Protocol for a mixed-method cohort study investigating the prevalence and impact of obsessive-compulsive disorder (OCD) in chronic pain rehabilitation.

INTRODUCTION: While there is considerable and growing research in the individual fields of obsessive-compulsive disorder (OCD) and chronic pain, focused research into their potential association remains limited. By exploring this potential association, better theoretical understanding of and better therapeutic approaches to chronic pain management could be developed. The study's aim is to explore the prevalence and impact of obsessions-compulsions on the experience and rehabilitation of chronic pain among individuals attending different branches of a New Zealand pain service. METHODS AND ANALYSIS: This is a cohort study using well-validated questionnaires and semistructured interviews. Participants will be recruited through community pain services from a private rehabilitation-focused company with branches across New Zealand. Participants will complete an OCD screening measure (Obsessive-Compulsive Inventory-Revised (OCI-R)). These results will be used to compare results from the specialist pain services benchmarking electronic Persistent Pain Outcomes Collaboration measure sets, at both participant intake and completion of each Pain Service Programme. Prevalence rates of OCD caseness from the OCI-R will be estimated with 95% CI. Generalised linear regression models will be used to explore differences in pain baseline and outcome factors between those with high and low obsessive-compulsive symptoms. Semistructured interviews, assessed through interpretative phenomenological analysis (IPA), will be used to provide information on lived experiences of individuals with comorbid chronic pain and OCD. This will be supported through the administration of an Obsessive Beliefs Questionnaire 44. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Health and Disability Ethics Committee (HDEC20/CEN/82). Study results will be disseminated at professional conferences and in peer-reviewed journals. A lay summary of findings will be provided to requesting participants or through attendance at a local hui (gathering). TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12621000758808).

Clinical and cost-effectiveness of an online-delivered group-based pain management programme in improving pain-related disability for people with persistent pain-protocol for a non-inferiority randomised controlled trial (iSelf-help trial).

INTRODUCTION: Persistent non-cancer pain affects one in five adults and is more common in Maori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability. METHODS AND ANALYSIS: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA). ETHICS AND DISSEMINATION: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent. TRIAL REGISTRATION NUMBER: ACTRN 12619000771156.

Physical Therapy Approaches in the Treatment of Low Back Pain.

Globally, in 2016, low back pain (LBP) contributed 57.6 million of total years lived with disability. Low Back Pain Guidelines regularly recommend the use of physical exercise for non-specific LBP. Early non-pharmacological treatment is endorsed. This includes education and self-management, and the recommencement of normal activities and exercise, with the addition of psychological programs in those whose symptoms persist. The aim of physical treatments is to improve function and prevent disability from getting worse. There is no evidence available to show that one type of exercise is superior to another, and participation can be in a group or in an individual exercise program. Active strategies such as exercise are related to decreased disability. Passive methods (rest, medications) are associated with worsening disability, and are not recommended. The Danish, United States of America, and the United Kingdom Guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies. These include tai chi, yoga, massage, and spinal manipulation. Public health programs should educate the public on the prevention of low back pain. In chronic low back pain, the physical therapy exercise approach remains a first-line treatment, and should routinely be used.

A proposed clinical conceptual model for the physiotherapy management of Complex Regional Pain Syndrome (CRPS).

There are no validated clinical models to show a reliable pathway of guaranteeing an effective recovery for Complex Regional Pain Syndrome (CRPS) with physiotherapy management. An array of medical, psychological and physiotherapy intervention methods show weak benefit. Spearman correlations, with significance p < 0.05, from an observational, prospective, longitudinal, multi-centre study of regional standard physiotherapy CRPS management showed complete recovery to be potentially associated with baseline factors of: better mental health; better functional ability and quality of life; higher scores of extraversion personality trait; lower scores of intraversion personality trait; and interventions such as concurrent prescription of the anticonvulsant secondary analgesia group and a higher intensity of physiotherapy education intervention. These correlations were integrated with the literature evidence and the crux of previously suggested models to conceptualise a clinical model that can contribute to the broader knowledge of physiotherapy management in CRPS that should be tested with future research.

Systematic Review of Pain Medicine Content, Teaching, and Assessment in Medical School Curricula Internationally.

INTRODUCTION: Pain management is a major health care challenge in terms of the significant prevalence of pain and the negative consequences of poor management. Consequently, there have been international calls to improve pain medicine education for medical students. This systematic review examines the literature on pain medicine education at medical schools internationally, with a particular interest in studies that make reference to: a defined pain medicine curriculum, specific pain medicine learning objectives, dedicated pain education modules, core pain topics, medical specialties that teach pain medicine, elective study opportunities, hours allocated to teaching pain medicine during the curriculum, the status of pain medicine in the curriculum (compulsory or optional), as well as teaching, learning, and assessment methods. METHODS: A systematic review was undertaken of relevant studies on pain medicine education for medical students published between January 1987 and May 2018 using PubMed, Medline, Excerpta Medica database (EMBASE), Education Resources Information Center (ERIC), and Google Scholar, and Best Evidence Medical Education (BEME) data bases. RESULTS: Fourteen studies met the inclusion criteria. Evaluation of pain medicine curricula has been undertaken at 383 medical schools in Australia, New Zealand, the United States of America (USA), Canada, the United Kingdom (UK), and Europe. Pain medicine was mostly incorporated into medical courses such as anaesthesia or pharmacology, rather than presented as a dedicated pain medicine module. Ninety-six percent of medical schools in the UK and USA, and nearly 80% of medical schools in Europe had no compulsory dedicated teaching in pain medicine. On average, the median number of hours of pain content in the entire curriculum was 20 in Canada (2009), 20 in Australia and New Zealand (2018), 13 in the UK (2011), 12 in Europe (2012/2013), and 11 in the USA (2009). Neurophysiology and pharmacology pain topics were given priority by medical schools in all countries. Lectures, seminars, and case-based instruction were the teaching methods most commonly employed. When it was undertaken, medical schools mostly assessed student competency in pain medicine using written examinations rather than clinical assessments. CONCLUSIONS: This systematic review has revealed that pain medicine education at medical schools internationally does not adequately respond to societal needs in terms of the prevalence and public health impact of inadequately managed pain.

A Review of the Opioid Epidemic: What Do We Do About It?

The opioid epidemic, with its noticeable increase in opioid prescriptions and related misuse, abuse and resultant deaths in the previous 12 years, is a particularly North American phenomenon. Europe, and particularly low- and middle-income countries, appear to be less influenced by this problem. There is undisputable value in using opioids not only in the treatment of acute pain, but in cancer pain as well. However, opioids are progressively being prescribed more and more for chronic non-cancer pain, despite inadequate data on their efficacy. In this paper, we describe the current prevalence of opioid misuse in a number of countries and the rationale for the commencement of opioid therapy. The safe initiation and monitoring of opioid therapy as well as the need for concurrent use of interdisciplinary multimodal therapy is discussed. The possible consequences of long-term use and predictors of high opioid use and overdose are presented. In particular, the management of opioid use disorders and the prevention of opioid abuse and dependence in the young, the old and the pregnant are discussed. Measures to prevent overprescribing and to alleviate risk are described, including the tapering of opioids and the use of opioid deterrents. Finally, the paper looks at the future development of pioneering medications and technologies to potentially treat abuse. In those parts of the world with an opioid epidemic, coroners and medical examiners, private and public health agencies, and agencies that enforce the law need to cooperate in an effort to slow down and reverse the indiscriminate use of prescribing opioids in the long-term for chronic non-cancer pain. Ongoing research is needed to create ways to minimise risks of opioid use, and to provide evidence for effective strategies for treating chronic pain.

Deaths from Opioid Overdosing: Implications of Coroners' Inquest Reports 2008-2012 and Annual Rise in Opioid Prescription Rates: A Population-Based Cohort Study.

INTRODUCTION: In the late 1990s multiple physicians and advocacy organizations promoted increased use of opioids for the treatment of acute, chronic and cancer pain. There has been an exponential growth in opioid prescribing in the last 20 years in the United States of America, in Australia, and in other developed Western countries. There are negative consequences associated with the liberal use of opioids. The primary aim of this population-based cohort study is to investigate the opioid-related death rate in New Zealand between 1 January 2008 and 31 December 2012. The secondary aims of this cohort study are: (1) to compare the opioid-related death rate per population in New Zealand in 2001/2002 with that between 2011/2012; (2) to investigate the number of opioid prescriptions in New Zealand between 2001 and 2012; (3) to compare the opioid-related death rate per population in New Zealand between 2001 and 2012 with the number of opioid prescriptions in New Zealand between 2001 and 2012. METHODS: Permission to access records from the Coronial Services Office in Wellington for 2008-2012 was acquired. Permission to access records for prescriptions containing opioids (dose and formulation) was obtained from the Pharmaceutical Collection. RESULTS: The rate of opioid-related deaths in New Zealand has increased by 33% from 2001 to 2012. More than half of the opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses. Opioid analgesic deaths were most likely due to methadone, morphine and codeine prescribed by healthcare professionals. That 179 of these opioid-related deaths between 2008 and 2012 were unintentional opioid overdoses, and thus could have been avoided, is tragic. This study shows that there was a steady annual increases in opioid prescriptions in New Zealand from 2001 to 2012. This rise in opioid analgesic deaths was associated with the increases in the numbers of opioid prescriptions. CONCLUSION: A multifaceted national public health approach is needed to bring together the various stakeholders involved with pain management, opioid dependence, opioid availability and opioid diversion. There needs to be a targeted approach to educate current and future medical practitioners regarding the appropriate use of opioid prescriptions for the management of pain, as well as a strengthening of primary, secondary and tertiary resources to support medical practitioners managing their patients who suffer with pain.

The Cold Pressor Test as a Predictor of Prolonged Postoperative Pain, a Prospective Cohort Study.

INTRODUCTION: Presently, it is difficult to predict which patients are at increased risk of ongoing pain problems postoperatively. This study followed a group of patients from the week before their operation until 3 months after it, to identify potential risk variables. METHODS: Fifty-four patients undergoing moderate-major gynaecological surgery at Christchurch Women's Hospital were recruited and assessed preoperatively over an 11-week period. At this initial assessment, participants were subjected to a cold pressor test (CPT). Telephonic follow-up was conducted at 6 weeks and 3 months postoperatively, to determine pain status. Information regarding the type of operation and surgical approach was collected from hospital records. RESULTS: Pain threshold (time taken to report the onset of pain), as measured by the CPT, was significantly predictive of prolonged pain outcomes (area under the curve = 0.80, 95 % CI 0.66, 0.95). Pain tolerance (total time taken to end the CPT voluntarily) was similarly predictive but non-significant (area under the curve = 0.69, 95 % CI 0.47, 0.90). CONCLUSION: The preoperative cold pressor test shows some promise for predicting ongoing postoperative pain. However, more research is needed to determine the clinical significance of these findings in larger samples and how they could be incorporated into clinical practice.

Perioperative Pain Correlates and Prolonged Postoperative Pain Predictors: Demographic and Psychometric Questionnaires.

INTRODUCTION: Perioperatively, patients are near-guaranteed to experience acute pain by virtue of the surgical tissue insult. The transition of acute pain to pathological chronic pain is a complex and poorly understood process. To study this, the prevalence of pain was examined preoperatively, and at 6 weeks and 3 months postoperatively. METHODS: Fifty-four patients undergoing moderate-major gynaecological surgery at Christchurch Women's Hospital (Christchurch, New Zealand) were recruited over a period of 11 weeks. Follow-up by telephone was conducted at 6 weeks and 3 months following surgery. Demographic information including age, gender, ethnicity, work, and education status were collected, as well as aspects of medical history. Participants were subjected to psychometric questionnaires at each time-point. RESULTS: Of the participants, 15.7% experienced significant pain at 6 weeks postoperatively; 8.2% of participants experienced significant pain at 3 months postoperatively. The psychometric questionnaires used found differences between those experiencing pain and those not experiencing pain at given observation points. Only the Brief Illness Perception Questionnaire (BIPQ) appeared predictive of developing prolonged postoperative pain. The mean difference (7.4 on a 0-50) scale should assist in clinical decision-making regarding analgesia. CONCLUSION: Only the BIPQ was predictive of developing prolonged postoperative pain. While none of the demographic factors observed significantly predicted the development of 'prolonged pain', the not significant data followed expected trends. Several relationships were detected in this study that should further efforts in developing preoperative predictors to promote the secondary prevention of postoperative pain states.

Vitamin D and Pain: Vitamin D and Its Role in the Aetiology and Maintenance of Chronic Pain States and Associated Comorbidities.

The emergence of new data suggests that the benefits of Vitamin D extend beyond healthy bones. This paper looks at Vitamin D and its role in the aetiology and maintenance of chronic pain states and associated comorbidities. The interfaces between pain and Vitamin D and the mechanisms of action of Vitamin D on pain processes are explored. Finally the association between Vitamin D and pain comorbidities such as sleep and depression is investigated. The paper shows that Vitamin D exerts anatomic, hormonal, neurological, and immunological influences on pain manifestation, thereby playing a role in the aetiology and maintenance of chronic pain states and associated comorbidities. More research is necessary to determine whether Vitamin D is useful in the treatment of various pain conditions and whether or not the effect is limited to patients who are deficient in Vitamin D.

Vitamin D Deficiency and Pain: Clinical Evidence of Low Levels of Vitamin D and Supplementation in Chronic Pain States.

INTRODUCTION: A number of studies suggest a link between low levels of 25-hydroxy vitamin D and incidence of acute and chronic pain. Clinical studies of vitamin D supplementation in patients with known vitamin D deficiency have shown mixed results in improving pain scores. METHODS: In this article, vitamin D deficiency risk factors are observed and adequate levels of 25-hydroxy vitamin D defined. Clinical supplementation with vitamin D is explored, including the schedules used in published clinical trials. Evidence of the effectiveness of vitamin D supplementation for the treatment of chronic pain conditions from double-blind randomized controlled trials (RCTs) is examined. RESULTS: The scientific evidence for vitamin D as a treatment option for chronic pain is limited due to lack of RCTs. It cannot be stated conclusively that vitamin D deficiency is directly linked to the etiology or maintenance of chronic pain states. CONCLUSION: There remains a growing body of both clinical and laboratory evidence pointing to a potential relationship between low levels of 25-hydroxy vitamin D and a variety of chronic pain states. More focused research involving large RCTs is necessary.

Potential risk factors for the onset of complex regional pain syndrome type 1: a systematic literature review.

Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.

The faculty of pain medicine of the Australian and New Zealand college of anaesthetists - history and strategic plan.

Since its formation, the Faculty of Pain Medicine (FPM) has grown into an organization with 369 fellows. It has 29 accredited pain medicine training units in Australia, New Zealand, Hong Kong, and Singapore. This article reviews the history of its birth and subsequent growth. The FPM fellowship is widely recognized as a high-quality qualification, based on a sound curriculum, excellent clinical exposure, and robust continuing professional development. But how does the Faculty position itself for the future? The Faculty's 5-year Strategic Plan (from 2013 to 2017) sets out its vision "to reduce the burden of pain in society through education, advocacy, training and research."

The christchurch earthquake: crush injury, neuropathic pain, and posttraumatic stress disorder.

On February 22, 2011, an earthquake of magnitude 6.3 struck Christchurch, New Zealand. The peak ground acceleration, a measure of the shaking or intensity of an earthquake, was one of the highest ever recorded worldwide. One hundred and eighty-five people lost their lives; many others were injured. Two cases both involving young women are presented; they sustained crush injuries to limbs after being trapped by falling debris and went on to develop severe neuropathic pain. This report examines the mechanisms of neuropathic pain in the setting of crush injury, the treatment modalities, and the association between chronic pain and posttraumatic stress disorder. These case reports highlight the fact that crush injury is relatively common during major earthquakes and that neuropathic pain is an important sequel of this. Post-traumatic stress disorder is common in earthquake survivors with a recognised association with chronic pain. Pain-related disability may increase as well. Issues such as chronic pain and physical disability should not be overlooked as attention focuses on disaster management and the treatment of life-threatening injuries.

Skin matters: identifying pain mechanisms and predicting treatment outcomes.

The skin acts as a complex sensory organ. The emerging new data on peripheral pain mechanisms from within the skin is presented. This data has led to new insights into the potential pain mechanisms for various pain conditions including neuropathic pain (from small fiber neuropathies) and Complex Regional Pain Syndrome. The somatosensory neurons that innervate our skin constantly update our brains on the objects and environmental factors that surround us. Cutaneous sensory neurons expressing nociceptive receptors such as transient receptor potential vanilloid 1 channels and voltage-gated sodium channels are critical for pain transmission. Epidermal cells (such as keratinocytes, Langerhans cells, and Merkel cells) express sensor proteins and neuropeptides; these regulate the neuroimmunocutaneous system and participate in nociception and neurogenic inflammation. In the past two decades, there has been widespread use of modalities such as punch skin biopsies, quantitative sensory testing, and laser-evoked potentials to evaluate small caliber nerve fibers. This paper explores these laboratory techniques as well as the phenomenon of small fiber neuropathy. Treatment using transdermal drug delivery is discussed. There is potential for these findings to predict treatment outcomes in clinical practice and to develop new therapies for different pain conditions. These findings should enhance the physician's ability to evaluate and treat diverse types of pain.