Identifying competencies for an advanced practice physiotherapy role within an interprofessional chronic pain clinic.

BACKGROUND: Advanced practice physiotherapy (APP) models of care have shown success in access, safety, satisfaction, and care quality for musculoskeletal pain conditions in various settings. Yet, there is a gap in defining competencies for physiotherapists to be the initial point of contact for people with chronic pain. This study aims to identify and agree upon the competencies necessary for a physiotherapist to fulfill the role of an APP in an interprofessional chronic pain clinic. METHODS: Three focus groups were conducted using a Nominal Group Technique and a modified Delphi process. Consensus on the competency, defined as agreement by ≥ 75% of participants, was sought. RESULTS: Twenty-three experts (17 healthcare providers and six individuals with chronic pain) participated in the focus group discussions. Twenty completed the follow-up Delphi surveys. Ten essential competencies for an APP role in interprofessional chronic pain clinics were identified and achieved consensus: 1) use an evidence-based approach to practice; 2) communicate effectively with the patient; 3) perform a comprehensive assessment; 4) determine pain-related diagnoses; 5) develop therapeutic relationships; 6) provide appropriate care; 7) support patients through transitions in care; 8) collaborate with members of the interprofessional team; 9) advocate for the needs of the patients; and 10) use a reflective approach to practice. CONCLUSION: This study identified ten competencies essential for physiotherapists to fulfill an APP role within interprofessional chronic pain clinics. These competencies serve as a foundation for informing a training program and future research evaluating the effectiveness of the APP model in this setting.

Changes in pain following bilateral intermittent theta-burst, transcranial magnetic stimulation for depression: A retrospective chart review.

Introduction: Pain management in patients with chronic pain and comorbid depression is challenging and understudied. There is interest in intermittent theta-burst stimulation (iTBS), a new modality of repetitive transcranial magnetic stimulation (rTMS). This retrospective review describes changes in pain, anxiety and depression throughout iTBS treatment at the dorsolateral prefrontal cortex (DLPFC). Methods: A retrospective chart review was conducted of patients who underwent their first acute series of iTBS treatments at the DLPFC for depression at a single institution between 2020 and 2023. Data on depression, anxiety, and pain were collected throughout iTBS treatment using the Beck Depression Inventory-II (BDI-II; higher scores indicate worse depression) and visual analogue scale (VAS; 0-100, higher scores indicate worse pain, anxiety, and depression). Nonparametric tests were used for all analyses. Results: Of 104 patients, 52 reported moderate pain at baseline (50.0%). Median BDI-II scores decreased from 38.0 (interquartile range [IQR] = 29.0-44.0) to 24.0 (IQR = 9.0-36.0) from pre- to posttreatment (P < 0.001). Of the 32 patients with both pre- and posttreatment pain scores, there was a significant decrease from 40.0 (IQR = 5.5-71.8) to 15.0 (IQR = 3.5-53.8; P = 0.037). In patients with at least moderate pain at baseline, pain scores decreased from 71.0 (IQR = 55.0-80.0) to 20.0 (IQR = 11.0-71.0; P = 0.004). Ten of 32 patients with available pre- and posttreatment scores reported ≥30% reduction in pain scores (31.2%). Conclusion: These preliminary results, suggesting decreases in pain following iTBS treatment, provide a rationale for future rigorous investigations to evaluate this intervention for depression and comorbid chronic pain.

Introduction: La prise en charge de la douleur chez les patients souffrant de douleur chronique et de dépression comorbide est difficile et sous-étudiée. Il existe un intérêt pour la stimulation thêta-burst intermittente (STBi), une nouvelle modalité de stimulation magnétique transcrânienne répétitive (SMTr). Cette revue rétrospective décrit les changements dans la douleur, l'anxiété et la dépression tout au long du traitement par STBi au niveau de la région du cortex préfrontal dorsolatéral.Un examen rétrospectif des dossiers a été mené pour les patients ayant reçu leur première série intensive de traitements par STBi pour la dépression dans la région du cortex préfrontal dorsolatéral dans un seul établissement entre 2020 et 2023. Les données sur la dépression, l'anxiété et la douleur ont été collectées tout au long des traitements par STBi à l'aide de l'Inventaire de dépression de Beck-II (IDB-II; des scores plus élevés indiquent une dépression plus grave) et de l'échelle visuelle analogique (EVA; 0-100, des scores plus élevés indiquent une aggravation de la douleur, de l'anxiété et de la dépression). Des tests non paramétriques ont été utilisés pour toutes les analyses.Résultats: Parmi les 104 patients inclus dans l'étude, 52 ont déclaré une douleur modérée au départ (50,0 %). Les scores médians de l'IDB-II ont diminué de 38,0 (intervalle interquartile [IQR] = 29,0-44,0) à 24,0 (IQR = 9,0-36,0) avant et après le traitement (P < 0,001). Parmi les 32 patients pour lesquels des scores de douleur avant et après le traitement étaient disponibles, une diminution significative a été constatée, passant de 40,0 (IQR = 5,5-71,8) à 15,0 (IQR = 3,5-53,8 ; P = 0,037). Chez les patients hospitalisés avec une douleur au moins modérée au départ, les scores de douleur ont diminué de 71,0 (IQR = 55,0-80,0) à 20,0 (IQR = 11,0-71,0 ; P = 0,004). Dix des 32 patients pour lesquels des scores avant et après le traitement étaient disponibles ont rapporté une réduction ≥30 % des scores de douleur (31,2 %).Conclusion: Ces résultats préliminaires, qui indiquent une diminution de la douleur après le traitement par STBi, offrent une justification pour la réalisation de futures études rigoureuses afin d'évaluer cette intervention pour la dépression et les douleurs chroniques comorbides.

Randomized, double-blind, controlled trial of a combination of alpha-lipoic acid and pregabalin for neuropathic pain: the PAIN-CARE trial.

ABSTRACT: We compared a combination of the nonsedating antioxidant, alpha-lipoic acid (ALA), with the sedating anticonvulsant, pregabalin, vs each monotherapy to treat neuropathic pain due to peripheral neuropathies. In this randomized, double-blind, 3-period crossover trial, participants received oral ALA, pregabalin, and their combination-each for 6 weeks. The primary outcome was mean daily pain intensity at maximal tolerated doses (MTD); secondary outcomes included quality of life (SF-36), sleep (Medical Outcomes Study-Sleep Scale), adverse effects, drug doses, and other measures. Of 55 participants randomized (20-diabetic neuropathy, 19-small fiber neuropathy, and 16-other neuropathies), 46 completed 2 periods, and 44 completed 3. At MTD, the primary outcome of mean pain intensity (0-10) was 5.32 (standard error, SE = 0.18), 3.96 (0.25), 3.25 (0.25), and 3.16 (0.25) at baseline, ALA, pregabalin, and combination, respectively ( P < 0.01 for ALA vs combination and pregabalin). Treatment differences were similar in subgroups with diabetic neuropathy and with other neuropathies. SF-36 total scores (higher number indicates better quality of life) were 66.6 (1.88), 70.1 (1.88), and 69.4 (1.87) with ALA, pregabalin, and combination ( P < 0.05 for ALA vs combination and pregabalin). At MTD, there were no statistically significant treatment differences in adverse effects or drug doses. This trial demonstrates superiority of pregabalin vs ALA but provides no evidence to suggest added benefit of combining ALA with pregabalin to treat neuropathic pain.

Patient Expectations and Therapeutic Alliance Affect Pain Reduction Following Lidocaine Infusion in an Interdisciplinary Chronic Pain Clinic.

Pain experience is affected by both ascending nociceptive signals and descending modulation. Expectations can affect pain experience and augment treatment-induced analgesia through descending inhibitory modulation of pain. This open-label, prospective cohort study examined the association between participant expectation ratings and pain reduction in adult participants with chronic pain receiving an intravenous lidocaine infusion. We aimed to explore whether: 1) participants' expectations of treatment efficacy were associated with pain reduction over 8 weeks after infusion; and 2) participants' therapeutic alliance was associated with expectations and/or pain reduction. We recruited 70 participants with chronic pain scheduled for lidocaine infusion. Study measures included pain intensity (pre-treatment, post-treatment, and daily for 8 weeks), treatment expectations (EXPECT), and therapeutic alliance (Trust in Physician and Working Alliance Inventory-Short Revised). Baseline treatment expectations were significantly correlated with pain reduction (r = .42, P < .01). Therapeutic alliance was significantly correlated with expectations (r = .27, P < .05) and pain reduction (r = .38, P < .01). This study quantifies the contribution of: 1) treatment expectations; and 2) therapeutic alliance to the magnitude of lidocaine-induced pain reduction. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes. PERSPECTIVE: This study evaluates the relationship between pain reduction and ratings of: 1) treatment expectations; and 2) therapeutic alliance following an intravenous lidocaine infusion. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes.

Assessing the feasibility of a clinical trial to evaluate an advanced practice physiotherapy model of care in chronic pain management: a feasibility study.

BACKGROUND: Chronic pain management is challenging for health systems worldwide. Clinical practice guidelines recommend interprofessional chronic pain management, but chronic pain clinics often have lengthy wait-lists. Advanced practice physiotherapists (APP) in orthopedic clinics and emergency departments have provided effective care and reduced wait times. The purpose of this study is to determine the feasibility of a clinical trial to evaluate the effects of integrating an APP into a chronic pain clinic setting. The primary objectives are as follows: (1) determine the feasibility of implementing trial methods by evaluating participant recruitment rates, retention, and assessment completion; (2) determine the feasibility of implementing the APP model of care by monitoring care provided and treatment fidelity; and (3) assess contextual factors that may influence implementation of the APP model of care by exploring the perspectives of patient participants and healthcare providers related to the model of care. METHODS: This will be a single-arm feasibility study with embedded qualitative interviews to assess contextual factors influencing implementation by exploring participant and provider perspectives. Approximately 40 adults with chronic musculoskeletal pain referred for care at an interprofessional chronic pain clinic will be invited to participate in the feasibility study. Approximately 10-12 patient participants and 5-10 health professionals from the interprofessional team will be interviewed using an interpretive description approach. The APP model of care will involve participants seeing a physiotherapist as the first point of contact within the interprofessional team. The APP will complete an initial assessment and make care recommendations. Outcome measures planned for the full trial will be reported descriptively, including pain severity, pain interference, health-related quality of life, psychosocial risk factors for chronic pain, treatment satisfaction, perceived change, healthcare utilization, and healthcare costs over one year. DISCUSSION: This study will inform plans to implement a full-scale study to evaluate the impact of an APP model of care in an interprofessional chronic pain management program. The results of the full study are intended to inform stakeholders considering this model to improve patient-centered and health system outcomes in interprofessional pain management program settings. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05336903 (Registered April 5, 2022).

Transition to Virtual Care Services during COVID-19 at Canadian Pain Clinics: Survey and Future Recommendations.

Introduction: Due to the COVID-19 pandemic, healthcare centers quickly adapted services into virtual formats. Pain clinics in Canada play a vital role in helping people living with pain, and these clinics remained essential services for patients throughout the pandemic. This study aimed to (1) describe and compare the transition from in-person to virtual pain care services at Canadian pain clinics during the onset of the COVID-19 pandemic and (2) provide postpandemic recommendations for pain care services to optimize the quality of patient care. Materials and Methods: We used a qualitative participatory action study design that included a cross-sectional survey for data collection and descriptive analysis to summarize the findings. Survey responses were collected between January and March of 2021. The survey was administered to the leadership teams of 11 adult pain clinics affiliated with the Chronic Pain Centre of Excellence for Canadian Veterans. Responses were analyzed qualitatively to describe the transition to the virtual pain services at pain clinics. Results: We achieved a 100% response rate from participating clinics. The results focus on describing the transition to the virtual care, current treatment and services, the quality of care, program sustainability, barriers to maintaining virtual services, and future considerations. Conclusions: Participating clinics were capable of transitioning pain care services to the virtual formats and have in-person care when needed with proper safety precautions. The pandemic demonstrated that it is feasible and sustainable for pain clinics to have a hybrid of virtual and in-person care to treat those living with pain. It is recommended that moving forward, there should be a hybrid of both virtual and in-person care for pain clinics. Ministries of Health should continue to develop policies and funding mechanisms that support innovations aimed at holistic healthcare, interdisciplinary teams, and the expansion of clinics' geographical reach for patient access.

Examining the roles of depression, pain catastrophizing, and self-efficacy in quality of life changes following chronic pain treatment.

Background: Adults with chronic pain have a lower quality of life (QOL) compared to the general population. Chronic pain requires specialized treatment to address the multitude of factors that contribute to an individual's pain experience, and effectively managing pain requires a biopsychosocial approach to improve patients' QOL. Aim: This study examined adults with chronic pain after a year of specialized treatment to determine the role of cognitive markers (i.e., pain catastrophizing, depression, pain self-efficacy) in predicting changes in QOL. Methods: Patients in an interdisciplinary chronic pain clinic (N = 197) completed measures of pain catastrophizing, depression, pain self-efficacy, and QOL at baseline and 1 year later. Correlations and a moderated mediation were completed to understand the relationships between the variables. Results: Higher baseline pain catastrophizing was significantly associated with increased mental QOL (b = 0.39, 95% confidence interval [CI] 0.141; 0.648) and decreased depression (b = -0.18, 95% CI -0.306; -0.052) over a year. Furthermore, the relationship between baseline pain catastrophizing and the change in depression was moderated by the change in pain self-efficacy (b = -0.10, 95% CI -0.145; -0.043) over a year. Patients with high baseline pain catastrophizing reported decreased depression after a year of treatment, which was associated with greater QOL improvements but only in patients with unchanged or improved pain self-efficacy. Conclusions: Our findings highlight the roles of cognitive and affective factors and their impact on QOL in adults with chronic pain. Understanding the psychological factors that predict increased mental QOL is clinically useful, because medical teams can optimize these positive changes in QOL through psychosocial interventions aimed at improving patients' pain self-efficacy.

Contexte: Les adultes souffrant de douleur chronique ont une qualité de vie inférieure à celle de la population en général. La douleur chronique nécessite un traitement spécialisé pour répondre à la multitude de facteurs qui contribuent à l'expérience de la douleur d'un individu. De plus, la prise en charge efficace de la douleur nécessite une approche biopsychosociale pour améliorer la qualité de vie des patients.Objectif: Cette étude a examiné des adultes souffrant de douleur chronique après un an de traitement spécialisé pour déterminer le rôle des marqueurs cognitifs (c.-à-d. la catastrophisation de la douleur, la dépression, l'efficacité personnelle face à la douleur) dans la prévision des changements dans la qualité de vie.Méthodes: Les patients d'une clinique interdisciplinaire de la douleur chronique (N = 197) ont effectué des mesures de la catastrophisation de la douleur, de la dépression, du sentiment d'efficacité personnelle face à la douleur, ainsi que de la qualité de vie au départ et un an plus tard. Des corrélations et une médiation modérée ont été effectuées pour comprendre les relations entre les variables.Résultats: Une plus grande catastrophisation de la douleur au départ était significativement associée à une augmentation de la qualité de vie mentale (b = 0,39, intervalle de confiance à 95 % [IC] 0,141; 0,648) et à une diminution de la dépression (b = -0,18, IC à 95 % −0,306; −0,052) sur une année. En outre, la relation entre la catastrophisation de la douleur au départ et les changements en matière de dépression a été modérée par le changement dans le sentiment d'efficacité personnelle face à la douleur (b = − 0,10, IC à 95 % − 0,145; − 0,043) sur une année. Les patients démontrant une catastrophisation de la douleur élevée ont signalé une diminution de la dépression après un an de traitement, associée à de plus grandes améliorations dans la qualité de vie mais seulement chez les patients présentant un sentiment d'efficacité personnelle face à la douleur inchangée ou améliorée.Conclusions: Nos résultats mettent en évidence le rôle des facteurs cognitifs et affectifs et leur effet sur la qualité de vie chez les adultes souffrant de douleur chronique. Il est cliniquement utile de comprendre les facteurs psychologiques qui prédisent une augmentation la qualité de vie mentale, car les équipes médicales peuvent optimiser ces changements positifs dans la qualité de vie par des interventions psychosociales visant à améliorer le sentiment d'efficacité personnelle des patients face à la douleur.

Melatonin for Neuropathic Pain: Protocol for a Double-blind, Randomized Controlled Trial.

BACKGROUND: Neuropathic pain (NP), a complication of several conditions (eg, diabetic neuropathy and varicella zoster), is a common challenging problem, and there is a growing need to develop safe and effective nonopioid treatments. Sleep disturbance is commonly associated with NP because pain intensity in NP conditions is often worse at night. The pineal hormone melatonin has been shown to reduce pain in both preclinical and clinical settings, in addition to multiple trials demonstrating efficacy for primary insomnia and delayed sleep phase syndrome. OBJECTIVE: We propose to conduct a clinical trial to evaluate the efficacy and safety of melatonin for NP. METHODS: Using a double-blind, placebo-controlled, crossover design, 30 adults with NP will be randomly allocated to one of two sequences of treatment with melatonin and placebo. During each of the two treatment periods, participants will take capsules containing melatonin or placebo for 4 weeks, followed by a 7-day washout period. The primary outcome will be mean daily pain intensity (scored 0-10) at maximally tolerated doses (MTDs) during each period. Secondary outcomes, assessed at MTDs, will include global improvement, adverse events, mood, and quality of life. RESULTS: This trial was registered in the International Standard Randomized Controlled Trial registry May 4, 2022 (ISRCTN #16215617), attained conditional ethics approval May 9, 2022 (Queen's University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board protocol number ANAE-387-22), and recruitment is set to start August 2022. CONCLUSIONS: This trial will provide rigorous evidence comparing the efficacy of melatonin to that of placebo in the treatment of NP. TRIAL REGISTRATION: ISRCTN Registry 16215617; https://www.isrctn.com/ISRCTN16215617. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/40025.

Pain-Related Fear in Adults Living With Chronic Pain: Development and Psychometric Validation of a Brief Form of the Tampa Scale of Kinesiophobia.

OBJECTIVE: To develop and validate a brief version of the Tampa Scale of Kinesiophobia (TSK) while preserving content validity in a mixed chronic pain population. DESIGN: Cross-sectional study. SETTING: Tertiary care interdisciplinary chronic pain clinic. PARTICIPANTS: Adults with chronic pain (N=933; mean age, 53.5±15.7 years; 63% women). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: TSK-11 measured at intake. Self-reported data from a patient registry were extracted from November 2017 to October 2019. RESULTS: An exploratory factor analysis identified a 2-factor structure from the TSK-11 and item reduction resulted in a 7-item TSK (TSK-7) with 61.2% explained variance and Cronbach's alphas of 0.76 and 0.70 for each of the 2 factors. To maximally reduce the number of items without affecting internal consistency, a 5-item TSK (TSK-5) with 72% explained variance was also explored. Strong correlations were found between the newly developed brief TSK versions and TSK-11 (r>0.93), suggesting good concurrent validity. TSK-11, TSK-7, and TSK-5 had similar convergent validity with moderate correlations for pain catastrophizing (r=0.57, 0.58, 0.54), depression (r=0.45, 0.46, 0.42), pain interference (r=0.43, 0.44, 0.40), and pain acceptance (r=-0.57, -0.59, -0.55). CONCLUSIONS: These 2 brief versions of the TSK may help to simplify questionnaires across chronic pain centers where multiple outcome measures are used for a complete biopsychosocial assessment of patients.

Spinal cord injury in mice affects central and peripheral pathology in a severity-dependent manner.

ABSTRACT: Chronic pain is a common medical complication experienced by those living with spinal cord injury (SCI) and leads to worsened quality of life. The pathophysiology of SCI pain is poorly understood, hampering the development of safe and efficacious therapeutics. We therefore sought to develop a clinically relevant model of SCI with a strong pain phenotype and characterize the central and peripheral pathology after injury. A contusion (50 kdyn) injury, with and without sustained compression (60 seconds) of the spinal cord, was performed on female C57BL/6J mice. Mice with compression of the spinal cord exhibited significantly greater heat and mechanical hypersensitivity starting at 7 days postinjury, concomitant with reduced locomotor function, compared with those without compression. Immunohistochemical analysis of spinal cord tissue revealed significantly less myelin sparing and increased macrophage activation in mice with compression compared with those without. As measured by flow cytometry, immune cell infiltration and activation were significantly greater in the spinal cord (phagocytic myeloid cells and microglia) and dorsal root ganglia (Ly6C+ monocytes) after compression injury. We also decided to investigate the gastrointestinal microbiome, as it has been shown to be altered in patients with SCI and has recently been shown to play a role in immune system maturation and pain. We found increased dysbiosis of the gastrointestinal microbiome in an injury severity-dependent manner. The use of this contusion-compression model of SCI may help advance the preclinical assessment of acute and chronic SCI pain and lead to a better understanding of mechanisms contributing to this pain.

High Prevalence of Falls Independent of Age in Adults Living With Chronic Pain.

OBJECTIVES: High risks of falls have been reported in older adults with chronic pain but chronic pain similarly affects adults of all ages. This cross-sectional study aimed to determine the prevalence of falls and associated risk factors in adults of all ages living with chronic pain. MATERIALS AND METHODS: Patient-reported data were analyzed from 591 adults with chronic pain enrolled in a local pain clinic between November 2017 and April 2019. Sociodemographic, history of falls, and biopsychosocial measures of pain were examined to identify and describe adults with chronic pain who fell in the previous year. Factors associated with falls were examined using logistic regression. RESULTS: A total of 268 (45%) reported at least 1 fall in the previous year (fallers) where 194 (33%) fell in the previous 3 months, and 185 (31%) had multiple falls. The prevalence of falls in the previous year was over 37% across age groups. Overall, fallers were older, had greater pain severity and interference, lower physical function and pain self-efficacy, greater depression, more reported neuropathic pain, and had more pain sites compared with nonfallers. Number of pain sites reported (odds ratio=1.12; 95% confidence interval, 1.02-1.22) and lower physical function (odds ratio=0.96; 95% confidence interval, 0.94-0.99) were independently associated with falls. DISCUSSION: A high prevalence of falls was found independent of age for adults with chronic pain. Although the risk of falls may increase with age, lower physical function and more pain sites are better indicators for falls. A better understanding of circumstances and consequences of falls in all adults with chronic pain is warranted.

A Tale of 2 Tubes for Emergency Management of Airway Obstruction From an Anterior Mediastinal Mass: A Case Report.

Anterior mediastinal masses are challenging. As induction of general anesthesia may result in complete airway obstruction or hemodynamic collapse, maintaining spontaneous ventilation and advancing the endotracheal tube (ETT) distal to the mass are recommended. We discuss the emergency management of an anterior mediastinal mass-induced near-complete airway obstruction at the carina. Despite maintaining spontaneous ventilation, airway obstruction persisted following placement of the ETT proximal to the obstruction. After advancing the ETT into the right mainstem bronchus distal to the mass, hypoxemia persisted, prompting placement of a second ETT into the left mainstem bronchus to overcome the obstruction and provide adequate oxygenation.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process.

Until recently, the belief that adequate pain management was not achievable while patients remained on buprenorphine was the impetus for the perioperative discontinuation of buprenorphine. We aimed to use an expert consensus Delphi-based survey technique to 1) specify the need for perioperative guidelines in this context and 2) offer a set of recommendations for the perioperative management of these patients. The major recommendation of this practice advisory is to continue buprenorphine therapy in the perioperative period. It is rarely appropriate to reduce the buprenorphine dose irrespective of indication or formulation. If analgesia is inadequate after optimisation of adjunct analgesic therapies, we recommend initiating a full mu agonist while continuing buprenorphine at some dose. The panel believes that before operation, physicians must distinguish between buprenorphine use for chronic pain (weaning/conversion from long-term high-dose opioids) and opioid use disorder (OUD) as the primary indication for buprenorphine therapy. Patients should ideally be discharged on buprenorphine, although not necessarily at their preoperative dose. Depending on analgesic requirements, they may be discharged on a full mu agonist. Overall, long-term buprenorphine treatment retention and harm reduction must be considered during the perioperative period when OUD is a primary diagnosis. The authors recognise that inter-patient variability will require some individualisation of clinical practice advisories. Clinical practice advisories are largely based on lower classes of evidence (level 4, level 5). Further research is required in order to implement meaningful changes in practitioner behaviour for this patient group.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): protocol of a practice advisory for the perioperative management of buprenorphine using a modified Delphi process.

INTRODUCTION: The ongoing opioid epidemic has necessitated increasing prescriptions of buprenorphine, which is an evidence-based treatment for opioid use disorder, and also shown to reduce harms associated with unsafe opioid administration. A systematic review of perioperative management strategies for patients taking buprenorphine concluded that there was little guidance for managing buprenorphine perioperatively. The aim of this project is to develop consensus guidelines on the optimal perioperative management strategies for this group of patients. In this paper, we present the design for a modified Delphi technique that will be used to gain consensus among patients and multidisciplinary experts in addiction, pain, community and perioperative medicine. METHODS AND ANALYSIS: A national panel of experts identified by perioperative, pain and/or addiction systematic review authorship established an international profile in perioperative, pain and/or addiction research, community clinical excellence and by peer referral. A steering group will develop the first round with a list of indications to be rated by the panel of national experts, patients and allied healthcare professionals. In round 1, the expert panel will rate the appropriateness of each individual item and provide additional suggestions for revisions, additions or deletions. The definition of consensus will be set a priori. Consensus will be gauged for both appropriateness and inappropriateness of treatment strategies. Where an agreement is not reached and items are suggested for addition/deletion/modification, round 2 will take place over teleconference in order to obtain consensus. ETHICS AND DISSEMINATION: Institutional research ethics board provided a waiver for this modified Delphi protocol. We plan on developing a national guideline for the management of patients taking buprenorphine in the perioperative period that will be generalisable across three sets of preoperative diagnoses including opioid use disorder and/or co-occurring pain disorders. The findings will be published in peer-reviewed publications and conference presentations.

The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes.

BACKGROUND: An increasing number of patients with opioid use disorder (OUD) are treated with opioid agonist-antagonists such as buprenorphine/naloxone. Perioperative management of patients on buprenorphine/naloxone is inconsistent and remains a controversial topic with mismanagement posing a significant risk to the long-term health of these patients. METHODS: We performed a systematic literature search involving Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst), and PubMed (NLM). RESULTS: Eighteen studies were included in the final sample, including one controlled study and four observational studies . Neither the controlled study nor the observational studies assessed addiction treatment retention, harm reduction, or long-term mortality rates as primary or secondary outcomes. Of the observational studies, authors showed equivalent peri- and postoperative pain control among buprenorphine continued patients. All but one authors described adequate analgesia among the case reports in which buprenorphine ≤ 16 mg sublingually (SL) daily was continued during the perioperative period. Long-term harm reduction was not reported with only three case reports including any long-term abstinence or relapse rates. CONCLUSIONS: The current understanding of the risks and benefits of continuing or stopping buprenorphine perioperatively is limited by a lack of high-quality evidence. Observational studies and case reports indicate no evidence against continuing buprenorphine perioperatively, especially when the dose is < 16 mg SL daily. In patients with significant potential for relapse, such as those with a recent history of OUD, the discontinuation of buprenorphine should have a strong rationale supported by patient and surgical preferences. Future studies require standardized reporting of median doses, details on the route of delivery, dosing schedules and any dosing changes, and rates of addiction relapse, including long-term morbidity and mortality where possible.

RéSUMé: CONTEXTE: Un nombre croissant de patients présentant un trouble d'utilisation des opioïdes (TUO) sont traités avec des agonistes/antagonistes des opioïdes, tels que la buprénorphine et la naloxone. La gestion périopératoire des patients sous buprénorphine/naloxone n'est pas constante et reste un sujet de controverses; de plus une mauvaise gestion pose un risque significatif pour la santé à long terme de ces patients. MéTHODES: Nous avons effectué une recherche systématique de la littérature dans les bases de données suivantes : Medline, Medline In-Process, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science (Clarivate), Scopus (Elsevier), CINAHL (EbscoHosst) et PubMed (NLM). RéSULTATS: Dix-huit études ont été incluses dans l'échantillon final, y compris une étude contrôlée et quatre études observationnelles. Ni l'étude contrôlée ni les études observationnelles n'ont évalué la continuation du traitement de l'addiction, la réduction des préjudices infligés ou les taux de mortalité à long terme parmi les critères d'évaluation principaux ou secondaires. Dans les études observationnelles, les auteurs ont montré qu'il y avait un contrôle équivalent de la douleur en péri- et postopératoire chez les patients continuant à recevoir de la buprénorphine. Tous les auteurs sauf un ont décrit une analgésie satisfaisante dans les rapports de cas où la buprénorphine sublinguale avec une dose ≤ 16 mg par jour était maintenue pendant la période périopératoire. La réduction des préjudices à long terme n'était pas décrite; seulement trois rapports de cas indiquaient le taux d'abstinence à long terme ou les taux de rechute. CONCLUSIONS: Les connaissances actuelles des risques et avantages de la poursuite ou de l'arrêt de la buprénorphine en période périopératoire sont limitées par le manque de données probantes de grande qualité. Les études observationnelles et les rapports de cas ne fournissent pas de données probantes à l'encontre de la poursuite de la buprénorphine dans la période périopératoire, en particulier quand la dose journalière par voie sublinguale est < 16 mg. Chez les patients présentant un risque significatif de rechute, comme ceux ayant des antécédents récents de TUO, l'arrêt de la buprénorphine devrait être solidement justifié avec le soutien des préférences des patients et des équipes chirurgicales. Les futures études nécessitent une normalisation du rapport des doses médianes, des détails sur les voies d'administration, de la posologie et de sa modification et des taux de rechute, en incluant aussi, chaque fois que possible, les taux de morbidité et mortalité à long terme.

Pain Improvement With Novel Combination Analgesic Regimens (PAIN-CARE): Randomized Controlled Trial Protocol.

BACKGROUND: Neuropathic pain (NP) (including painful diabetic neuropathy, postherpetic neuralgia, etc) affects approximately 7% to 8% of the population and is associated with a devastating symptom burden as well as a profound economic impact for patients, their families, and the health care system. Current therapies have limited efficacy and dose-limiting adverse effects (AEs). Rational combination therapy with carefully selected NP drugs has shown potential for measurable improvements in pain relief, quality of life, and health care use. Today, over half of NP patients concurrently receive 2 or more analgesics but combination use is based on little evidence. Research is urgently needed to identify safer, more effective combinations. OBJECTIVE: We hypothesize that analgesic combinations containing at least 1 nonsedating agent would be as safe but more effective than either monotherapy without increasing overall AEs because of additive pain relief. Pregabalin (PGB), a sedating anticonvulsant, is proven effective for NP; the antioxidant alpha-lipoic acid (ALA) is one of the only nonsedating systemic agents proven effective for NP. Thus, we will conduct a clinical trial to compare a PGB+ALA combination to each monotherapy for NP. METHODS: Using a double-blind, double-dummy, crossover design, 54 adults with NP will be randomly allocated to 1 of 6 sequences of treatment with PGB, ALA and PGB+ALA combination. During each of 3 different treatment periods, participants will take 2 sets of capsules containing (1) ALA or placebo and (2) PGB or placebo for 31 days, followed by an 11-day taper/washout period. The primary outcome will be mean daily pain intensity (0-10) at maximally tolerated dose (MTD) during each period. Secondary outcomes, assessed at MTD, will include global improvement, adverse events, mood, and quality of life. RESULTS: Participant recruitment is expected to begin September 1, 2017. The proposed trial was awarded external peer-reviewed funding by the Canadian Institutes of Health Research (Canada) on July 15, 2016. CONCLUSIONS: This trial will provide rigorous evidence comparing the efficacy of a PGB+ALA combination to PGB alone and ALA alone in the treatment of NP. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number ISRCTN14577546; http://www.isrctn.com/ISRCTN14577546?q=&filters=conditionCategory:Signs%20and%20Symptoms,trialStatus: Ongoing,recruitmentCountry:Canada&sort=&offset=1&totalResults=2&page=1&pageSize=10&searchType=basic-search (Archived by WebCite at http://www.webcitation.org/6qvHFDc6m).

The effect of triple vs. double nonopioid therapy on postoperative pain and functional outcome after abdominal hysterectomy: a randomised double-blind control trial.

BACKGROUND: Movement-evoked pain is more severe than pain at rest and is likely to interfere more with functional recovery after surgery. OBJECTIVE: To compare triple vs. double nonopioid perioperative analgesic regimens in women undergoing abdominal hysterectomy. DESIGN: A randomised, parallel design, double-blind controlled trial. SETTING: A single-centre trial. Study period from November 2009 to July 2013. PATIENTS: Adults (>18 years) of American Society of Anesthesiologists' status 1 to 2 scheduled for abdominal hysterectomy. INTERVENTIONS: Patients were randomised to one of four study treatment groups: acetaminophen, meloxicam and gabapentin (AMG); acetaminophen and meloxicam; acetaminophen and gabapentin; and meloxicam and gabapentin. In addition to intravenous patient-controlled opioid analgesia, study treatments were administered for 48 h, starting 1 h preoperatively. MAIN OUTCOME MEASURES: The primary outcome was cough-evoked pain. Secondary outcomes included pain at rest, during sitting and peak expiration, opioid consumption, side effects, peak expiratory flow rate, timed up and go test (TUG), and modified Brief Pain Inventory (mBPI). RESULTS: Interim analysis indicated a minimal chance of demonstrating superiority of the triple regimen group over all three double regimen groups if the trial were to be recruited to planned sample size. Thus, the trial was prematurely terminated for futility. All four analgesic regimens were well tolerated. Exploratory analyses revealed consistent significant negative correlations between pain and TUG and between pain and interference with activity, walking and sleep. CONCLUSION: This trial failed to demonstrate substantial benefits with the addition of a third nonopioid analgesic to three different double-drug regimens. Further research is needed that will more definitively support expanding multimodal analgesic practices. Our results demonstrate consistent correlations between evoked pain and functional outcomes further emphasising the need for improved analgesic regimens that will accelerate postsurgical functional recovery. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register 12723675.

Body image, eating disorders, and the drive for muscularity in gay and heterosexual men: the influence of media images.

This Internet research project examined the relationship between consumption of muscle and fitness magazines and/or various indices of pornography and body satisfaction in gay and heterosexual men. Participants (N = 101) were asked to complete body satisfaction questionnaires that addressed maladaptive eating attitudes, the drive for muscularity, and social physique anxiety. Participants also completed scales measuring self-esteem, depression, and socially desirable responding. Finally, respondents were asked about their consumption of muscle and fitness magazines and pornography. Results indicated that viewing and purchasing of muscle and fitness magazines correlated positively with levels of body dissatisfaction for both gay and heterosexual men. Pornography exposure was positively correlated with social physique anxiety for gay men. The limitations of this study and directions for future research are outlined.

The bispectral index does not correlate with clinical signs of inhalational anesthesia during sevoflurane induction and arousal in children.

PURPOSE: Validation of the bispectral index (BIS) in children requires correlating BIS with several levels of sedation, hypnosis and anesthesia. Our purpose was to compare BIS values with objective assessments of the level of hypnosis in children. We postulated that BIS predicted the level of anesthesia during induction and emergence in children. METHODS: In a prospective observational study, we evaluated the BIS monitor in 87 children (ages: 0.3 to 14 yr) ASA physical status I-II undergoing general surgery under sevoflurane and nitrous oxide. Clinical signs of inhalational anesthesia (CSA), the motor response to surgical incision and signs of arousal were used as indicators of the depth of anesthesia. CSA and BIS measurements were paired every minute during induction and emergence until arousal. RESULTS: CSA scores decreased during induction and increased during emergence (P < 0.001) and correlated with changes in sevoflurane concentrations (r = -0.46; P < 0.001). BIS was associated with changes in CSA scores during induction (r = 0.49; P < 0.01) and emergence (r = 0.62; P < 0.01), but the ranges of individual BIS values overlapped several levels of hypnosis. A BIS value greater than 50 had a positive predictive value of 25% for distinguishing between responders and non-responders to surgical incision. A BIS score equal or greater than 72 had a predictive value of 63% for discriminating between pre-arousal and arousal. CONCLUSIONS: BIS correlates with several levels of hypnosis during inhalational induction and emergence in children, but individual BIS values show large inter-individual variability. The BIS monitor identified the physiological changes associated with arousal and distinguished the effects of preoperative sedation during emergence. The use of movement as an endpoint of hypnosis during surgical stimulation does not correlate with BIS values in children. The large inter-individual variability of BIS at different levels of anesthetic depth may limit the applicability of BIS to pediatric anesthesia.