Patient Presentations in a Community Pain Clinic after COVID-19 Infection or Vaccination: A Case-Series Approach.

OBJECTIVES: Early case report studies and anecdotes from patients, medical colleagues, and social media suggest that patients may present to chronic pain clinics with a number of complaints post COVID-19 infection or vaccination. The aim of this study is to systematically report on a consecutive series of chronic pain patients seen in a community-based pain clinic, who acquired symptoms after COVID-19 infection or vaccination. METHODS: This retrospective cross-sectional descriptive study identified all patients seen at the clinic over a 4-month period (January-April 2022) with persistent symptoms after COVID-19 infection, vaccination, or both. Information was collected on sex, gender, age, details of vaccination, new pains, or exacerbation of old pain plus the development of novel symptoms. RESULTS: The study identified 21 community dwellers (17 females and 4 males; F/M 4.25/1; age range 22-79 years; mean age 46.3 years), with symptoms attributed to COVID-19 infection or vaccination. Several patients suffered exacerbation of previous pains or developed novel pains, as well as high levels of anxiety and mood disorders. A review of the existing literature provides support for the spectrum of symptoms displayed by the study group. CONCLUSIONS: Information collected in this study will add to the body of COVID-19-related literature and assist particularly community practitioners in recognizing and managing these conditions.

Diagnosis and conservative management of sural neuropathy: a case report.

Nerve entrapments in the lower extremity are rare and can be difficult to diagnose. Here we describe a Canadian Armed Forces veteran with left posterior-lateral calf pain. The patient's condition was previously misdiagnosed as a left-sided mid-substance Achilles tendinosis, which subsequently led to mismanagement, persistent pain and severe functional limitations. After performing a thorough evaluation, we diagnosed the patient with chronic left-sided sural neuropathy secondary to entrapment within the gastrocnemius fascia. The patient's physical symptoms abated completely with chiropractic care, while overall disability improved substantially after taking part in an interdisciplinary pain program. The objectives of this case report are to describe a challenging differential diagnosis of sural neuropathy, and present conservative whole-person management options according to the patient's needs and goals.

La compression des nerfs dans les membres inférieurs est rare et peut être difficile à diagnostiquer. Nous décrivons ici le cas d'un vétéran des Forces armées canadiennes souffrant d'une douleur postéro-latérale gauche au mollet. L'état du patient avait été diagnostiqué à tort comme une tendinite achilléenne moyenne du côté gauche, ce qui a entraîné une mauvaise prise en charge, une douleur persistante et de graves limitations fonctionnelles. Après une évaluation approfondie, nous avons diagnostiqué chez le patient une neuropathie surale chronique du côté gauche, secondaire à une compression du fascia gastrocnémien. Les symptômes physiques du patient ont complètement disparu grâce aux soins chiropratiques, tandis que l'incapacité globale s'est considérablement améliorée après avoir participé à un programme interdisciplinaire de lutte contre la douleur. Les objectifs de ce rapport de cas sont de décrire un diagnostic différentiel difficile de neuropathie surale et de présenter des options de gestion conservatrice de la personne entière en fonction des besoins et des objectifs du patient.

Comparison of Older and Younger Patients Referred to a Non-interventional Community Pain Clinic in the Greater Toronto Area (GTA).

AIM: To compare demographic and pain characteristics of older (≥ 65) vs younger (< 65) chronic non-cancer pain patients referred to a community pain clinic in the Greater Toronto Area (GTA), Ontario, Canada. METHODS: This is a retrospective study of 644 consecutive new patients with pain seen during 2016-2017 (older group n = 126; younger group n = 518). Demographic characteristics, Brief Pain Inventory pain ratings, and diagnosis were obtained using retrospective chart review. Patients were classified into group I (pure biomedical pathology), group II (mixed biomedical causes and psychological factors) and group III (no detectable physical pathology but psychological factors were considered important). RESULTS: Older patients comprised 19.6% of the overall population (higher than the average GTA older population). Regarding older vs younger group, male/female ratio was 1:1.3 vs 1:1.7 respectively, while 71% of the older patients were foreign born vs 37% of the younger group (p < 0.001). Low back was the most prevalent pain site for both groups; 70% of the older patients were classified as group I vs 35% of the younger patients (p < 0.0001), and only 6% as group III (vs 18% of the younger population, p < 0.05). CONCLUSION: The study points to considerable differences between younger and older patients with pain with the latter presenting with significant biomedical pathology but lesser psychopathology. The results are comparable to those obtained from a university pain clinic as well as a rural Northern Ontario clinic. Implications of the study for planning of pain care are discussed.

Evolution of a chronic pain management program in a Northwestern Ontario community: from structural elements to practical application.

BACKGROUND: Chronic pain is a highly prevalent health problem especially in rural regions. There is a dearth of comprehensive pain management programs particularly in rural areas. AIM: The objectives of this paper are to describe the evolution of an interprofessional chronic pain team employing a patient-centered model of care with a biopsychosocial approach, and health services metrics. METHOD: This descriptive case study approach includes an overview of the Chronic Pain Management Program (CPMP) services at St. Joseph Care Group in Thunder Bay, NW Ontario; the process involved in the development of an interprofessional chronic pain team employing a patient-centered model of care with a biopsychosocial approach; and metrics of the program's operations. RESULTS: Established in 1998, CPMP has evolved to become inter-professional, providing consultations and management, with partial funding by the Ontario Ministry of Health and Long term Care that has allowed expansion of services. The CPMP currently provides three distinct program streams as follows: a) Intensive 6-week, four half-days/week, outpatient program that offers an interdisciplinary team approach in groups and individual format; b) PACE-IT (Pain Assessment Collaborative Education Inter-professional Therapy), 8-week long, half-day/ week, interprofessional treatment program, in person; and c) Individual format for one-on-one services for patients not fitting in either the 6-Week or PACE-IT programs. In addition, Additional services provide virtual consultations and didactic videoteleconference sessions on opioid stewardship and pain management to health providers. Health services outcomes, research, and educational opportunities across the Northwestern Ontario Region, challenges and future needs are discussed. CONCLUSION: The CPMP's model of care can serve as a foundation for expert chronic pain care delivery across rural Canada, and as template for similar institutionally-based and publicly funded pain clinics.

Long term outcomes of chronic pain patients attending a publicly funded community-based interdisciplinary pain program in the Greater Toronto area: results of a practice-based audit.

BACKGROUND: Chronic pain management multi/interdisciplinary programs attempt to address all elements of the biopsychosocial model. The primary objective of this retrospective study (based on practice-based audit) was to determine the effectiveness of a patient-centered, comprehensive and intense interdisciplinary pain management program in a publicly funded community-based pain clinic in the Greater Toronto Area. METHOD: This retrospective longitudinal study was conducted on 218 carefully selected sequential chronic pain patients, with 158 completing a 3-4-month interdisciplinary program between January 2016 and December 2018. Data collected upon exit, at 6 months and 12 months post-discharge included demographic information, pain characteristics, emotional/functional status obtained by validated instruments and global impression of change (GIC). Additionally, social health outcomes (return to work or school) were retrieved through retrospective chart review. Means of pre-and post-program variables were compared to assess changes of each patient's "journey". RESULTS: Physical and mental/ emotional health outcomes at exit, 6 months and 12 months post-discharge, showed initial and sustained, statistically and clinically significant improvement from pre-treatment levels, with GIC (much/very much improved) reported as 77%, 58% and 76%, respectively. Additionally, a substantial positive change in social health outcomes was noted particularly in patients on disability (29%), part time workers gaining full time employment (55%), and students (71%) who improved their level of schooling. CONCLUSION: The study showed that careful patient selection in a community-based publicly funded interdisciplinary pain management program can produce significant improvement in pain, physical, mental/emotional health and social function, with sustained long-term outcomes.

Demographics, Pain Characteristics and Diagnostic Classification Profile of Chronic Non-Cancer Pain Patients Attending a Canadian University-Affiliated Community Pain Clinic.

INTRODUCTION: Little information exists regarding the characteristics of patients with chronic non-cancer pain (CNCP) attending Canadian pain clinics. The study describes the demographics, pain characteristics and the diagnostic classification profile of such patients attending a university-affiliated community-based pain clinic in the Greater Toronto Area. METHODS: Retrospective descriptive study based on 644 unique consecutive CNCP patients assessed between January 2016 and December 2017. RESULTS: The female/male ratio was 1.6:1; 80% were younger than 65 years; 43% held some form of employment (full-time, part-time or self employment); median pain duration was 3 years; car accidents and medical conditions accounted for 28 and 27% of pain onset, respectively; 34% had four or more distinct areas of pain; and low back pain (LBP) was the most prevalent site (66%), but was the sole site of pain in less than a third of these patients. Age was positively associated with LBP prevalence. Self-reported health service utilization (visits to the emergency room, pain physician or psychologist) increased with patient psychopathology. Cannabis was used by 15% of the cohort and opioids by 34.5%, with only one in six opioid users exceeding 90 mg of morphine equivalent dose per day. Comparison of our data to three previously published studies from other Canadian pain clinics demonstrated both similarities and substantial differences between the populations. CONCLUSION: Our study highlights regional differences between CNCP population phenotypes. Recognition of biomedical, psychological and socio-environmental factors affecting pain should be considered for patient stratification and rational approaches to treatment, as "one size treatment does not fit all".

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients.

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

From (Ontario Ministry of Health and Long-Term Care) policy to implementation: A retrospective look at a community-based patient-centered model of care for chronic pain.

Background: Chronic pain is one of the most widely recognized, disabling, and expensive health problems in Canada. Interdisciplinary multimodal pain management is effective in helping chronic pain patients lessen symptoms and reclaim functionality, but most patients lack access to such treatments. Aim: The aim of this study was to describe the development and implementation of a publicly funded and patient-centered model of care in the community. Methods: The study was set in the Pain & Wellness Centre (PWC) in Vaughan, the only community-based chronic pain clinic in Ontario funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as a demonstration project of a template for similar future community clinics. The study is descriptive, including a brief review of the Ontario comprehensive pain strategy framework and an overview of the PWC and the process involved in the development of an interdisciplinary pain program (IDP), based on the biopsychosocial model of chronic pain management. Results: During a 2.5-year period, the PWC has offered 1055 new patient medical consultations and 1921 follow-up visits and admitted 242 patients in the IDP program (demonstrating significant success in patient outcomes at the 3-month exit from the program). It established robust outcomes research, organized educational programs for pain trainees, and cultivated a collaborative relationship with the Toronto Academic Pain Medicine (TAPMI) network and the community at large. Conclusions: This demonstration program has shown the feasibility and applicability of the principles of the MOHLTC comprehensive pain strategy, providing an effective, evidence-based, and accountable approach to chronic pain diagnosis and management in the community.

Contexte: La douleur chronique est l'un des problèmes de santé les plus reconnus, invalidants et coûteux au Canada. La prise en charge multimodale interdisciplinaire est efficace pour aider les patients souffrant de douleur chronique à diminuer leurs symptômes et à recouvrer leur fonctionnalité, mais la plupart des patients n'ont pas accès à de tels traitements.But: Le but de cette étude était de décrire l'élaboration et la mise oeuvre d'un modèle communautaire de soins axé sur le patient, financé par des fonds publics.Méthodes: L'étude s'est déroulée au Pain and Wellness Centre à Vaughan, la seule clinique de la douleur chronique communautaire en Ontario. Elle était financée par le MSSLD en tant que projet de démonstration pouvant servir de modèle pour des cliniques communautaires semblables dans l'avenir. L'étude est descriptive et comprend notamment un survol du cadre stratégique global pour la douleur de l'Ontario et un aperçu du Pain & Wellness Centre, de même que du processus menant à l'élaboration d'un programme interdisciplinaire de la douleur fondé sur le modèle bio-psycho-social de la prise en charge de la douleur chronique.Résultats: Au cours d'une période de 2,5 ans, le PWC a offert des consultations médicales à 1055 nouveaux patients et 1921 visites de suivi, en plus d'accueillir 242 patients dans le programme interdisciplinaire de la douleur (tout en démontrant un important succès dans les résultats des patients trois mois après leur sortie du programme). Il a obtenu des résultats de recherche robustes, organisé des programmes de formation pour des stagiaires et cultivé une relation de collaboration avec le réseau du Toronto Academic Pain Medicine, ainsi qu'avec la collectivité dans son ensemble.Conclusions: Ce programme a démontré la faisabilité et l'applicabilité des principes de la stratégie globale du ministère de la Santé et ds Soins de longue durée de l'Ontario en matière de douleur, offrant ainsi une approche communautaire efficace, fondée sur des données probantes, ainsi que sur une approche responsable du diagnostic et de la prise en charge de la douleur chronique.

Efficacy of Low-Dose Oral Liquid Morphine for Elderly Patients with Chronic Non-Cancer Pain: Retrospective Chart Review.

INTRODUCTION: The use of medications among older persons can often be challenging as physiological changes may affect metabolism and cognitive abilities. Several studies show that the elderly with chronic pain are seriously undertreated or inappropriately treated, particularly with respect to opioids. OBJECTIVE: To determine whether very low doses of oral liquid morphine (LM) in patients over 65 years of age with chronic non-cancer pain provides meaningful pain improvement. METHODS: A retrospective chart review was conducted for ten carefully selected older patients seen at a tertiary care pain clinic in Toronto Ontario (2009-2011) with serious biomedical painful conditions and intolerance to other opioid analgesics. Data collected included demographics, LM dosing, diagnosis and average Numeric Rating Scale (NRS) pain ratings pre- and post-administration of LM. RESULTS: Of the ten eligible patients, the female/male ratio was 4:1, mean age 75.5 years and mean pain duration 7.9 years. The initial dose of LM for all patients was 1-3 mg three times/day and the maintenance dose ranged from 5 to 30 mg/day. Overall, pain ratings dropped from 6.35 to 2.95 (3.4 point drop on the NRS score) with a mean follow-up of 14 months (range 10-21). CONCLUSION: The case series showed that carefully selected elderly patients with biomedical pathology can benefit from very low doses of LM. Future larger and well-designed studies need to focus on the use of LM for elderly patients.

Adjudication of fibromyalgia syndrome: challenges in the medicolegal arena.

The medicolegal challenges surrounding fibromyalgia (FM) arise from the subjectivity of symptoms, causal attribution and reported symptoms sufficiently severe to cause disablement. In the present article, the authors have endeavoured to provide clarification of some current issues by referencing the current literature, including the 2012 Canadian Fibromyalgia Guidelines. While FM is accepted as a valid condition, its diagnosis is vulnerable to misuse due to the subjectivity of symptoms. Without a defining cause, a physical or psychological event may be alleged to trigger FM, but adjudication of causation must be prudent. Although some individuals may experience severe symptoms, the prevalent societal concept of disablement due to FM must be tempered with the knowledge that working contributes to psychosocial wellbeing. Evidence provided in the present report may assist the courts in reaching decisions concerning FM.

Evidence-based guideline for neuropathic pain interventional treatments: spinal cord stimulation, intravenous infusions, epidural injections and nerve blocks.

BACKGROUND: The Special Interest Group of the Canadian Pain Society has produced consensus-based guidelines for the pharmacological management of neuropathic pain. The society aimed to generate an additional guideline for other forms of neuropathic pain treatments. OBJECTIVE: To develop evidence-based recommendations for neuropathic pain interventional treatments. METHODS: A task force was created and engaged the Institute of Health Economics in Edmonton, Alberta, to survey the literature pertaining to multiple treatments. Sufficient literature existed on four interventions only: spinal cord stimulation; epidural injections; intravenous infusions; and nerve blocks. A comprehensive search was conducted for systematic reviews, randomized controlled trials and evidence-based clinical practice guidelines; a critical review was generated on each topic. A modified United States Preventive Services Task Force tool was used for quality rating and grading of recommendations. RESULTS: Investigators reviewed four studies of spinal cord stimulation, 19 studies of intravenous infusions, 14 studies of epidural injections and 16 studies of nerve blocks that met the inclusion criteria. The task force chairs rated the quality of evidence and graded the recommendations. Feedback was solicited from the members of the task force. CONCLUSION: There is sufficient evidence to support recommendations for some of these interventions for selected neuropathic pain conditions. This evidence is, at best, moderate and is often limited or conflicting. Pain practitioners are encouraged to explore evidence-based treatment options before considering unproven treatments. Full disclosure of risks and benefits of the available options is necessary for shared decision making and informed consent.

Dissociation between cutaneous and deep sensibility in central post-stroke pain (CPSP).

We present three cases of central post-stroke pain after right hemorrhagic or ischemic stroke associated with severe impairment of cutaneous sensibility but preservation of stimulus-evoked pain from periosteum. This is the first such report of dissociation of cutaneous- from deep-tissue sensibility loss.

Compulsive targeted self-injurious behaviour in humans with neuropathic pain: a counterpart of animal autotomy? Four case reports and literature review.

Four cases of compulsive self-injurious behaviour (SIB) with variable degrees of tissue damage targeted to the painful body part are reported in humans with neuropathic pain. Review of human literature revealed several cases, primarily after central nervous system (CNS) lesions, during which non-psychotic verbally communicating humans (mostly with intact mental status) target specifically the painful part which is usually analgesic or hypoalgesic. In few instances, however, the involved part is not only sentient but also hyperalgesic in part or as a whole. The act is characterized by uncontrollable urge and compulsion, aggravated under conditions of stress, isolation, confusion or depression, and occasionally occurring in patients with personality disorders, ongoing drug abuse and pre-existing compulsive habits (i.e., habitual nail biting or picking). It fails to be deterred by the appearance of the injured part, social mores or even the experience of pain. Successful treatment of underlying painful dysesthesiae with specific medications, neurostimulation or surgery has resulted in marked improvement of dysesthesiae accompanied by wound healing in several cases. The four presented cases and the human literature experience provide evidence that compulsive targeted SIB in humans with neuropathic pain and painful dysesthesiae is consistent with the concept that animal autotomy may result from chronic neuropathic pain after experimental peripheral or CNS lesions.