravenous hydromorphone and were asked the same question 30 minutes after receiving it. Those responding no did not receive additional opioid and were asked the question again 30 minutes later. Each patient was queried 4 times. The primary endpoint was the proportion of patients achieving satisfactory pain control, defined as declining additional pain medication on 1 or more occasions. RESULTS: Of 215 patients enrolled, there were 8 protocol violations, leaving 207 patients with analyzable data; 205 of 207 patients (99%; 95% confidence interval 97% to 100%) achieved satisfactory analgesia at 1 or more points during the study. Nine patients desaturated below 95% on room air, 2 had respiratory rates less than 10 breaths/min, and 2 had pulse rates less than 50 beats/min. No adverse events were associated with amount of hydromorphone received. CONCLUSION: A pain protocol, based on titration of 1 mg intravenous hydromorphone, driven solely by patient response to a simple standardized question repeated at intervals, resulted in achievement of satisfactory analgesia on at least 1 occasion in 99% of patients.

French laypeople's and health professionals' views on the acceptability of terminal sedation.

AIM: To study the views on the acceptability of terminal sedation (TS) of laypeople and health professionals in France. METHOD: In November 2013-June 2015, 223 laypeople and 53 health professionals (21 physicians and 32) judged the acceptability of TS in 48 realistic scenarios composed of all combinations of four factors: (a) the patients' life expectancy, (b) their request for sedation, (c) the decision-making process and (d) the type of sedation. In all scenarios, the patients were women with a terminal illness suffering from intractable pain and receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance. RESULTS: Five qualitatively different positions were found that were termed TS acceptable if decision taken collectively (15%), TS acceptable if patient explicitly requested it (19%), TS acceptable if patient did not explicitly oppose it (47%), 24-hour sedation not acceptable (6%) and TS always acceptable (13%). The percentage of older participants in the 'always acceptable' cluster was higher than the percentage of younger participants. CONCLUSIONS: Laypeople and health professionals do not appear to be systematically opposed to TS. The most important factors in increasing its acceptability were the patients' request for sedation and the collective character of the decision-making process.

History and present state of targeted intrathecal drug delivery.

Nearly 50 years ago, the seminal experiments of Melzack and Wall, culminating in the gate control theory, coupled with the discovery of endogenous opioid receptors, helped shape modern understandings of pain and provided interventionalists a potent therapeutic gateway to neuraxial analgesia. This paper emphasizes the historical antecedents, present state, and emerging future of the neuromodulatory technique of targeted intrathecal drug delivery (TIDD) for chronic pain. The strengths of TIDD are its customizability, reversibility, programmability, and low risk profile. Its benefits are evidenced by improved pain relief and quality of life and reduced demand for health-care resources.

A Systematic Review of the Association Between Psychiatric Disturbances and Endometriosis.

OBJECTIVE: An association between endometriosis and psychiatric disturbances has been identified by some researchers. The purpose of this systematic review was to consolidate existing empirical findings to clarify the association between endometriosis and psychiatric conditions. DATA SOURCES: We searched three electronic databases (Medline/PubMed, PsychInfo, and ClinicalTrials.gov) using the following search items: "endometriosis" combined with "mood," "bipolar disorder," "major depressive disorder," "anxiety," "psychiatric," "psychosocial," "antidepressants," "antianxiety," "pharmacotherapy," or "psychotherapy." STUDY SELECTION: We included all relevant articles published in English. We identified 18 original research studies examining the association between endometriosis and psychiatric symptoms, with a combined total of 999 endometriosis patients being examined. DATA EXTRACTION AND SYNTHESIS: Of the 18 studies examined, 14 reported that endometriosis was associated with at least some aspect of reduced psychological functioning or mental health quality of life. Tabulation of raw frequencies of the studies using clinical diagnostic criteria and a comparison group revealed that at least 56.4% of women (44/78) with a diagnosis of endometriosis and 43.6% of women (48/110) without such a diagnosis met the criteria for a psychiatric disorder. CONCLUSION: The limited research suggests that women presenting with endometriosis are at risk for psychosocial disturbances or psychiatric distress. Whether such disruptions are a consequence of endometriosis, the associated chronic gynaecological pain, or another factor such as inflammation remains to be delineated. In the interim, women presenting with symptoms of endometriosis should also be screened for psychosocial and psychiatric disturbances.

Objectif : Une association entre l'endométriose et des perturbations psychiatriques a été identifiée par certains chercheurs. Cette analyse systématique avait pour but de consolider les constatations empiriques existantes en vue de clarifier l'association entre l'endométriose et des troubles psychiatriques. Sources de données : Nous avons mené des recherches dans trois bases de données électroniques (Medline/PubMed, PsychInfo et ClinicalTrials.gov) au moyen des termes suivants : « endometriosis ¼ en combinaison avec « mood ¼, « bipolar disorder ¼, « major depressive disorder ¼, « anxiety ¼, « psychiatric ¼, « psychosocial ¼, « antidepressants ¼, « antianxiety ¼, « pharmacotherapy ¼ ou « psychotherapy ¼. Sélection des études : Nous avons inclus tous les articles pertinents publiés en anglais. Nous avons identifié 18 études originales s'étant penchées sur l'association entre l'endométriose et des symptômes psychiatriques (pour un total combiné de 999 cas d'endométriose soumis à une analyse). Extraction et synthèse des données : Parmi les 18 études examinées, 14 ont signalé que l'endométriose était au moins d'une certaine façon associée à une atténuation du fonctionnement psychologique ou de la qualité de vie liée à la santé mentale. La tabulation des fréquences brutes de ces études au moyen de critères diagnostiques cliniques et d'un groupe de comparaison a révélé qu'au moins 56,4 % des femmes (44/78) ayant obtenu un diagnostic d'endométriose et 43,6 % des femmes (48/110) n'ayant pas obtenu un tel diagnostic satisfaisaient aux critères permettant d'établir la présence d'un trouble psychiatrique. Conclusion : Les recherches limitées semblent indiquer que les femmes qui présentent une endométriose sont exposées à des risques de perturbations psychosociales ou de détresse psychiatrique. La question de savoir si de telles perturbations sont une conséquence de l'endométriose, de la douleur gynécologique chronique connexe ou d'autres facteurs tels que l'inflammation demeure à élucider. Entre-temps, les femmes qui présentent des symptômes d'endométriose devraient également faire l'objet d'un dépistage visant des perturbations psychosociales et psychiatriques.

Provoked Vestibulodynia and the Health Care Implications of Comorbid Pain Conditions.

OBJECTIVE: Sexual pain secondary to provoked vestibulodynia (PVD) is a chronic pain condition affecting up to 16% of women. Women with PVD may report other chronic pain conditions. The goals of this study were (1) to identify the prevalence of self-reported chronic pain conditions in a sample of women with a diagnosis of PVD and seeking treatment, and (2) to compare demographic and clinical characteristics and health care needs of women with PVD alone and women with PVD and two or more self-reported chronic pain conditions. METHODS: We assessed the characteristics of 236 women with PVD alone and 55 women with PVD and comorbid chronic pain using a standardized questionnaire, the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Pain Vigilance and Awareness Questionnaire, and the Female Sexual Distress Scale. RESULTS: Compared with women with PVD alone, women with PVD and other concurrent pain reported a significantly longer duration of pain, pain radiating to other parts of the vulva, and pain interfering in a variety of daily activities. This group was also significantly more likely to have seen more gynaecologists, and to have had more office visits with their gynaecologist than women with PVD alone. They were more likely to have tried anticonvulsants, antidepressants, and stress/relaxation therapy for their PVD and were also more likely to have allergies and skin sensitivities. Finally, this group of women had higher symptoms of depression, trait anxiety, and showed a trend towards more pain vigilance. CONCLUSION: Taken together, these findings suggest that physicians caring for women with PVD and concurrent chronic pain must be alert to the potentially greater health needs among this subsample of women.

Objectif : La douleur sexuelle attribuable à la vestibulodynie provoquée (VDP) est un trouble de douleur chronique qui affecte jusqu'à 16 % des femmes. Les femmes qui présentent une VDP pourraient en venir à signaler d'autres troubles de douleur chronique. Cette étude avait pour objectif (1) d'identifier la prévalence des troubles de douleur chronique auto-signalés au sein d'un échantillon de femmes ayant obtenu un diagnostic de VDP et cherchant à obtenir un traitement; et (2) de comparer les caractéristiques démographiques et cliniques et les besoins en soins de santé des femmes qui ne présentent qu'une VDP et des femmes qui présentent une VDP et au moins deux troubles de douleur chronique auto-signalés. Méthodes : Nous avons évalué les caractéristiques de 236 femmes ne présentant qu'une VDP et de 55 femmes présentant une VDP et une douleur chronique comorbide au moyen d'un questionnaire standardisé, de l'Inventaire de dépression de Beck, du State-Trait Anxiety Inventory, du Pain Vigilance and Awareness Questionnaire et de la Female Sexual Distress Scale. Résultats : Par comparaison avec les femmes qui ne présentaient qu'une VDP, les femmes qui présentaient celle-ci et une autre douleur concomitante ont signalé une douleur d'une durée significativement prolongée, une douleur irradiant vers d'autres parties de la vulve et une douleur nuisant à diverses activités de la vie quotidienne. Les femmes de ce groupe étaient également significativement plus susceptibles que les femmes ne présentant qu'une VDP d'avoir consulté un plus grand nombre de gynécologues et de s'être rendues un plus grand nombre de fois au cabinet de leur gynécologue. Elles étaient plus susceptibles d'avoir fait l'essai d'anticonvulsivants, d'antidépresseurs et d'une thérapie anti-stress / de relaxation pour contrer leur VDP, et également plus susceptibles de connaître des allergies et des sensibilités cutanées. Enfin, les femmes de ce groupe présentaient des symptômes accrus de dépression, une anxiété réactionnelle et une tendance envers une vigilance accrue en ce qui concerne la douleur. Conclusion : Considérées dans leur ensemble, ces constatations semblent indiquer que les médecins qui offrent des soins à des femmes qui présentent une VDP et une douleur chronique concomitante doivent être sensibles aux besoins de santé potentiellement accrus au sein de ce sous-groupe de femmes.

[Are artificial disorders common in palliative care? A Case report]. / Sind artifizielle Störungen im palliativen Kontext häufig? Ein Fallbericht.

The main task of palliative care specialists is to focus on symptom control such as pain, nausea or fatigue. Thorough anamnesis, physical examination, laboratory examination, and differential diagnosis can ensure appropriate treatment. In an increasing number of cases psychiatric conditions like depression or anxiety increase also occur so palliative care physicians need to be more prepared to handle them. The question of this case report is, how a palliative care specialist can distinguish between a malignant disease or neurological disease progression and a presentation primarily psychiatric in etiology, as is the case in factitious disorders. We are also interested in the incidence rate of such factitious disorders. Our case study demonstrates that it is rare but not impossible that a doctor will encounter factitious symptoms in the palliative setting. This suggest being aware of evidence of psychiatric origins even in discharge letters and referrals that indicate palliative care needs, to ensure that palliative care really is the best treatment option for the patient. We do believe such cases to be rare in a palliative setting, however.

Neuromodulation, agency and autonomy.

Neuromodulation consists in altering brain activity to restore mental and physical functions in individuals with neuropsychiatric disorders and brain and spinal cord injuries. This can be achieved by delivering electrical stimulation that excites or inhibits neural tissue, by using electrical signals in the brain to move computer cursors or robotic arms, or by displaying brain activity to subjects who regulate that activity by their own responses to it. As enabling prostheses, deep-brain stimulation and brain-computer interfaces (BCIs) are forms of extended embodiment that become integrated into the individual's conception of himself as an autonomous agent. In BCIs and neurofeedback, the success or failure of the techniques depends on the interaction between the learner and the trainer. The restoration of agency and autonomy through neuromodulation thus involves neurophysiological, psychological and social factors.

French Swiss physicians' attitude toward palliative sedation: Influence of prognosis and type of suffering.

OBJECTIVE: Palliative sedation is a last resort medical act aimed at relieving intolerable suffering induced by intractable symptoms in patients at the end-of-life. This act is generally accepted as being medically indicated under certain circumstances. A controversy remains in the literature as to its ethical validity. There is a certain vagueness in the literature regarding the legitimacy of palliative sedation in cases of non-physical refractory symptoms, especially "existential suffering." This pilot study aims to measure the influence of two independent variables (short/long prognosis and physical/existential suffering) on the physicians' attitudes toward palliative sedation (dependent variable). METHODS: We used a 2 × 2 experimental design as described by Blondeau et al. Four clinical vignettes were developed (vignette 1: short prognosis/existential suffering; vignette 2: long prognosis/existential suffering; vignette 3: short prognosis/physical suffering; vignette 4: long prognosis/physical suffering). Each vignette presented a terminally ill patient with a summary description of his physical and psychological condition, medication, and family situation. The respondents' attitude towards sedation was assessed with a six-point Likert scale. A total of 240 vignettes were sent to selected Swiss physicians. RESULTS: 74 vignettes were completed (36%). The means scores for attitudes were 2.62 ± 2.06 (v1), 1.88 ± 1.54 (v2), 4.54 ± 1.67 (v3), and 4.75 ± 1.71 (v4). General linear model analyses indicated that only the type of suffering had a significant impact on the attitude towards sedation (F = 33.92, df = 1, p = 0.000). Significance of the results: The French Swiss physicians' attitude toward palliative sedation is more favorable in case of physical suffering than in existential suffering. These results are in line with those found in the study of Blondeau et al. with Canadian physicians and will be discussed in light of the arguments given by physicians to explain their decisions.

Calciphylaxis and Intractable Pain in a Veteran with Psychological Trauma History.

Guidelines are lacking for patients with calciphylaxis on renal replacement therapy, often leading to difficulty optimally treating these patients. A 60-year-old male veteran receiving hemodialysis presented with calciphylaxis of the left lower extremity and intractable pain. His condition was complicated by chronic back pain, long-term opioid therapy, and psychological trauma history. He was ultimately transferred to a calciphylaxis treatment center but was unable to tolerate further treatments due to sepsis and hemodynamic instability. He was transitioned to comfort measures and died in the hospital. Addressing complicated pain physiologies and complex trauma is challenging even in well-resourced tertiary medical centers. Despite the availability of calciphylaxis therapies and trauma-informed care, there remains a high rate of suffering and mortality in this patient population. There is much work to be done in this cohort, particularly when considering the implications of past traumatic experiences on health care engagement and pain management.

Prospective evaluation of pain control and quality of life in patients with chronic pancreatitis following bilateral thoracoscopic splanchnicectomy.

BACKGROUND: Abdominal pain in chronic pancreatitis (CP) is the most common symptom with a highly unfavorable impact on the quality of life. It has been shown that bilateral thoracoscopic splanchnicectomy (BTS) may produce marked pain relief for the majority of patients. The aim of this study was to evaluate the effectiveness of BTS in pain control and quality-of-life improvement in patients with a severe form of CP. METHODS: Between April 2000 and April 2009, a total of 30 patients qualified for BTS due to CP-related pain. Their age ranged from 28 to 60 years. A 12-month follow-up period was planned for all the patients enrolled. To evaluate effectiveness of BTS, an 11-point Numeric Rating Scale (NRS) and the Quality of Life Questionnaire C-30 (QLQ-C30) in its basic form, developed by European Organization for Research and Treatment of Cancer, were used. An NRS value between 0 and 3 was considered a positive postoperative pain control result. RESULTS: The bilateral splanchnicectomy procedure was performed successfully in 27 of 30 qualified patients. A positive effect based on decreased pain (p < 0.05) at 12 months was achieved in 24 patients (80 %). The initial change in quality of life was not significant but it gradually improved with time (preop vs. 12 months QLQ-C30 score, p < 0.001). CONCLUSIONS: This study showed that BTS is safe and efficacious for pain alleviation in patients with severe CP. It may significantly increase the chances of a long-lasting, life-changing improvement in the quality of life.

[Fibromyalgia syndrome. General principles and coordination of clinical care and patient education]. / Das Fibromyalgiesyndrom. Allgemeine Behandlungsgrundsätze, Versorgungskoordination und Patientenschulung.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: A diagnosis of FMS should be explicitly communicated with the afflicted individual. A step-wise treatment, depending on the severity of FMS and the responses to therapeutic measures, is recommended. Therapy should only be continued if the positive effects outweigh the side effects. The English full-text version of this article is available at SpringerLink (under "Supplemental").

[Inpatient pain consultation service at a university hospital: a retrospective analysis of patient characteristics and the rate of the implementation of recommendations]. / Stationäre Schmerzkonsile einer universitären Schmerzambulanz : Eine retrospektive Analyse der Patientencharakteristika und der Umsetzungsrate der Empfehlungen.

BACKGROUND: The aim of this study was to conduct an audit of a university inpatient pain consultation service and to examine the quality and the implementation of the recommended therapeutic measures. Factors that influenced the implementation should be identified. PATIENTS AND METHODS: All inpatients treated by the consultation service in the years 2009 and 2010 were analyzed retrospectively. Demographic patient characteristics as well as quality parameters of the consultation service and pharmacological and non-pharmacological recommendations and their implementation were analyzed. RESULTS: In total 1,048 requests for the consultation service were processed of which 39.7% of the requests were for patients with acute pain, 33.8% with chronic and 19.9% with tumor-associated pain. Measures recommended most were medication, physiotherapy and psychological treatment. Recommended medications were actually prescribed in more than 80%, physiotherapy recommended in about 75% and psychological treatment recommended in 47% of the cases. Only a few influencing factors for the implementation of the recommended measures could be identified. CONCLUSION: Many different pain states are seen in an inpatient pain consultation service. The recommendations given are implemented in most cases especially concerning the medication.

Effects of TrkA inhibitory peptide on cancer-induced pain in a mouse melanoma model.

PURPOSE: Tropomyosin receptor kinase (Trk) A, a high-affinity receptor of nerve growth factor, is a therapeutic target for both noxious and neuropathic pain. The present study examined the effects of an inhibitory peptide of Trk activity (IPTRK) 3 that inhibits TrkA activity on cancer-induced pain in a mouse melanoma model. METHODS: The hind paws of mice were inoculated with B16-F1 mouse melanoma cells on day 0. We administered IPTRK3 (20 mg/kg i.p.) repetitively on days 5, 6, 7, 8, and 9, and evaluated pain-related behaviors on days 0, 5, 10, 15, and 20 after tumor inoculation. RESULTS: Following inoculation, mice demonstrated mechanical allodynia and thermal hyperalgesia with an increased number of flinches, and paw volume increased gradually. However, an intraperitoneal injection of IPTRK3 significantly inhibited mechanical allodynia on day 15 and suppressed the number of flinches on day 20. The increased paw volume was significantly suppressed on day 20 after tumor inoculation. IPTRK3, however, showed no significant effect on thermal hyperalgesia. CONCLUSIONS: These results suggest that TrkA inhibitory peptide likely suppress melanoma-induced pain with concomitant reduction in the increased paw volume in a mouse skin cancer pain model.

Decision-making processes for the self-management of persistent pain: a grounded theory study.

Persistent pain negatively impacts upon the individual suffering this condition. Almost all care related to persistent pain is self-managed. Decision-making is a critical skill of the self-manager and without these skills it would be improbable that effective self-management would emerge. However, current theories regarding decision-making and self-management have not adequately accounted for the many difficulties faced by individuals enduring persistent pain and the consequences of these experiences for the decision-maker. This grounded theory study revealed that individuals will transform into three distinct types of decision-makers using three different styles of decision-making in response to the many and varied problems related to the experience of persistent pain. These findings will provide nurses with valuable information to better equip individuals with persistent pain through the decision-making processes necessary for successful self-management.

A new approach to the treatment of non-specific male genital pain.

OBJECTIVES: • To review the literature and the generally accepted unsatisfactory management of chronic genital pain in men. • To refer such patients for Journey psychotherapy and record the outcomes of such treatment. PATIENTS AND METHODS: • We describe an alternative psychotherapeutic approach in the treatment of such men, whereby deep-seated emotions are considered an underlying cause in the expression of chronic genital pain. • Eleven men with refractory chronic genital pain were counselled, and given one Journey process, lasting 2-3 h. • They were followed up for up to 4 years in some cases, and their outcomes recorded. • No further treatment was undertaken in this time. RESULTS: • Of the 11 cases, four had significant pain relief, four had partial relief of their symptoms, and three did not (or may have had some relief but were lost to follow-up). CONCLUSION: • Chronic genital pain syndromes are common and often debilitating. Patients are subject to an array of investigations that usually identify non-specific abnormalities at best. Treatment is usually aimed at symptomatic control as underlying organic pathology is rarely identified. Patients have been given multiple courses of antibiotics even in the absence of identifiable organisms, anti-inflammatory drugs in the absence of proven inflammation, and narcotic analgesics in an attempt to control chronic pain. Occasionally surgery, such as orchidectomy, has been performed to remove the painful organ, without satisfactory results. We therefore looked for an alternative approach that had the promise of a more satisfactory outcome. • Given the usual psychotherapeutic requirement of lengthy periods of therapy, and given that each patient only had one session, we find the above results remarkable and very encouraging. • With this experience, we now offer this approach early to avoid wasting time and money, and would persist with further therapy sessions especially in those with partial relief of their pain.

Persistent shoulder pain in the first 6 months after stroke: results of a prospective cohort study.

OBJECTIVE: To identify factors associated with persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke. DESIGN: Prospective inception cohort study. SETTING: Stroke units of 2 teaching hospitals. PARTICIPANTS: Patients (N=31) with a clinical diagnosis of stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The development of pPSSP within the first 6 months after stroke. Clinical assessment of motor, somatosensory, cognitive, emotional, and autonomic functions, undertaken within 2 weeks (t0), at 3 months (t1), and at 6 months (t2) after stroke. RESULTS: Patients with pPSSP (n=9) were compared with patients without pPSSP (n=22). Bivariate logistic regression analyses showed that pPSSP was significantly associated with impaired voluntary motor control (t0, t1, t2), diminished proprioception (t0, t1), tactile extinction (t0), abnormal sensation (t1, t2), spasticity of the elbow flexor muscles (t1, t2), restricted range of motion (ROM) for both shoulder abduction (t2) and shoulder external rotation (t1, t2), trophic changes (t1), and type 2 diabetes mellitus (t0). CONCLUSIONS: These findings suggest a multifactorial etiology of pPSSP. The association of pPSSP with restricted, passive, pain-free ROM and signs indicative of somatosensory sensitization may implicate a vicious cycle of repetitive (micro)trauma that can establish itself rapidly after stroke. Intervention should therefore be focused on maintaining and restoring joint ROM as well as preventing injury and somatosensory sensitization. In this perspective, strategies that aim to intervene simultaneously at various levels of function can be expected to be more effective than treatment directed at merely 1 level.

Refractory suffering: the impact of team dynamics on the interdisciplinary palliative care team.

OBJECTIVE: This qualitative study aimed to describe the skill sets that experienced palliative care clinicians possess when managing refractory suffering. METHOD: Thirteen tape recorded semi-structured interviews and four online questionnaires were completed by participants with at least two years clinical palliative care experience. The research team undertook cross sectional thematic analysis of the transcribed interviews. RESULTS: In the face of refractory suffering, team cohesion was identified as a key requirement to support the interdisciplinary team. However, team cohesion was found to be undermined by philosophical differences between team members, a paradigm shift concerning cure versus care and individual opinions regarding the chosen approach and levels of respect between the individual disciplines involved in the care of a person with a life limiting illness. SIGNIFICANCE OF RESULTS: The findings of this study highlight the precarious nature of the interdisciplinary team when significant challenges are faced. As a result of witnessing refractory suffering the division and fracturing of teams can easily occur; often team members are completely unaware of its cause. The findings of this study contribute to the limited literature on the nature of refractory suffering from the perspective of the interdisciplinary team.

[Pharmacological treatment of chronic pain]. / Medikamentöse Schmerztherapie.

The pharmacological treatment of chronic pain differs from acute pain management. In chronic non-cancer pain patients pharmacological treatment is only one element of an interdisciplinary approach. Not pain reduction only but gain in physical and social functioning is mandatory for continuation of therapy. The developpement of a strategy is the most important and difficult step toward an individual and sustained pharmacological pain treatment. Simple practical guidelines can help to find an individual therapeutic straight. Outcome parameters have to be determined. Check-ups for discontinuation of the therapy have to be done periodically. Exact documentation of effect and side effects prevents ungrateful and potential dangerous treatments. The WHO ladder remains the cornerstone of pharmacological pain treatment. Further analgesics as antidepressants and anticonvulsants are important in treatment of neuropathic or mixed pain states. Special considerations have to be done in opioid treatment of non-cancer pain regarding the lack of evidence in long term outcome and possible side effects and risks.