FMP2_3

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Pain Week Schedule Saturday, March 22, 2008

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History of Pain Week Saturday, March 22, 2008

History Origin of this Interfaculty Education Initiative More people seek help from health professionals for pain than for any other re ason. W ith pain management strategies, standards and guidelines available now, he alth professionals can re lieve almost all acute and cance r pain and reduce most chronic nonmalignant pain. Effective pain m anagement has the ability to significantly improve patients' health and quality of life .

Ye t, despite the availability and benefits of e ffective pain re lief, patients do not always receive the pain management they ne e d. 1,2 Many patients continue to experience moderate to severe pain, and the consequence s of this unrelieved pain can be long lasting and severe . According to re search: • patie nts with unrelieved acute pain have longer hospital stays and are more likely to experience other health com plications, including pulmonary and cardiovascular dysfunction 3,8,9 • patie nts are being discharged home with considerable interference in their usual activities because of pain 11

• • •

untre ated acute pain may predispose patients to chronic pain 7 pre ve ntion or minimizing acute pain is critical to preventing long -term problems4,6

unde rstanding the multidimensionality of pain and the need for a te am approach is critical to effective m anagement, particularly of chronic pain5 According to the C anadian Pain Society 10, the continuing gap betwe en re search evidence and the pain management provided by health professionals may be due to lack of understanding of the knowle dge and principles that underlie pain m anagement standards. Pain theory is poorly understood. Pain management and the mechanisms that can re lieve pain are e x tremely complex. In the course of their e ducation, m any health professionals rece ive little or no instruction about the im pact of pain or how to e ffectively assess and m anage it. Unless they have chosen to specialize in pain treatment, he alth professionals are generally unaware of the subjective nature of pain, the long-term consequences of unre lieved pain, or the range of approaches available to tre at pain. They m ay lack the skills required to assess and diagnose pain.

The y m ay not understand that m any patients experience both acute pain and chronic pain, or that principles guiding the assessment and management of malignant and non -malignant pain are very similar. They may also be unaware of significant new information emerging about the similarities and differences betwe en nociceptive and neuropathic pain.

Providing Leadership in Pain Relief

The University of Toronto Centre for the Study of Pain (UTCSP) is committed to closing the gap betwe en e vidence -based pain m anagement practices, and the pain re lief provided by health professionals. The UTCSP, a unique partnership of pain spe cialists in the Faculties of Dentistry, Medicine, Nursing and Pharmacy, was established in 2000 to " lead both nationally and internationally in pain re search, education and clinical activities." To fulfill its role, the UTCSP has assembled a te am of inte rnationally re cognized clinician and basic scientists from all health disciplines, whose work contributes significantl y to the study and understanding of pain m anagement across the lifespan, from newborns to older people.

In its structure and focus, the UTCSP re cognizes that pain m anagement crosses all health disciplines. When re covering from surgery or injury or dealing with pain, patients are likely to re ceive care and advice from a variety of health profe ssionals. Each one m ay have a different understanding of pain, and different pain management strategies. A shift in the practice of one profession alone will not change the curre nt approach to pain re lief.

To provide the best possible patient care, it is extremely important that all members of the care te am share the same com m itment to pain relief, understand the different pain management strategies and resources available, and work toge ther to manage pain as we ll as the unde rlying disease or condition.

The UTCSP's vision is to be a model of interdisciplinary collaboration, to create and disseminate knowle dge about pain, and to promote excellence in scholarship. The C entre will share strategies to alleviate pain and suffering, and encourage he alth professionals to provide consistent, comprehensive, evidence-based pain practices. Leading by example, the UTC SP will e ncourage collaborative pain management practice. It also believes it can play a k ey role in helping the health profe ssions develop e ffective, skilled pain management teams and network s.

Educating to Close the Gap

O ne of the UTCSP's main roles is to "develop, implement, and support co -ordinated e ducational programs in pain at unde rgraduate, graduate and postgraduate levels." The Centre's aim is to incre ase pain content in all hea lth science curricula, focusing on interdisciplinary models of e ducation and pain management. Its education programs are designed to influence health professionals' attitudes towards pain re lief and e ncourage the use of best practices.

UTCSP Education Committee De ntistry:

David Mock

Me dicine:

Allan Gordon, Larry Librach, Mike Salter (Director UTCSP)

Nursing:

Judy W att-Watson (Chair)

Pharmacy:

Pe te r Pennefather

Physical Therapy:

Judi Hunter

The UTCSP e stablished an Education Committee to: ide ntify the pain education re quirements at all levels of health professional education develop appropriate, e ffective, inte rdisciplinary e ducational programs. Through a survey, committee members determined that pain-related content provided by the Faculties was variable and not compre hensive.

In de veloping curricula, the UTCSP decided to begin at the undergraduate level, whe re it has the opportunity to shape rathe r than change practice, and to help students develop an understanding of pain and attitudes toward pain m anagement that will influence the care they provide for patients throughout their careers.

Pain Education Requirements for Undergraduate Students

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Pain Education Requirements for Undergraduate Students W ork ing with curricula published by the International Association for the Study of Pain (IASP) and a Position Statement on Pain Relief developed by the Canadian Pain Society (see next page), the UTCSP Education Committee developed the following goal for undergraduate students and a series of re commendations to help faculties achieve that goal.

Goal: Graduating health professionals will understand that pain is a unique and frequently encountered human problem that requires comprehensive management. They will develop their abilities to render sound evidence -based clinical judgments to effectively manage acute and chronic pain, within their individual and interdisciplinary team scope of practice. They will recognize the need to continually update and integrate new developments in pain research.

Recommendations

The Health Professional Faculties will: • de ve lop implementation strategies to increa se the theore tical and clinical pain m anagement expertise of their graduates • utilize the IASP curriculum guidelines as a re source for these strategies

• inte grate pain content throughout each program beginning early in undergraduate e ducation • work within and betwe en faculties • de ve lop strategies to evaluate learning outcomes • utilize UTCSP members as re source s whe n developing implementation strategies • de ve lop strategies to facilitate faculty development whe re needed.

The Undergraduate Pain Curriculum Committee To de velop the interfaculty undergraduate (second -entry) pain curriculum, the UTCSP Education Committee formed an Inte rfaculty Undergraduate Pain Curriculum Committee which first met in September 2000 chaired by Judy Watt -Watson.

Judi Hunter is the 2004 Chair. The committee is made up of re presentatives of each faculty who are responsible for curriculum as we ll as individuals who are skilled in information te chnology, e -based re search and evaluation. Dr. Catharine Whiteside, Chair-Interprofessional Education Management Committee, has acted as a consultant for the inte rfaculty education initiative, and the committee also had the support and assistance of university departments with e x pertise in information technology, e-learning and case study development.

Students Participating in the IPC 2006 3 rd ye ar & Q P Dentistry:

92

2 nd ye ar Medicine:

197

2 nd ye ar Nursing:

149

3 rd ye ar Pharmacy:

194

2 nd ye ar Physical Therapy:

76

2 nd ye ar Occupational Therapy

76

Total:

784

By de ve loping a collaborative program, the UTCSP has re inforced the interdisciplinary nature of pain m anagement and e nsure the quality and consistency of pain education at the undergraduate level, which should lead to the best clinical pain m anagement by graduates of these programs. Offering the same pain curriculum to undergraduate students in six he alth profession programs helps to e nsure they have a common understanding of the impact of pain on the patient, m e thods to assess pain, mechanisms that guide m anagement choices, and specific strategies to prevent or minimize pain.

Educating undergraduates from different professional programs together will also help e nsure that they appreciate both the similar and unique approaches different professions use to assess and manage pain, and will be able to draw on all the se re sources. O ffering the curriculum in one, intensive "The Interfaculty Pain Curriculum" underlines the importance of e ffe ctive, collaborative pain m anagement and gives this vital aspect of patient care the profile it has lacked in traditional he alth professional curricula.

References 1. Cle eland C., Gonin R., Hatfield A., Edmonson J., Blum R., Stewart J. & Pandya, K. (1994) Pain and its treatment in outpatients with m etastatic cancer. New England Journal of Medicine 330, 592-596.

2. Die trick -Gallagher M., Palomano R . & C arrick L. (1994) Pain as a quality management initiative. Journal of Nursing Care 9, 30-42.

3. Draye r R ., Henderson J. & R e idenberg M. (1999) Barriers to better pain control in hospitalized patients. Journal of Pain & Symptom Management 17, 434-440.

4. Dwork in R . (1997). W hich individuals with acute pain are most likely to develop a chronic pain syndrome? Pain Forum, 6, 127-136 5. Joint C ommission on Accre ditation of Healthcare Organizations(JCAHO)(2000): http://www.jcaho.org.

6. Kalso E: Pre vention of chronicity. In Jensen T, Turner J, Wiesenfeld-Hallin, Z, editors: Proceedings of the 8th World Congress on Pain, vol 8, Se attle, 1997, IASP Press.

7. Katz J: Perioperative predictors of long-term pain following surgery. In Jensen T, Turner J, Wiesenfeld-Hallin, Z, e ditors: Proceedings of the 8th World Congress on Pain, vol 8, Se attle, 1997, IASP Press.

8. O 'Gara P. (1988) The hemodynamic consequences of pain and its management. Journal of Intensive Care Medicine 3, 3-5.

9. Puntillo K. & W e iss S. (1994) Pain: Its mediators and associated morbidity in critically ill cardiovascular surgical patie nts. Nursing Research 43, 31-36.

10. W att-Watson, J, Clark, AJ, Finley, A., & W atson, P. (1999) C anadian Pain Society Position Statement on Pain Relief.

Pain Research & Management 4(2), 75-78.

11. W att-Watson J., Garfinkel P., Gallop R ., Ste vens B. & Stre iner D. (2000) The impact of nurses' e mpathic re sponses on patie nts' pain management in acute care. Nursing Research 49, 1-1

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Pasted from <http://icarus.med.utoronto.ca/pain2008/history.htm>

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Recognition & Contributions Saturday, March 22, 2008

UofT INTERFA CULTY PA IN CURRICULUM COMMITTEE Faculty of Dentistry

Lawrence S. Bloomberg Faculty of Nursing

Thuan Dao, DMD, MSc, Dip Prostho, PhD, FRCD(C) Associate Professor, Faculty of Dentistry, Unive rsity of Toronto C linical Associate, Wasser Pain Management Centre Mount Sinai Hospital Helen Grad, MScPHM Assistant Professor, Faculty of Dentistry, Unive rsity of Toronto David K. Lam, DDS, PhD(c) C hie f Resident, Oral and Maxillofacial Surgery & Anaesthesia David Mock, DDS, PhD, FR CD(C) De an and Professor, Faculty of Dentistry, Unive rsity of Toronto Associate Director, W asser Pain Management Centre Mount Sinai Hospital Me m ber, Advisory Committee, Unive rsity of Toronto Centre for the Study of Pain Faculty of Medicine Martin Schreiber, MD, FR C P(C) Associate Professor, Faculty of Medicine, Pre cle rkship Director C ourse Director, Foundations of Medical Practice, Unive rsity of Toronto Staff Ne phrologist, St. Michaelâ&#x20AC;&#x2122;s Hospital Leila Lax, BA, BScAAM, MEd, PhD(c) Assistant Professor, Biomedical Communications, Institute of Medical Scie nce, Faculty of Medicine, Unive rsity of Toronto Denyse Richardson, BScPT, MD, MEd, FRCP(C) Clinician Educator, Dept. of Medicine Assistant Professor, Faculty of Medicine, Unive rsity of Toronto Physiatrist, Toronto R ehabilitation Institute Larry Librach, MD, CCFP, FCFP Dire ctor, Temmy Latner Centre for Palliative Care Mount Sinai Hospital W . Gifford-Jones Professor Pain C ontrol and Palliative C are, Faculty of Medicine, University of Toronto Nora Cullen, BSc, MD, MSc, FR CP(C), Assistant Professor, Faculty of Medicine, Unive rsity of Toronto Physiatrist, Ne uroRehabilitation, Toronto Rehabilitation Institute Michael W. Salter, MD, PhD Dire ctor, University of Toronto Centre for the Study of Pain Profe ssor, Dept. of Physiology, Faculty of Medicine Se nior Scientist, R esearch, Hospital for Sick Childre n A llan Gordon, MD, FR CP(C) Associate Professor, Faculty of Medicine, Unive rsity of Toronto Ne urologist and Director, W asser Pain Management Centre, Mount Sinai Hospital Me m ber, Advisory Committee Unive rsity of Toronto Centre for the Study of Pain E-Based Education Rosemary Waterston, PhD E=base d Education Researcher and De veloper University of Toronto Libraries Sandra Langlands, BA, MLS Dire ctor, Ge rstein Information C entre Ge rste in Science Information Centre Suzanne Tabur, BA, MLS My.library Webmaster & R efere nce Librarian Ge rste in Science Information Centre

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Judy Watt-Watson, R N, PhD Profe ssor, Lawre nce S. Bloomberg Faculty of Nursing Me m ber, Advisory Committee Unive rsity of Toronto Centre for the Study of Pain Michael McGillion, R N, PhD Lawre nce S. Bloomberg Faculty of Nursing, University of Toronto Jennifer Stinson, R N, C PNP, PhD C linician Scientist, Child Health Evaluative Science s Advance Practice Nurse, Dept. of Ane sthesia C hronic Pain Program, Hospital for Sick C hildren Assistant Professor, Lawre nce S. Bloomberg Faculty of Nursing, Unive rsity of Toronto Tricia Kavanagh, R N, PhD(c) Graduate Student Lawre nce S. Bloomberg Faculty of Nursing, Unive rsity of Toronto Department of Occupational Science and Occupational Therapy Lynn Cockburn, M. Ed, O T, R eg.

(O nt), OT(C), PhD(student), Assistant Professor, Dept. of O ccupational Science and O ccupational Therapy, Faculty of Medicine, University of Toronto Mandy Lowe MSc, BSc(OT) Inte rprofessional Education Leader Le cture r, Status Appointment, De partment of Occupational Scie nce and O ccupational Therapy, Unive rsity of Toronto Faculty of Pharmacy A ndrea Cameron, BSc Phm, MBA Se nior Lecturer, Leslie Dan Faculty of Pharmacy, Unive rsity of Toronto Lalitha Raman-Wilms, BSc Phm , Pharm D, FCSHP Associate Professor, Leslie Dan Faculty of Pharmacy, University of Toronto C linical Pharmacist, The Anne Johnston Health Station Peter Pennefather, PhD Profe ssor, Leslie Dan Faculty of Pharmacy, Unive rsity of Toronto Me m ber, Advisory Committee Unive rsity of Toronto Centre for the Study of Pain Department of Physical Therapy

Ge rste in Science Information Centre

Judith Hunter, BScPT, MSc, PhD (Chair of UTCSP Interfaculty Pain Curriculum Committee) Assistant Professor, Dept. of Physical Therapy, Unive rsity of Toronto C PA O ntario Research Fellow Robyn Davies, BHScPT, MScPT Physiotherapist, Sunnybrook & W om en’s College HSC, Lecturer, De pt. of Physical Therapy Faculty of Medicine, University of Toronto University of Toronto Centre for the Study of Pain Nancy Mitchell Adm inistrative Coordinator Student Members Eugenia Cheveleva He alth Scie nce Student R e presentative Celia Lai Proje ct Assistant RECOGNITION & CONTRIBUTIONS

The University of Toronto Centre for the Study of Pain (UTCSP) Interfaculty Pain Curriculum Committee would like to thank the following contributors to this interfaculty education opportunity: Dr. Catharine Whiteside, Dean, Faculty of Medicine is gratefully acknowledged for ongoing support.

Dr. Jay Rosenfield, Associate Dean, Faculty of Medicine, In-kind consultation, support, and contribution to e valuation by Dr. Katherine MacRury and Mr. A lan Pike.

Dr. Glen Regehr, Associate Dire ctor of the Wilson Centre for Research in Education. In-kind program e valuation and statistical consultation.

Dr. Ivan Silver, Director, Ce ntre for Faculty Development Faculty of Medicine, Unive rsity of Toronto is gratefully acknowle dged for his in -kind contribution to the de ve lopment of UTCSP Interfaculty Pain Curriculum Facilitator training.

Deans/ Chairs and Course Co-ordinators from e ach professional program are grate fully acknowle dged for their support and integration of this interprofessional e ducation.

Ms. Diana Tabak, Associate Director, Mr. Cameron MacLennan, Digital Media Spe cialist, Standardized Patient Program, University of Toronto, Wilson Centre for R e search in Education for preparation of digital media for the case.

Dr. Claire Bombardier, C linical R esearch Coordinator, Institute for W ork and He alth (IWH), Dr. A ndrea Furlan, Evidence Based Practice C oordinator IWH, and Victoria Pennick, Se nior C linical re search Project m anager IWH and Acting C ochrane Back Review Group Coordinator, for in -kind contribution to development of the case and providing links to the e vidence.

Dr. David Etlin, Dire ctor, R e habilitation Solutions, TWH, and staff including Karen MacLellan, for in-k ind contribution to the development of the case.

Dr. Karen Davis, Dr. Jonathan Dostrovsky, Dr. Mike Salter and Dr. Barry Sessle, UTCSP, in-k ind contributions and support to the development of UTCSP Inte rfaculty Pain Curriculum and the Ne uroscience R epository are gratefully ack nowledged.

Ms. Debra Moy, Lecturer, Leslie Dan Faculty of Pharmacy is gratefully acknowledged for organizing pharmacy profession-specific sessions.

UofT CONTRIBUTIONS TO IT/E-LEA RNING COMPONENTS Dr. A vi Hyman, Dire ctor, Discovery Commons, Academic Computing, Faculty of Me dicine, In-kind contribution of we b media development by: • Ms. Meaghan Brierley, BFA, MScBMC , Discovery C ommons, Medical Multim edia Designer.

• Mr. Ju Ho Park, BSc, Discove ry Commons, E-based Instructional Developer, Inte ractive Evaluation Forms Programming.

• Ms. Elana Zatzman, Discovery Commons, W eb Designer Dr. Joan Leishman, Dire ctor, Scie nce Libraries and Deputy Chief Librarian, Unive rsity of Toronto , In-kind contribution of Mylibrary we b -based resource s for the study of pain.

INTERFA CULTY PA IN CURRICULUM FUNDING

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University of Toronto Council of Health Science and Social Work Deans is grate fully acknowle dged for providing funding for the implementation of the UTCSP Inte rfaculty Pain Curriculum.

University of Toronto Centre for the Study of Pain, (Dr. Mike Salter, Dire ctor) is grate fully acknowle dged for providing e ducational re search funding.

The Faculty of Nursing is grate fully ack nowle dged for support of the audiovisual facilitie s for the multi-professional sessions.

CORPORA TE A ND INDUSTRY SPONSORS OF UTCSP INTERFA CULTY PA IN CURRICULUM

Purdue Pharma Inc., Merck Frosst Canada Ltd., Pfizer Canada Inc., and Shoppers Drug Mart are grate fully acknowle dged for their contributions through unre stricted e ducational grants to support development and implementation of the UTCSP Interfaculty Pain Curriculum.

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01 CULLEN 2008 Intro to Rehab.pdf 3/24/2008, 1:14 PM

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TEACHD

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SHAFT

HORSES

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Faaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaantastic!

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02 CULLEN 2008 Brain and SCI Injury rehab.pdf

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• The response that we fuss over the most is Confused and Agitated ○ Makes caregivers uptight; work really hard as a team to manage

• Use restraints ONLY as a final measure

Common to find DVT's because of immobility

• Trazadone: Non-addicting but slightly sedating

medication

○ trazodone hydrochloride: [USP] an antidepressant used to treat major depressive episodes with or without prominent anxiety; administered orally.

• Give radio-opaque food to people of different consistencies; can see food going down and trickling into trachea if any problems; can see what consistency can they manage and can't they manage; most people outgrow this stage • PEG tubes: right through abdomen into stomach • Keep track of liver enzymes bc meds use and pt's often had alc.

Abuse and challenged liver

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• Pressure ulcers can be big problem for QoL in recovery ○ Reason to NOT use restraints since higher incidence of pressure ulcers ○ Treat incontinence aggressively • Respiratory system: lots people with tracheotomies;

• If someone drowsy all the time and you're expecting them to wake up but they're not, consider seizure; can do EEG, and if that doesn't giv eyou evidence, do a sleep deprived one • Lit supports use of anti-epileptic arter 1 week of trauma (eg.

Dilantin) will reduce risk of early but not late seizures; typically then ppl. Taken off one week after incident • If til lhave seizure after this then will b prob. Need anti-seizure meds for life

• Mr. B.: Wanderguard; if you go through a door that's triggered, will sound an alarm; can tell exactly which patient has left the unit; • Still a few cog. Issues; was ready to go home when suddenly had grand mal seizure; this is common after any insult to the brain; incidence is 5-7% post TBI; ○ This risk is even higher if the person has had damage to the actual parenchyma of the brain

• Brain sending lots of signals to limbs to contract on one side and other signals to the opposed muscle (eg. Stimulation to biceps to flex and inhibition of triceps)

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• Many of the same issues mentioned minus the cognitive ones

•

• Way to ID level and degree of SC impairment a person has; can say for example "ASIA D" and that means complete paraplegic and name level (T4)…will see in acute care in neurology and neurosurg, commonly

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â&#x20AC;˘ Just like TENS; gives little jolt to the muscle

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autonomic dysreflexia, a syndrome affecting persons with lesions of the spinal cord above the midthoracic level, characterized by paroxysmal hypertension, bradycardia, excessive sweating, facial flushing, nasal congestion, pilomotor responses, and headache. It is due to an exaggerated autonomic response to such stimuli as distention of the bladder or rectum.

Level of Spinal Cord Injury: T6 or above 1) 2) 3) 4) 5) 6) 7)

Full bladder stimulus from the bowel Afferent stimulus Massive sympathetic response Widespread vasoconstriction Hypertension systemically Baroreceptors --> detects hypertensive crisis, signals in brain Heart rate slowed 7b) Descending inhibitory signals blocked at spinal and injury 8) Vasodilation above the level of the lesion

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• Is life threatening and need to go on search and destroy mission; if SCI above T6 and the person has skyrocketing BP, then need to find the source and if can't find it then need give anti -hypertensive ○ Have systemic hypertension ○ If the spinal cord lesion is below T6 then there are other roots above it; if you injure above T6 then the autonomic system is cut off above it ○ AGAIN, ONLY FOR PEOPLE WITH INJURIES AT T6 AND ABOVE

• Common symp. That u see:

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OTHER COMPLICATIONS OF SPINAL CORD INJURY: AUTONOMIC DYSREFLEXIA (HYPERREFLEXIA) Monday, March 24, 2008 3:08 PM Autonomic dysreflexia, also known as hyperreflexia, is a state that is unique to patients after spinal cord injury at a T-5 level and above. Patients with spinal cord injuries at Thoracic 5 (T-5) level and above are very susceptible.

Patients with spinal cord injuries at Thoracic 6 - Thoracic 10 (T6-T10) may be susceptible. Patients with Thoracic 10 (T-10) and below are usually not susceptible. Also, the older the injury the less likely the person will experience autonomic dysreflexia.

Autonomic dysreflexia can develop suddenly, and is a possible emergency situation. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.

Autonomic dysreflexia means an over-activity of the Autonomic Nervous System. It can occur when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure. Nerve receptors in the heart and blood vessels detect this rise in blood pressure and send a message to the brain. The brain sends a message to the heart, causing the heartbeat to slow down and the blood vessels above the level of injury to dilate. However, the brain cannot send messages below the level of injury, due to the spinal cord lesion, and therefore the blood pressure cannot be regulated.

• • •

Symptoms and causes Treatment Prevention

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Autonomic dysreflexia in spinal cord injury Monday, March 24, 2008 3:09 PM

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03 CULLEN 2008 Returning to Work and Driving.pdf

• Whether or not they have a driver's licence, you have to tell the government

• Physicians can be held liable!

•

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This is not a family decision; it's a medical decision

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Prof's dad

4. not fit to drive but nobody reports it; sadly this is way too often

ALGORITHM FOR EACH OF 4 RESPONSES IN ASSESSING MEDICAL FITNESS TO DRIVE

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SKIPPED THIS CASE; WENT TO RESOURCES

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04 CHAN 2008 Headache.pdf

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05 VAIDYANATH 2008 Soft Tissue Injury and Pain- Final Tuesday, April 01, 2008 10:13 PM <file://C:\Documents and Settings\Mr. Intensity\My Documents\1Medicine\2ndYearFiles\1FMP-2007\Week13\05 VAIDYANATH 2008 Soft Tissue Injury and Pain- Final.pdf> (150 slide PDF; not printed; link to original file)

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Jovey Introduction March 24 Slide Handout.pdf

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Thinking of pain as an onion, layered approach

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• Two separate studies combined; looking what percentag e pl after srugery had pain; 75 to 80% had pain; high proportion mod-severe pain • YOU SHOULD NOT expected to have terrible pain, for example, after hip fracture

• Cancer pain perhaps best treated of all the pains

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• 3 major pain surveys in Canada highlighted above ○ Arthritis and back pain most common reasons for chronic pain ○ CCPS1 and 2 studies • Also SES Canadian pain study

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• In western society, valued to be a stoic, eg. Of john wayne attitude

• Asked random set of prof. fac. : how many hours devoted to the study of pain • 2/3 of faculties couldn't identified any • Nurses get about 3 times as much training on pain • Vets most amount of pain training

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Developed by patients and health care professionals

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• This protein has one aa subsh at the 158 position, can have either valine or methionine; this can have profound inf. On how enzyme functions; enzyme will be more active with val; if met, less active

Much smaller percent ppl in poph who have 2 or 3 copies of 2D6; spin codeine v. rapidly into morphene

• Codeine: tyl 3 : transforms to morphine in body • Story of Mother: fast metabolizer codeine: breast feeding newly born infant: high levels morphine transferred to baby and baby died

• Showed slide on genotyping, personalized medicine, CYP p450 array

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What is the difference between the temporal profile of acute vs. chronic pain?

What is the major cause of neuropathic pain?

Does neuropathic pain affect the peripheral or central nervous system?

In a mechanistic pain classificaiton of nociceptive vs. neuropathic pain, what are the subcategories of these?

Give examples of conditions that can lead to neuropathic pain?

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Within the context of pain assessment, unidimensional scales address the ___ of pain?

List 4 different pain scales?(5)

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Mcgill pain questionnaire

As opposed to unidimensional scales which address the INTENSITY of pain, multidimensional scales assess the ___ component of pain and assess its ___ impact?

Give an example of a multidimensional pain scale?(2)

• Total out of 70

• Secondary outcomes of pain: disuse atrophy/weakness/stiffness

• Examlpe of finding treatable underlying disease using investigations: ○ One of common caues of mysterous neuropathic pain feet first then hands is type II diabetes; first manifestation may be neuropathic pain

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â&#x20AC;˘ Let's say you have injury and you experience pain: if you don't have fear avoidance, then you go about your daily activities; this happens to most people; â&#x2014;&#x2039; Let's say you have a personality or genetic makeup and you catastrophize, worry constantly, have this tendency to become hypervigilant; close your eyes and can tell everyone every single type of pain you're experiencing

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(altv meds)

â&#x20AC;˘ 60% of ppl. With chronic pain have been to an alternative meds practitioner

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Jovey Pharmacotherapy Basics Slide Handout.pdf

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Jovey Pharmacotherapy Clinical Slide Handout.pdf

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Jovey Suppl Handout for Wednesday Talk.pdf

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Common Acute Pain Challenges: post-surgical pain

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Acute Pain Challenges in Children

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Juvenile Idiopathic Arthritis: An Overview

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The Prevention of Herpes Zoster and Post-herpetic Neuralgia: Can Chronic Pain be Prevented?

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Cancer Pain: An interprofessional approach

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Cases

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THE CASE OF FRANK AWEIDA

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THE CASE OF GERALD ROBERTSON

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THE CASE OF HAYLEY MORRISON

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UTCSP Interfaculty Pain Curriculum Presentations and Slides Letter of Understanding

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Links to past lectures on pain

Week 6 Answers to Objectives

Questions for Week5,6,7 Headache Seminar, Part 1 Headache Seminar, Part 2

Headache Symposium on Pain Phantom Limb Pain Pain 1

Pain 2

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Resources: Interfaculty Pain Curriculum 2008 Pain: Putting the Person at the Centre

Resources: Interfaculty Pain Curriculum 2008 Pain: Putting the Person at the Centre Research Guide Table of Contents 1. Preparatory Readings 2. Monday Evening Readings: Acute Pain 3. Tuesday Evening Readings: Persistent Pain 4. Pain Measures 5. Evidence-based Reviews S. Langlands, BA MLS, Coordinator, Reference & Research, Gerstein Science Information Centre, 6. Additional University of Toronto. Winter, 2008.

S. Tabur, BA MLS, Librarian, Reference & Research, Gerstein Science Information Centre, University References Home of Toronto. Winter, 2008.

Resources: Interfaculty Pain Curriculum 2008 presents the readings and resources recommended by faculty planners and instructors for this unit of study in a my.library resource guide format. 路 Use the menu on the right to access readings and other resources. The first time you choose a resource in a session you will be asked to enter your UTORID & UTORID password OR your library barcode and your pin number. Note that some items will only be linked during the weeks of the course in March. 路 P r e paratory R eadings to help you prepare for March 25-28, 2008 can be found near the top of the menu to the right. 路 Direct links to electronic full text documents are provided where possible. Books and other readings are available at the Gerstein Science Information Centre.

The A d ditional R eferences in Section 9 are provided for those with a keen interest in further background information.

C o pyright: 2008, Gerstein Science Information Centre, University of Toronto.

Please send suggestions for this guide to s.langlands.melvin@ut oronto.ca.

Last updated March 13, 2008.

Pasted from <http://link.library.utoronto.ca/MyUTL/guides/index.cfm?guide=pain08 >

1. Preparatory Readings The readings below will help you prepare for the Interfaculty Pain Curriculum 2008. Please read them before Tuesday, March 25 th.

Article: Cousins MJ et al. (2004) Pain relief: a universal human right. Pain 112(1-2):1-4 A r ticle: Watt-Wattson J., et al. (1999). Canadian Pain Society position statement on pain relief. P a in R esearch & M a nagement 4(2):75-78. Held in print at UHN and HSC libraries.

I A SP D efinitions & C lassifications o f P ain IASP Pain Terminology Pasted from <http://link.library.utoronto.ca/MyUTL/guides/folder.cfm?guide=pain08&folderID=436380 >

2 . M onday E vening R eadings: A cute P ain A r ticle: Rasmussen PV, Sindrup SH, Jensen TS, Bach FW et al. (2004). Symptoms and signs in patients with suspected neuropathic pain. P a i n 110(1/2):461-469.

A r ticle: Gilron I et al. (2006) Neuropathic pain: a practical guide for the clinician. C MAJ 175(3):265-275.

A r ticle:

Craig AD. & Sorkin LS. (2001). Pain and analgesia. In: Encyclopedia of Life Sciences. London: Nature Publishing Group.

G u ide t o A ssessing P sychosocial Y ellow F lags i n A cute L ow B ack P ain: R isk F actors f or L ong-Term D isability a nd W ork L o ss.

SCROLL TO Page 24 for Guide. Wellington, NZ: New Zealand Guidelines Group, 2003.

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3 . T uesday E vening R eadings: P ersistent P ain

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A r ticle ( print o nly): Lynch ME, Watson CPN. (2006). The pharmacotherapy of chronic pain: A review. P a i n R esearch a nd M anagement 11(1):11-38.

A r ticle: Dworkin RH, Backonja M, Rowbotham MC et al. (2003). Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. A r chives o f N eurology 60(11):1524-1534.

A r ticle: Main CJ, Keefe FK. & Rollman G. (2002). Psychological assessment and treatment of the pain patient. Chapter 30. In: Giamberardino MA (ed). Pain 2002-An Updated Review.(Course Syllabus). pp.281-301. Seattle, Wash.:IASP Press. P E NDING C OPYRIGHT P ERMISSION A r ticle: LeFort SM, et al. (1998). Randomised controlled trial of a community-based psychoeducation program for the self-management of chronic pain. P a i n 74(2-3):297-306.

Pasted from <http://link.library.utoronto.ca/MyUTL/guides/folder.cfm?guide=pain08&folderID=436375 >

4 . P ain M easures A r ticle:

Williams AC. (2001). Outcome assessment in chronic non-cancer pain treatment. A c ta A naesthesiologica S c andinavica 45(10):1076-1079.

M c Gill P ain Q uestionnaire Melzack R & Katz J (2001). McGill pain questionnaire: appraisal and current status. In: D. Turk & R. Melzack (eds). H a ndbook o f P ain A ssessment. pp.35-52. London, Guilford Press.

N u merical P ain R ating S cale Paice J & Cohen F (1997). Validity of a verbally administered numerical rating scale to measure cancer pain intensity. C ancer N ursing 20(2):88-93.

P a in A ssessment S cales: B rief P ain I nventory Tan G et al. (2004). Validation of the Brief Pain Inventory for chronic nonmalignant pain. J o urnal o f P ain 5(2):133-137.

Pasted from <http://link.library.utoronto.ca/MyUTL/guides/folder.cfm?guide=pain08&folderID=436377 >

5 . E vidence-based R eviews

Go To:

Evidence-based Reviews | Evidence-based Reviews: Low Back Pain | Evidence-based Reviews: Neck Pain | Guidelines for Acute Pain Management | Guidelines for Chronic Pain Management | Other Evidence-based reviews for pain management |

E v idence-based R eviews A r ticle: Furlan A, Sandoval JA, Mailis-Gagnon A, Tunks E. (2006). Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. C M A J 174(11): 1589-1594.

A r ticle: Jovey RD et al. Use of opiod analgesics for the treatment of chronic noncancer pain - a consensus statement and guidelines from the Canadian Pain Society, 2002. P a i n R esearch & M anagement 2003;8 Suppl A:3A-28A. [PMID: 14685304] A r ticle:

Dworkin RH, O'Connor AB, Backonja M et al . (2007). Pharmacologic management of neuropathic pain: evidence based recommendations. P ain 132(3): 237-251.

C o chrane R eview:

Milne S., et al. (2003). Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain.

C o chrane D atabase o f S ystematic R eviews 2005, Issue 3. DOI: 10.1002/14651858.CD003008.pub2.

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C o chrane R eview: Karjalainen K., et al. (2003). Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. C o c hrane D atabase o f S ystematic R eviews 2003, Issue 2. DOI: 10.1002/14651858.CD002194.

C o chrane R eview: Verhagen AP et al. Conservative treatments for whiplash. C o c hrane D atabase o f S ystematic R eviews 2004, Issue 1. DOI: 10.1002/14651858.CD003338.pub2.

E v idence-based R eviews: L ow B ack P ain A r ticle: Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G; COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. E u r opean S pine J ournal 2006 Mar;15 Suppl 2:S192-300. PMID: 16550448 A r ticle: van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. E u ropean S pine J ournal 2006 Mar;15 Suppl 2:S169-91. PMID: 16550447 A r ticle: Burton AK, Balagué F, Cardon G, Eriksen HR, Henrotin Y, Lahad A, Leclerc A, Müller G, van der Beek AJ; COST B13 Working Group on Guidelines for Prevention in Low Back Pain. Chapter 2. European guidelines for prevention in low back pain : November 2004. E u ropean S pine J ournal 2006 Mar;15 Suppl 2:S136-68. PMID: 16550446 Eur Spine J (2006) 15 (Suppl. 2): S136–S168

E v idence-based R eviews: N eck P ain A r ticle: E. L. Hurwitz, E. J. Carragee, G. van der Velde, L. J. Carroll, M. Nordin, J. Guzman, P. M. Peloso, L. W. Holm, P. Cote, S. Hogg-Johnson, J. D. Cassidy, and S. Haldeman. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. S pine 33 (4S):S123-S152, 2008.

A r ticle: M. Nordin, E. J. Carragee, S. Hogg-Johnson, S. S. Weiner, E. L. Hurwitz, P. M. Peloso, J. Guzman, G. van der Velde, L. J. Carroll, L. W. Holm, P. Cote, J. D. Cassidy, and S. Haldeman. Assessment of Neck Pain and Its Associated Disorders: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. S p ine 33 (4S):S101-S122, 2008.

A r ticle: L. J. Carroll, S. Hogg-Johnson, P. Cote, G. van der Velde, L. W. Holm, E. J. Carragee, E. L. Hurwitz, P. M. Peloso, J. D. Cassidy, J. Guzman, M. Nordin, and S. Haldeman. Course and Prognostic Factors for Neck Pain in Workers: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

S p ine 33 (4S):S93-S100, 2008.

A r ticle: J. Guzman, S. Haldeman, L. J. Carroll, E. J. Carragee, E. L. Hurwitz, P. Peloso, M. Nordin, J. D. Cassidy, L. W. Holm, P. Cote, G. van der Velde, and S. Hogg-Johnson. Clinical Practice Implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: From Concepts and Findings to Recommendations. S pine 33 (4S):S199-S213, 2008.

A t icle:

E. L. Hurwitz, E. J. Carragee, G. van der Velde, L. J. Carroll, M. Nordin, J. Guzman, P. M. Peloso, L. W. Holm, P. Cote, S. Hogg-Johnson, J. D. Cassidy, and S. Haldeman. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. S pine 33 (4S):S123-S152, 2008.

G u idelines f or A cute P ain M anagement

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G u idelines f or A cute P ain M anagement I C SI G uideline: A dult L ow B ack P ain Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 I C SI G uideline: A ssessment a nd m anagement o f c hronic p ain

Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2005 Nov. G u idelines f or C hronic P ain M anagement W o rk L oss D ata I nstitute G uideline: N eck a nd u pper b ack ( acute & c hronic)

Work Loss Data Institute. Neck and upper back (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2005 O t her E vidence-based r eviews f or p ain m anagement C o chrane R eview:

Kroeling P et al. Cervical Overview Group. Electrotherapy for neck disorders. C o chrane D atabase o f S ystematic R e views: 2005,Issue 2.John Wiley & Sons, Ltd Chichester, UK DOI:10.1002/14651858.CD004251.pub.3.

C o chrane R eview: Peloso P et al. Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders.

C o chrane D atabase o f S ystematic R eviews: 2004,Issue 2.John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD000319.pub3.

C o chrane R eview: Kay TM et al. Cervical overview group. Exercises for mechanical neck disorders. C o chrane D atabase o f S y stematic R eviews: 2005, Issue 3.John Wiley & Sons, Ltd Chichester, UK DOI: 10.1002/14651858.CD004250.pub 3.

C o chrane R eview: Green S et al. Acupuncture for shoulder pain. C o chrane D atabase o f S ystematic R eviews: 2005,Issue 2. John Wiley & Sons, Ltd. Chichester, UK DOI: 10.1002/14651858.CD005319.

C o chrane R eview: Green S et al. Physiotherapy interventions for shoulder pain. C o c hrane D atabase o f S ystematic R eviews: 2003, Issue 2. John Wiley & Sons, Ltd. Chichester, UK DOI: 10.1002/14651858.CD004258.

Pasted from <http://link.library.utoronto.ca/MyUTL/guides/folder.cfm?guide=pain08&folderID=436376 >

6 . A dditional R eferences We have also compiled a list of references that we recommend for you in your future studies and practice; they are n o t required for the present curriculum.

Go To:

Acute pain | Evidence-based therapeutics | Multidimensional pain assessment scales - special populations | Pain assessment | Pain management | Pain measurement | Pain physiology (physiological mechanisms) | Persistent pain |

A c ute p ain A c ute P ain C a rr D B, G oudas L C. ( 1999). A cute P ain. L ancet 3 53(9169):2051-2058.

E v idence-based t herapeutics M c Quay H J, M oore R A. ( 1998) A n e vidence-based r esource f or p ain r elief. N ew Y ork: O xford U niversity P ress.

O n S hort T erm L oan a t G erstein R M319 . M38 1 998X N o n-steroidal A nti-inflammatory D rugs ( NSAIDs) S ubcommittee R eport O r egon H ealth R esources C ommission ( 2003).

S t rong J , e t a l. ( 2002)

P a in: a t extbook f or t herapists. N ew Y ork: C hurchill L ivingstone.

O n S hort T erm L oan a t G erstein: R B127 . P331757 2 002 G ERSTM

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M u ltidimensional p ain a ssessment s cales - s pecial p opulations B e haviours c aregivers u se t o d etermine p ain M c Grath P J, R osmus C , C amfield C , C ampbell M A, H ennigar A W. ( 1998). B ehaviours c aregivers u se t o d etermine p a in i n n on-verbal, c ognitively i mpaired i ndividuals. D ev M ed C hild N eurol 4 0:340-343.

G e rstein P eriodical S tacks C h ecklist o f n onverbal p ain i ndicators ( CNPI) F e ldt K . ( 2000). C hecklist o f n onverbal p ain i ndicators ( CNPI). P ain M anag N urs 1 (1):12-21.

C h ecklist o f N onverbal P ain I ndicators ( CNPI).

P r emature i nfant p ain p rofile: d evelopment a nd i nitial v alidation

S t evens B , J ohnston C , P etryshen P , T addio A . ( 1996). P remature i nfant p ain p rofile: d evelopment a nd i nitial v a lidation. C lin J P ain 1 2:13-22.

S t evens B . 1 998

C o mposite m easure o f p ain. I n F inley G A, M cGrath P J. ( eds). M easurement o f P ain i n I nfants a nd C hildren.

P r ogress i n P ain R esearch M anagement 1 0:161-178.

G e rstein S tacks R J365 . M4 1 998X S w eet S D, M cGrath P J. ( 1998) P h ysiological M easures o f P ain. I n F inley G A, M cGrath P J. ( Eds.) M easurement o f P ain i n I nfants a nd C hildren, P r ogress i n P ain R esearch M anagement 1 0:59-81.

G e rstein S tacks R J365 . M4 1 998X P a in a ssessment A c ute L ow B ack P roblems i n A dults

B i gos S ,Bowyer O , B raen G , e t a l. A cute L ow B ack P roblems i n A dults. C linical P ractice G uideline N o. 1 4.

A H CPR P ublication N o. 9 5-0642. R ockville, M D: A gency f or H ealth C are P olicy a nd R esearch, P ublic H ealth S e rvice, U .S. D epartment o f H ealth a nd H uman S ervices.

A s sess t he p erson, n ot j ust t he p ain

T u rk D D. ( 1993). A ssess t he p erson, n ot j ust t he p ain. I ASP C lin U pdates 1 (3).

B a ckguide T o ronto: I nstitute f or W ork a nd H ealth ( IWH). ( 1999).

C o nfronting t he u se o f p lacebos f or p ain F o x A E. ( 1994). C onfronting t he u se o f p lacebos f or p ain. A m J N sg 9 4(9):42-46.

K a hn D , S teeves R . ( 1996) A n u nderstanding o f s uffering g rounded i n c linical p ractice a nd r esearch. I n B . F errell S uffering ( pp.1-28).

B o ston: J ones & B artlett P ub.

T o ronto E ast G eneral H ospital L ibrary W M172 . S9448 1 996 P a in m anagement A n ticonvulsant d rugs f or a cute a nd c hronic p ain W i ffen P , C ollins S , M cQuay H , C arroll D , J adad A , M oore A . A nticonvulsant d rugs f or a cute a nd c hronic p ain. ( 2 000). C ochrane D atabase o f S ystematic R eviews, 3 .

N o te: T he f ull t ext l ink t akes y ou t o t he C ochrane D atabase. E nter t he a rticle t itle i n t he s earch b ox a t t he t o p r ight o f t he s creen.

A r ticle ( Print o nly): S p itzer W O, S kovron M L, S almi L R, C assidy D J, D uranceau J , S uissa S , Z eiss E . S cientific m onograph o f t he Q u ebec t ask f orce o n w hiplash-associated d isorders: r edefining ' whiplash' a nd i ts m anagement. S pine 1 9 95;Suppl:20 ( 8S):2S-73S. A r ticle ( print o nly):

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S h ields N , C apper J , P olak T , T aylor N . ( 2006). A re c ervical p illows e ffective i n r educing n eck p ain? N ew Z e aland J ournal o f P hysiotherapy 3 4(1):3-9.

A r ticle: L a vin R , P appagallo M , K uhlemeier K . ( 1997). C ervical p ain: a c omparison o f t hree p illows. A rch P hys M ed R e habil 7 8(2):193-198.

A r ticle: M u zin S , I saac Z , W alker J , E l A bd O , B aima J . ( 2007). W hen s hould a c ervical c ollar b e u sed t o t reat n eck p a in? C urrent R eviews i n M usculoskelet M ed D OI 1 0.1007/s12178-007-9017-9 F r eedom f rom p ain. E stablishing a c onstitutional r ight t o p ain r elief W e inman B P. ( 2003). F reedom f rom p ain. E stablishing a c onstitutional r ight t o p ain r elief. J L eg M ed 2 4 (4):495-539.

P o rtenoy R . ( 1996)

C o ntrol o f P athological P ain I n K ruger L . ( Ed.) P ain a nd T ouch, 2 nd e dition. S an D iego: A cademic P ress, 1 996 p . 3 54 - 3 57.

Robarts Library Stacks BF275 .P35 1996X Relationship between pain knowledge and pain management outcomes Watt-Watson J, Stevens B, Streiner D, Garfinkel P, Gallop R. (2001). Relationship between pain knowledge and pain management outcomes for their postoperative cardiac patients. J Adv Nurs 36(4):535-45.

The New JCAHO Pain Standards: Implications for Pain Management Nurses

Berry PH, Dahl JL. (2000). The New JCAHO Pain Standards: Implications for Pain Management Nurses. Pain Manag Nurs 1(1):3â&#x20AC;&#x201C;12.

Watt-Wilson J. (1992) Misbeliefs about pain. In Watt-Watson J, Donovan M. (Eds.). Pain management: Nursing perspective (pp. 36-58), St. Louis: Mosby Yearbook.

Gerstein Stacks RT87 .P35 P36 1992 Pain measurement Article (Print only): Jensen MP, Karoly P, O'Riordan EF, Bland F Jr, Burns RS. (1989). The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain 5(2):153-9.

Gerstein Periodical Stacks The visual analogue pain intensity scale Collins S, Moore A, McQuay H. (1997). The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 72:95-97.

Validity of a verbally administered numerical rating scale

Paice J, Cohen F. (1997). Validity of a verbally administered numerical rating scale to measure cancer pain intensity. Cancer Nurs 20:88-93.

Pain physiology (physiological mechanisms) Basbaum A, Jessel T. (2000) The perception of pain. pp.472-491. In: Kandel E. et al. (eds). Principles of neural science. New York: McGraw-Hill.

On Short Term Loan at Gerstein: QP355.2 .P76 2000X GERSTM Molecular mechanisms of nociception Julius D, Busbaum A. (2001). Molecular mechanisms of nociception. Nature 413(6852):203-210.

Neuronal plasticity: increasing the gain in pain Woolf CJ, Salter M. (2000). Neuronal plasticity: increasing the gain in pain. Science 288(5472):1765-1768.

Neuroplasticity - an important factor in acute and chronic pain Petersen-Felix A, Curatolo M. (2002). Neuroplasticity - an important factor in acute and chronic pain. Swiss Med Wkly 132:273-278.

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Pain: neuroanatomy, chemical mediators and clinical McHugh JM, McHugh WB. (2000). Pain: neuroanatomy, chemical mediators and clinical implications. AACN clin issues 11(2):168-171.

Persistent pain Suffering: the contributions of persistent pain Chapman CR, Garvin J. (1999). Suffering: the contributions of persistent pain. Lancet 353(9171):2233-2237 Pasted from <http://link.library.utoronto.ca/MyUTL/guides/folder.cfm?guide=pain08&folderID=436379 >

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1. Preparatory Readings Saturday, March 22, 2008

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Pain Relief: A Universal Human Right Saturday, March 22, 2008

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Canadian Pain Society Position Statement on Pain Relief Saturday, March 22, 2008

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IASP Pain Terminology Saturday, March 22, 2008

IASP Pain Terminology The following pain terminology is from "Part III: Pain Terms, A C urrent List with Definitions and Notes on Usage" (pp 209-214) C lassification of C hronic Pain, Second Edition, IASP Task Force on Taxonomy, edited by H. Merskey and N. Bogduk, IASP Press, Seattle, Š 1994.

IASP members: PDF version available in English and en EspĂŁnol.

More information on permission to use, reprint or translate any IASP Publications.

TERMS: Allodynia

Neuritis

Analgesia

Neuropathic Pain

Anesthesia Dolorosa Neuropathy C ausalgia

Nociceptor

C entral Pain

Noxious Stimulus

Dysesthesia

Pain

Hyperesthesia

Pain Threshold

Hyperalgesia

Pain Tolerance Level

Hypoalgesia

Paresthesia

Hypoesthesia

Peripheral Neurogenic Pain

Neuralgia

Peripheral Neuropathic Pain

Introduction Changes in the 1994 list. There was substantial correspondence from 1986 to 1993 among members of the Task Force on Taxonomy and other colleagues. The previous definitions all remain unchanged, except for very slight alterations in the wording of the definitions of C entral Pain and Hyperpathia. Two new terms have been introduced here: Neuropathic Pain and Peripheral Neuropathic Pain.

The terms Sympathetically Maintained Pain and Sympathetically Independent Pain have also been employed; however, these terms are used in connection with syndromes I-4 and I-5, now called C omplex Regional Pain Syndromes, Types I and II. These were formerly labeled Reflex Sympathetic Dystrophy and C ausalgia, and the discussion of Sympathetically Maintained Pain and Sympathetically Independent Pain is found with those categories.

C hanges have been made in the notes on Allodynia to clarify the fact that it may refer to a light stimulus on damaged skin, as well as on normal skin. Also, in the tabulation of the implications of some of the definitions, the words lowered threshold have been removed from the features of Allodynia because it does not occur regularly. Small changes have been made to better describe Hyperpathia in the definition and note. A sentence has been added to the note on Hyperalgesia to refer to current views on its physiology, although as with other definitions, that for Hyperalgesia remains tied to clinical criteria. Last, the note on neuropathy has been expanded.

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expanded.

The 1986 list. A list of pain terms was first published in 1979 (Pain, 6, 249-252). Many of the terms were already established in the literature. One, allodynia, quickly came into use in the columns of Pain and other journals. The terms have been translated into Portuguese (Rev. Bras. Anest., 30, 5, [1980] 349-351,) into French (H. Dehen, Lexique de la douleur, La Presse MĂŠdicale 12, 23, [1983] 1459-1460), and into Turkish (as Agri TerimlĂŤri, translated by T. Aldemir, J. Turkish Soc. Algology, 1 [1989] 45-46). A supplementary note was added to these pain terms in Pain (14 [1982] 205-206).

The original list was adopted by the first Subcommittee on Taxonomy of IASPÂŽ. Subsequent revisions and additions were prepared by a subgroup of the C ommittee, particularly Drs. U. Lindblom, P.W. Nathan, W. Noordenbos, and H. Merskey. In 1984, in particular response to some observations by Dr. M. Devor, a further review was undertaken both by correspondence and during the 4th World C ongress on Pain of IASP. Those taking part in that review included Dr. Devor, the other colleagues just mentioned, and Dr. J.M. Mumford, Sir Sydney Sunderland, and Dr. P.W. Wall. Following that review, it was agreed to take advantage of the publication of the draft collection of syndromes and their system for classification, to issue an updated list of terms with definitions and notes on usage.

The versions now presented are based upon some subsequent discussions by correspondence. The form of the definitions and notes at this point has been the responsibility of the editor (H.M.). It would be difficult now to single out individual contributions, but the editor remains heavily indebted to those five members of the original Subcommittee on Taxonomy who sustained this work in the form of an Ad Hoc group and whose names are listed at the beginning of this report. Their knowledge and patience was repeatedly provided freely and with good will.

The revised current list follows. The original comments provided as an introduction to the terms are given in the following two paragraphs, which indicate both the process by which the terms were first delivered and the justification for them.

"The usage of individual terms in medicine often varies widely. That need not be a cause of distress provided that each author makes clear precisely how he employs a word. Nevertheless, it is convenient and helpful to others if words can be used which have agreed technical meanings. Following correspondence and meetings during the period 1976-1978, the present committee agreed on the definitions which follow, and the notes have been prepared by the chairman in the light of members' comments. The definitions are intended to be specific and explanatory and to serve as an operational framework, not as a constraint on future development. They represent agreement between diverse specialties including anesthesiology, dentistry, neurology, neurosurgery, neurophysiology, psychiatry, and psychology. A starting point for some of these definitions was provided by the reports of a workshop on Oro-Facial Pain held at the U.S. National Institute of Dental Research in November 1974.

"The terms and definitions are not meant to provide a comprehensive glossary but rather a minimum standard vocabulary for members of different disciplines who work in the field of pain. We hope that they will prove acceptable to all those in the health professions who deal with pain. Not only are they a limited selection from available terms, but it is emphasized that except for pain itself, they are defined primarily in relation to the skin and the special senses are excluded. They may be used when appropriate for responses to somatic stimulation elsewhere or to the viscera. Except for Pain, the arrangement is in alphabetical order."

It is important to emphasize something that was implicit in the previous definitions but was not specifically stated: that the terms have been developed for use in clinical practice rather than for experimental work, physiology, or anatomical purposes.

Pain Terms Allodynia Pain due to a stimulus which does not normally provoke pain. Note: The term allodynia was originally introduced to separate from hyperalgesia and hyperesthesia, the conditions seen in patients with lesions of the nervous system where touch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin. Allo means "other" in Greek and is a common prefix for medical conditions that diverge from the expected. Odynia is derived from the Greek word "odune" or "odyne," which is used in "pleurodynia" and "coccydynia" and is similar in meaning to the root from which we derive words with -algia or -algesia in them. Allodynia was suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario.

The words "to normal skin" were used in the original definition but later were omitted in order to remove any suggestion that allodynia applied only to referred pain. Originally, also, the pain-provoking stimulus was described as "non-noxious." However, a stimulus may be noxious at some times and not at others, for example, with intact skin and sunburned skin, and also, the boundaries of noxious stimulation may be hard to delimit.

Since the C ommittee aimed at providing terms for clinical use, it did not wish to define them by reference to the specific physical characteristics of the stimulation, e.g., pressure in kilopascals per square centimeter.

Moreover, even in intact skin there is little evidence one way or the other that a strong painful pinch to a normal person does or does not damage tissue. Accordingly, it was considered to be preferable to define allodynia in terms of the response to clinical stimuli and to point out that the normal response to the stimulus could almost always be tested elsewhere in the body, usually in a corresponding part. Further, allodynia is

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could almost always be tested elsewhere in the body, usually in a corresponding part. Further, allodynia is taken to apply to conditions which may give rise to sensitization of the skin, e.g., sunburn, inflammation, trauma.

It is important to recognize that allodynia involves a change in the quality of a sensation, whether tactile, thermal, or of any other sort. The original modality is normally non-painful, but the response is painful. There is thus a loss of specificity of a sensory modality. By contrast, hyperalgesia (q.v.) represents an augmented response in a specific mode, viz., pain. With other cutaneous modalities, hyperesthesia is the term which corresponds to hyperalgesia, and as with hyperalgesia, the quality is not altered. In allodynia the stimulus mode and the response mode differ, unlike the situation with hyperalgesia. This distinction should not be confused by the fact that allodynia and hyperalgesia can be plotted with overlap along the same continuum of physical intensity in certain circumstances, for example, with pressure or temperature.

See also the notes on hyperalgesia and hyperpathia.

Analgesia Absence of pain in response to stimulation which would normally be painful. Note: As with allodynia (q.v.), the stimulus is defined by its usual subjective effects.

Anesthesia Dolorosa Pain in an area or region which is anesthetic.

Causalgia A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes.

Central Pain Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

Dysesthesia An unpleasant abnormal sensation, whether spontaneous or evoked. Note: C ompare with pain and with paresthesia. Special cases of dysesthesia include hyperalgesia and allodynia. A dysesthesia should always be unpleasant and a paresthesia should not be unpleasant, although it is recognized that the borderline may present some difficulties when it comes to deciding as to whether a sensation is pleasant or unpleasant. It should always be specified whether the sensations are spontaneous or evoked.

Hyperalgesia An increased response to a stimulus which is normally painful. Note: Hyperalgesia reflects increased pain on suprathreshold stimulation. For pain evoked by stimuli that usually are not painful, the term allodynia is preferred, while hyperalgesia is more appropriately used for cases with an increased response at a normal threshold, or at an increased threshold, e.g., in patients with neuropathy. It should also be recognized that with allodynia the stimulus and the response are in different modes, whereas with hyperalgesia they are in the same mode. C urrent evidence suggests that hyperalgesia is a consequence of perturbation of the nociceptive system with peripheral or central sensitization, or both, but it is important to distinguish between the clinical phenomena, which this definition emphasizes, and the interpretation, which may well change as knowledge advances.

Hyperesthesia Increased sensitivity to stimulation, excluding the special senses. Note: The stimulus and locus should be specified. Hyperesthesia may refer to various modes of cutaneous sensibility including touch and thermal sensation without pain, as well as to pain. The word is used to indicate both diminished threshold to any stimulus and an increased response to stimuli that are normally recognized.

Allodynia is suggested for pain after stimulation which is not normally painful. Hyperesthesia includes both allodynia and hyperalgesia, but the more specific terms should be used wherever they are applicable.

Hyperpathia A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold. Note: It may occur with allodynia, hyperesthesia, hyperalgesia, or dysesthesia. Faulty identification and localization of the stimulus, delay, radiating sensation, and after-sensation may be present, and the pain is often explosive in character. The changes in this note are the specification of allodynia and the inclusion of hyperalgesia explicitly. Previously hyperalgesia was implied, since hyperesthesia was mentioned in the previous note and hyperalgesia is a special case of hyperesthesia.

Hypoalgesia Diminished pain in response to a normally painful stimulus. Note: Hypoalgesia was formerly defined as diminished sensitivity to noxious stimulation, making it a particular case of hypoesthesia (q.v.). However, it now refers only to the occurrence of relatively less pain in response to stimulation that produces pain.

Hypoesthesia covers the case of diminished sensitivity to stimulation that is normally painful.

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The implications of some of the above definitions may be summarized for convenience as follows: Allodynia: lowered threshold: stimulus and response mode differ Hyperalgesia: increased response: stimulus and response mode are the same Hyperpathia: raised threshold: stimulus and response mode may be the increased response: same or different Hypoalgesia: raised threshold: stimulus and response mode are the same lowered response: The above essentials of the definitions do not have to be symmetrical and are not symmetrical at present.

Lowered threshold may occur with allodynia but is not required. Also, there is no category for lowered threshold and lowered response - if it ever occurs.

Hypoesthesia Decreased sensitivity to stimulation, excluding the special senses. Note: Stimulation and locus to be specified.

Neuralgia Pain in the distribution of a nerve or nerves. Note: C ommon usage, especially in Europe, often implies a paroxysmal quality, but neuralgia should not be reserved for paroxysmal pains.

Neuritis Inflammation of a nerve or nerves. Note: Not to be used unless inflammation is thought to be present.

Neurogenic Pain Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.

Neuropathic Pain Pain initiated or caused by a primary lesion or dysfunction in the nervous system. Note: See also Neurogenic Pain and C entral Pain. Peripheral neuropathic pain occurs when the lesion or dysfunction affects the peripheral nervous system. C entral pain may be retained as the term when the lesion or dysfunction affects the central nervous system.

Neuropathy A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy. Note: Neuritis (q.v.) is a special case of neuropathy and is now reserved for inflammatory processes affecting nerves. Neuropathy is not intended to cover cases like neurapraxia, neurotmesis, section of a nerve, or transitory impact like a blow, stretching, or an epileptic discharge. The term neurogenic applies to pain due to such temporary perturbations.

Nociceptor A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged. Note: Avoid use of terms like pain receptor, pain pathway, etc.

Noxious Stimulus A noxious stimulus is one which is damaging to normal tissues. Note: Although the definition of a noxious stimulus has been retained, the term is not used in this list to define other terms.

Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.

Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain.

Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause.

Pain Threshold The least experience of pain which a subject can recognize. Note: Traditionally the threshold has often been defined, as we defined it formerly, as the least stimulus intensity at which a subject perceives pain. Properly defined, the threshold is really the experience of the patient, whereas the intensity measured is an external event. It has been common usage for most pain research workers to define the threshold in terms of the stimulus, and that should be avoided. However, the threshold stimulus can be recognized as such and

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measured. In psychophysics, thresholds are defined as the level at which 50% of stimuli are recognized. In that case, the pain threshold would be the level at which 50% of stimuli would be recognized as painful. The stimulus is not pain (q.v.) and cannot be a measure of pain.

Pain Tolerance Level The greatest level of pain which a subject is prepared to tolerate. Note: As with pain threshold, the pain tolerance level is the subjective experience of the individual. The stimuli which are normally measured in relation to its production are the pain tolerance level stimuli and not the level itself. Thus, the same argument applies to pain tolerance level as to pain threshold, and it is not defined in terms of the external stimulation as such.

Paresthesia An abnormal sensation, whether spontaneous or evoked. Note: C ompare with dysesthesia. After much discussion, it has been agreed to recommend that paresthesia be used to describe an abnormal sensation that is not unpleasant while dysesthesia be used preferentially for an abnormal sensation that is considered to be unpleasant. The use of one term (paresthesia) to indicate spontaneous sensations and the other to refer to evoked sensations is not favored. There is a sense in which, since paresthesia refers to abnormal sensations in general, it might include dysesthesia, but the reverse is not true. Dysesthesia does not include all abnormal sensations, but only those which are unpleasant.

Peripheral Neurogenic Pain Pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral nervous system.

Peripheral Neuropathic Pain Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system.

Pasted from <http://www.iasp-pain.org/AM/Template.cfm?

Section=General_Resource_Links&Template=/CM/HTMLDisplay.cfm&ContentID=3058>

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2. Monday Evening Readings: Acute Pain Saturday, March 22, 2008

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Symptoms and signs in patients with suspected neuropathic pain Saturday, March 22, 2008

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Neuropathic pain: a practical guide for the clinician Saturday, March 22, 2008

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Pain and Analgesia Saturday, March 22, 2008

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New Zealand Acute Low Back Pain Guide Saturday, March 22, 2008

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3. Tuesday Evening Readings: Persistent Pain Saturday, March 22, 2008

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Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations Saturday, March 22, 2008

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Psychological assessment and treatment of the pain patient.

Saturday, March 22, 2008

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Randomised controlled trial of a community-based psychoeducation program for the self-management of chronic pain.

Saturday, March 22, 2008

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4. Pain Measures Saturday, March 22, 2008

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Outcome assessment in chronic non-cancer pain treatment Saturday, March 22, 2008

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McGill pain questionnaire: appraisal and current status Saturday, March 22, 2008 Handbook of Pain Assessment - Google Book Search http://books.google.com/books?hl=en&lr=&id=uwdW66V1Lt8C&oi=fnd&pg=PA35&dq=%22MELZACK%22+%22The+McGill+Pain+Questionnaire: +Appraisal+and+Current+Status%22+&ots=le0Cop0uJY&sig=9QjsG09ItISXSY86N2tS8A6MQWI#PRA1-PA35,M1

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Validity of a verbally administered numeric rating scale to measure cancer pain intensity Saturday, March 22, 2008

Validity of a verbally administered numeric rating scale to measure cancer pain intensity ISSN: 0162-220X Accession: 00002820-199704000-00002 Email Jumpstart ≪ Find Citing Articles≫ Table of Contents About this Journal

Author(s):

Paice, Judith A. Ph.D., R.N.; Cohen, Felissa L. Ph.D., R.N.

Issue:

Volume 20(2), April 1997, pp 88-93

Publication Type:

[Article]

Publisher:

© Lippincott-Raven Publishers

Institution(s): Judith A. Paice is a Clinical Nurse Specialist in Pain Management at the Department of Neurosurgery at the Rush -Presbyterian-St. Luke's Medical Center, and an Associate Professor at the College of Nursing, Rush University, Chicago, Illinois, U.S.A. Felissa L. Cohen is the Dean of the School of Nursing and Professor at the Southern Illinois University at Edwardsville, Edwa rdsville, Illinois, U.S.A. Address correspondence and reprint requests to Dr. Judith A. Paice, Rush Neuroscience Institute, 1725 W. Harrison St., Ste. 7 55, Chicago, IL 60612, U.S.A. Accepted for publication September 24, 1996.

Keywords: Pain, Measurement, Visual analog scale, Numeric rating scale, Simple descriptor scale. ≪ Table of Contents: ≫ Analysis of recent literature concerning relaxation and imagery interventions for cancer pain.

Distress symptoms and support systems of Chinese parents of children with cancer.

Links Abstract Complete Reference Get it! UofT Libraries

Outline • Abstract • REVIEW OF PAIN INTENSITY MEASURES ○ SDS ○ VAS ○ NRS • METHODS ○ Sample ○ Materials and Methods ○ Statistical Analysis • RESULTS ○ Demographic Characteristics of Subjects ○ Construct Validity ○ Preference and Use of the Scales ○ Inability to Complete the Scales • DISCUSSION • REFERENCES

Graphics • Table 1 • Table 2 • Table 3 • Table 4 Abstract The ability to quantify pain intensity is essential when caring for individuals in pain in order to monitor patient progress and analgesic effectiveness.

Three scales are commonly employed: the simple descriptor scale (SDS), the visual analog scale (VAS), and the numeric (pain i ntensity) rating scale (NRS). Patients with English as a second language may not be able to complete the SDS without translation, and visually, cognitively, or physically impaired patients may have difficulty using the VAS. The NRS has been found to be a simple and valid alternative in some disease states; however, the validity of this scale administered verbally, without visual cues, to oncology patients has not yet been established. The present study examined validity of a verbally administered 0-10 NRS using convergence methods. The correlation between the VAS and the NRS was strong and statistically significant (r = 0.847, p < 0.001), supporting the validity of the verbally administered NRS. Although all subjects were able to complete the NRS and SDS without apparent difficulty, 11 subjects (20%) were unable to complete the VAS. The mean opioid intake was significantly higher for the group that was unable to complete the VAS (mean 170.8 mg, median 120.0 mg, SD = 135.8) compared to the group that had no difficulty with the scale (mean 65.6 mg, 33.0 mg, SD = 99.7) (Mann-Whitney test, p = 0.0065). The verbally administered 0-10 NRS provides a useful alternative to the VAS, particularly as more contact with patients is established via telephone and patients within the hospital are more acutely ill .

The ability to quantify pain intensity is essential when evaluating the efficacy of analgesic therapies. The Agency for Health Care Policy and Research

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The ability to quantify pain intensity is essential when evaluating the efficacy of analgesic therapies. The Agency for Health Care Policy and Research Management of Cancer Pain clinical practice guideline recommends that health professionals should ask about pain, and the patient's self-report should be the primary source of assessment (1). Three scales are commonly employed to assess pain intensity: the simple descriptor (pain intensity) scale (SDS), the visual analog scale (VAS), and the 0-10 numeric rating (pain intensity) scale (NRS). Because the VAS generates continuous data that can be analyzed using parametric statistics, this scale is frequently used in pain research. Unfortunately, several factors have been reported to limit its use in measuring cancer pain intensity in clinical settings: (a) patients are often too ill to physically mark the line: (b) elderly or very sick patients may be unable to conceptualize pain in an abstract fashion along a line; and (c) this scale cannot be used in some patients who a re visually, cognitively, or physically impaired.

The NRS appears to hold two advantages for measuring pain: the 0-10 NRS is simple and has been found to be a valid measure of pain intensity (2,3).

However, the validity of the NRS administered verbally, without visual cues, to a group of oncology patients has not yet been established. The psychometric adequacy of this instrument must be known in order to ascertain whether it truly measures pain intensity in this population (4).

Furthermore, the need to establish the validity of a verbally administered scale is critical at a time when more contact is established via telephone and when the acuity levels of those patients within the hospital is higher. The present study examined construct validity of a verbally administered 0-10 NRS using convergence methods. Additionally, this study confirms the usefulness of the 11-point NRS, administered without visual cues, in a population of oncology patients.

REVIEW OF PAIN INTENSITY MEASURES SDS The SDS, also referred to as the verbal rating scale(VRS) or verbal descriptor scale (VDS), consists of adjectives that are r anked in order of severity (Table 1). The SDS generally employs three to six adjectives that describe various states of pain intensity; however, the descriptors used are not consistent in every version of the scale (4). Scales may include terms such as "nil, mild, moderate, severe, very severe" or "no pain, mild, moderate, horrible, excruciating"(1,4). This inconsistency hampers comparison of data from different studies that employ these type of pain intensity scales.

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TABLE 1. Pain intensity scales

Patient acceptance of the use of the SDS also varies among different populations. Although Kremer et al.(2) found that patients in their study preferred the SDS. Ahles (5) discovered poor compliance with recording daily pain intensity using this tool.

Statistical limitations are another consideration in the use of the SDS. The limited number of points for rating pain intensi ty results in a less sensitive scale than other pain intensity measures. Although some investigators consider the scale to be ordinal, the distances between its descriptors are not shown to be equal; hence, it is categorical (6). Thus, nonparametric statistical procedures are appropriate to analyze data generated from this scale.

VAS Although the VAS is the current standard by which pain intensity scales are measured (Table 1) (7), its use poses problems in some clinical situations.

The VAS uses a 10-cm line anchored at each end by verbal descriptors, such as "no pain" and "the worst pain imaginable." The subject is asked to mark a spot that best represents their pain intensity. Vertical and horizontal scales, with or without calibration, have also been used, as have mechanical versions patterned after a slide rule (8-11).

The VAS has been studied extensively and has been found to be a reliable and valid tool in assessing pain (12,13). However, Kremer et al.(2) note that as many as 11% of those subjects surveyed may be unable to complete the VAS, particularly the elderly who may not be able to abstractly consider the representation of pain along a 10-cm continuum. In another study of pain rating scales, the association between advanced age and inability to correctly complete the VAS was positively correlated and statistically significant (r = 0.31, p < 0.01)(14). Other investigators also support the findings of difficulty completing the VAS (15,16). Furthermore, physical disability, such as immobility or reduced visual acuity, may limit the individual's ability to mark the appropriate spot on the line. Scott and Huskisson (9) recommend exposing patients to these scales prior to initiating their use in clinical trials to reduce failure rates.

Controversy exists regarding whether the VAS is a ratio (17) or interval scale (18). Either scaling property allows analysis using powerful parametric statistics. In an excellent review, Gift (19) discusses the strengths and weaknesses of the use of the VAS to measure pain and other subjective

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statistics. In an excellent review, Gift (19) discusses the strengths and weaknesses of the use of the VAS to measure pain and other subjective phenomenon.

NRS The third scale employed to measure pain intensity is the NRS (Table 1). Variations of this tool include a six-point scale (0-5), an 11-point scale (0-10), and a 101-point scale (0-100)(20). Patients choose a number that best represents their pain intensity. Zero indicates no pain; the highest number represents the worst pain imaginable.

The NRS appears both valid and usable, and has strong positive correlation with the VAS (2). Downie et al.(3) explored differences between the VAS, NRS, and SDS in a population of rheumatology patients and found the least amount of error variance when using the NRS; they concluded that the NRS was also the preferred tool because it offers more choices that the SDS, but fewer choices than the potentially confusing VAS. Of concern to those using the NRS is the number of points necessary to most accurately measure pain intensity. Jensen et al.(21) found that when using a 101-point NRS in chronic noncancer pain patients a substantial number treated the tool as an 11-point scale. Thus, these investigators conclude that a 0-10 NRS provides sufficient sensitivity to measure pain in most patients. In a comparison of pain ratings using a six-point NRS and the standard 10-cm VAS in a cancer population, statistically significant discrepancies were noted when comparing patient pain intensity reports (22). Only 24% of the ratings given by cancer patients were mathematically equivalent, with VAS scores averaging 1.5 points or cm (using a 0-10 cm measure) lower. Thus, a 0-5 NRS cannot be considered equivalent to the VAS. Other benefits of the NRS include the ease of administration of the scale. Verbal administration of the NRS obviates the need for specially printed paper or cards, such as required in the use of the VAS. Verbal administration also allows those individuals who are visually or physically disabled, as well as those patients communicating by telephone, to quantify their pain intensity. A recent comparison of the verbally admi nistered NRS(called a nonvisual analog scale by the authors) with the VAS revealed good agreement between these scales (correlation coefficient r = 0.797) in a population of postoperative patients (23). In another investigation, strong correlation was found between the VAS and the NRS (in repeated measures, r = 0.77-0.89); however, the sample size was small, consisting of 15 patients (24).

Despite these observations, however, few studies have examined the use of the NRS in pain: none have studied the validity of the 0-10 scale in a larger sample of cancer patients. The present study sought to establish the convergent validity of the verbally administered 11-point (0-10) NRS in a group of oncology patients.

METHODS Sample The admission roster identified hospitalized adult patients with cancer at a large tertiary care hospital. A convenience sample of 50 subjects was chosen. All subjects met the following criteria: (a) documentation of malignancy, (b) current experience of pain, and (c) abi lity to understand English.

Materials and Methods Approval for this study was obtained from the Investigational Review Boards of Rush-Presbyterian-St. Luke's Medical Center (where data collection occurred) and the University of Illinois at Chicago. The purpose of the study was described to the subjects, and they were guaranteed that the individual's response would remain anonymous. After receiving consent for participation, the investigator recorded data, such as age, gender, education, diagnosis, pain location, daily opioid intake, and length of time the subject had experienced pain, on a standardi zed form developed for this study. The investigator also rated the subjects's physical performance status using the Zubrod scale, a five-point measure of physical function frequently used in chemotherapy clinical trials.

The VAS and SDS (adapted from the Present Pain Intensity subscale of the McGill Pain Questionnaire) were pictured on separate 5 Ă&#x2014; 7" cards (25).

Another card displayed the statement "On a scale of 0 to 10, in which 0 is no pain, and 10 is the most severe pain you can possibly imagine, what number would you give your pain at this moment?" This NRS card ensured consistency in the instructions given to each subject. The investigator read this statement to the patient in place of the visual NRS. The order of administration of the three pain intensity scales (VAS, NRS, and SDS) was determined by the use of a random numbers table. After completing all three pain intensity scales, subjects were asked to identify the scale that they preferred to use to measure their pain.

Statistical Analysis All opioids ordered and administered were converted to morphine equivalencies using an accepted equianalgesic table (1). The SPSS-PC (V 6.1) statistical software package was used to generate [chi]2 , Mann-Whitney tests, and descriptive statistics. Spearman correlation coefficients were determined to establish the similarity between the three pain intensity scales, providing evidence for convergent validity.

RESULTS Demographic Characteristics of Subjects The subjects ranged in age from 19 to 76 years, with a mean age of 54.8 years (SD = 13.5 years). They had completed an average of 13.0 years of formal education (SD = 2.9 years). A wide variety of malignancies and pain locations was represented (Tables 2 and 3). All subjects complained of pain at the time of the interview. The length of time of chronic pain of subjects ranged from <1 month to 72 months, with an avera ge length of time in pain of 6.9 months (SD = 12.5 months). The average daily amount of opioid analgesics ordered for their use was 119.8 mg (SD= 125.4 mg). Their average daily intake of opioid in morphine equivalents was 87.1 mg, with a range of no opioid intake to 556 mg/day (SD = 114.6 mg/day).

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TABLE 2. Demographic characteristics of patients(n = 50) From: Paice: Cancer Nurs, Volume 20(2).April 1997.88-93

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TABLE 2. Demographic characteristics of patients(n = 50)

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TABLE 3. Pain characteristics of patients (n = 50)

Construct Validity A Spearman correlation coefficient was obtained for each relationship. The strong positive correlation between the VAS and the NRS was also highly statistically significant (r = 0.847, p < 0.001). This correlation matrix appears in Table 4. Correlations between the VAS and SDS (r = 0.708, p < 0.001) are similar to those previously reported (26). Given that the VAS is widely accepted as a valid tool to measure pain intensity and the NRS is highly correlated with the VAS, the validity of the verbally administered NRS in measuring pain intensity is supported.

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TABLE 4. Correlation matrix of three pain intensity scales

Preference and Use of the Scales A majority of subjects (50%) preferred the use of the NRS when comparing the three scales used to measure pain intensity. When comparing these patients with the overall sample, there were no statistically significant differences when evaluating age, gender, education, diagnosis, length of time in pain, or location of pain. Fewer patients preferred the SDS (38%), with the VAS chosen least often (12%). These results ma y reflect a bias by the

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subjects toward the NRS as more nurses and physicians currently use this scale to evaluate pain at the study institution. Thus, patients may have been exposed to this scale in the past and may have been more comfortable with the NRS. Previous exposure to these three scales wa s not evaluated.

Inability to Complete the Scales Several authors have reported an inability to complete the VAS. Eleven subjects (20%) in this study were unable to complete the VAS or did so with great difficulty. Problems included marks made that were very wide or were far above the line. These responses made interpretation difficult. Two of these 11 subjects marked the opposite end of the line they intended to and asked to re-mark the line after completing the other intensity scales. One patient required assistance in holding the pencil. Eight subjects asked to have the instructions regarding the VAS read to them several times. All subjects were able to complete the NRS and SDS without apparent difficulty.

There were no statistically significant differences in age, gender, activity level or educational level among those subjects who were unable or able to complete the VAS (p > 0.05). The mean opioid intake was significantly higher for the group who was unable to complete the VAS (mean 170.8 mg, median 120.0 mg, SD = 135.8) compared to the group who had no difficulty with the scale (mean 65.6 mg, median 33.0 mg, SD = 99.7). This difference was statistically significant (Mann-Whitney test, p = 0.0065).

DISCUSSION This study indicates that the verbally administered NRS is valid as a measure of pain intensity among oncology patients. The majority of subjects also preferred the NRS, and although 20% had some difficulty completing the VAS, the NRS presented no apparent difficulty. Of interest are the characteristics of those patients unable to complete the VAS. Although previous investigators have postulated that the elderl y might have more difficulty completing the VAS, our study did not support this belief. In fact, opioid intake was the only predictor of inabil ity to complete the VAS. Future studies must address whether this is a result of cognitive impairment due to the opioid, or if opioid intake is an indirect measure of the severity of the patient's pain or disease status. Additionally, the performance status scale we employed in this study may not have been sufficiently sensitive to detect differences between these groups.

One cannot generalize beyond this sample because selection was not random and because of the small sample size. Replication of this study, including a larger, random sample, is necessary. Despite these limitations, these results have implications for both clinical practice and further research. Over time, clinicians tend to re-use the simplest tools. The VAS requires a card for each assessment, the SDS requires knowledge of English adjectives, but the NRS requires neither. As a clinical tool for consistent use, the NRS is the logical choice.

Those caring for cancer patients experiencing pain must also realize that although pain intensity is an important component of the pain assessment, measuring intensity alone is insufficient. Location and quality of the pain, as well as alleviating and aggravating factors s hould be assessed and documented. Many multidimensional tools are available to measure pain: these are described in several excellent reviews (27-31).

REFERENCES 1. Jacox A, Carr D, Payne R, et al. Management of cancer pain. Clinical practice guideline no. 9. AHCPR publication no. 94-0592. Rockville, MD: Agency for Health Care Policy and Research. U.S. Department of Health and Human Services, Public Health Service, 1994. [Context Link] 2. Kremer E. Atkinson, JH, Ingelzi RJ. Measurement of pain: patient preference does not confound pain measurement. Pain 1981;10:241-8. Full Text Bibliographic Links [Context Link] 3. Downie WW, Leatham PA, Rhind VM, et al. Studies with pain rating scales. Ann Rheum Dis 1978; 37:378-81. Bibliographic Links [Context Link] 4. Turk DE, Rudy DC. Assessing pain among oncology and terminally ill patients: psychometric considerations. Hospice J 1986;2:61-73. Bibliographic Links [Context Link] 5. Ahles TA, Tuckdeschel JC, Blanchard EB. Cancer-related pain. II. Assessment with visual analogue scales. J Psychosom Res 1984; 28:121-4. Full Text Bibliographic Links [Context Link] 6. Ohnhaus EE, Adler R. Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale. Pain 1975;1:379-84. [Context Link] 7. Huskisson EC. Measurement of pain. Lancet 1974;2:1127-31. Bibliographic Links [Context Link] 8. Scott J, Huskisson EC, Vertical or horizontal visual analogue scales. Ann Rheum Dis 1979;38:560. [Context Link] 9. Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175-84. Full Text Bibliographic Links [Context Link] 10. Price DD, Bush FM, Long S, et al. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 1994;56:217-26. Full Text Bibliographic Links [Context Link] 11. Grossman SA, Sheidler VR, McGuire DB, et al. A comparison of the Hopkins Pain Rating Instrument with standard visual analogue and verbal descriptor scales in patients with cancer pain. J Pain Symptom Manage 1992;7:196-203. Bibliographic Links [Context Link] 12. Joyce CRB, Zutshi DW, Hrubes V, et al. Comparison of fixed interval and visual analogue scales for rating chronic pain. Eur J Clin Pharmacol 1975;8:415-20. [Context Link] 13. Revill SI, Robinson JO, Rosen M, et al. The reliability of a linear analogue for evaluating pain. Anaesthesia 1976;31:1191-8. Bibliographic Links [Context Link] 14. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain 1986;27:117-26. Full Text Bibliographic Links [Context Link] 15. Sriwatanakul K, Kelvie W, Lasagna L. The quantification of pain: an analysis of words used to describe pain and analgesia in clinical trials. Clin Pharmacol Ther 1982;32:143-8. Bibliographic Links [Context Link] 16. Shannon MM, Ryan MA, D Agostino N, et al. Assessment of pain in advanced cancer patients. J Pain Symptom Manage 1995;10:274-8. Full Text Bibliographic Links [Context Link] 17. Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain.

Pain 1983;17:45-56. [Context Link] 18. Syrjala KL, Chapman CR. Measurement of clinical pain: a review and integration of research findings. In: Benedetti C, Chapman CR, Moricca G, eds.

Advances in pain research and therapy, vol. 7. New York: Raven Press, 1984:71-97. [Context Link] 19. Gift AG. Visual analogue scales: measurement of subjective phenomena. Nurs Res 1989;38:286-9. Ovid Full Text Bibliographic Links [Context Link] 20. Jensen MP, Karoly P, O'Riordan EF, et al. The subjective experience of acute pain: an assessment of the utility of 10 indices. Clin J Pain 1989;5:153-9. Ovid Full Text Bibliographic Links [Context Link] 21. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain 1994;58:387-92. Full Text Bibliographic Links [Context Link] 22. Carpenter JS, Brockopp D. Comparison of patients ratings and examination of nurses responses to pain intensity rating sca les. Cancer Nurs 1995;18:292-8. Ovid Full Text Bibliographic Links [Context Link] 23. Murphy DF, McDonald A, Power C, et al. Measurement of pain: a comparison of the visual analogue scale with a nonvisual analogue scale. Clin J Pain 1988;3:197-9. Ovid Full Text [Context Link] 24. Wilkie D, Lovejoy N, Dodd M, et al. Cancer pain intensity measurement: concurrent validity of three tools -finger dynamometer, pain intensity number scale, visual analogue scale. Hospice J 1990;6:1-13. Bibliographic Links [Context Link] 25. Melzak R. The McGill pain questionnaire: major properties and scoring methods. Pain 1975;1:277-99. [Context Link]

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26. Machin D, Lewith GT, Wylson S. Pain measurement in randomized clinical trials: a comparison of two pain scales. Clin J Pain 1988;4:161-8. Ovid Full Text [Context Link] 27. Chapman CR, Casey KL, Dubner R, et al. Pain measurement: an overview. Pain 1985;22:1-31. Full Text Bibliographic Links [Context Link] 28. Cherny NI, Portenoy RK. Cancer pain: principles of assessment and syndromes. In: Wall PD, Melzack R, eds. Textbook of pai n. 3rd ed. London: Churchill Livingstone, 1994:787-823. [Context Link] 29. Deschamps M. Band PR, Coldman AJ. Assessment of adult cancer pain: shortcomings of current methods. Pain 1988;32:133-9. Full Text Bibliographic Links [Context Link] 30. Jensen MP, Karoly P. Measurement of cancer pain via patient self-report. In: Chapman CR, Foley KM, eds. Current and emerging issues in cancer pain: research and practice. New York: Raven Press, 1993:193-218. [Context Link] 31. McGuire DB. The measurement of clinical pain. Nurs Res 1984;33:152-6. Ovid Full Text Bibliographic Links [Context Link] Key Words: Pain; Measurement; Visual analog scale; Numeric rating scale; Simple descriptor scale.

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Validation of the Brief Pain Inventory for chronic nonmalignant pain Saturday, March 22, 2008

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5. Evidence-Based Reviews Saturday, March 22, 2008

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Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects.

Saturday, March 22, 2008

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Pharmacologic management of neuropathic pain: evidence-based recommendations.

Saturday, March 22, 2008

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ICSI Guideline: Adult Low Back Pain Saturday, March 22, 2008

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ICSI Guideline: Assessment and management of chronic pain Saturday, March 22, 2008

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6. Additional References Saturday, March 22, 2008

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Acute Pain Saturday, March 22, 2008

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