British Pain Society

444364
2012
BJP0010.1177/2049463712444364AbstractsBritish Journal of Pain
Abstracts
British Pain Society
Annual Scientific Meeting
Bournemouth, United Kingdom

16 19 April 2013
British Pain Society Scientific/Abstract Committee were:

Professor Gary Macfarlane (Chair)
Professor Mike Bennett
Professor Candy McCabe
Dr Beverly Collett
Professor Roger Knaggs
Professor Maria Fitzgerald
Professor Stephen Morley
Professor Kate Sears
Professor Paul Watson
University of Aberdeen
University of Leeds
University of the West of England
Leicester Royal Infirmary
University of Nottingham
University College London
University of Leeds
University of Warwick
University of Leicester
Support for the Abstract Committee and for the production of this British Journal of Pain supplement was
provided by Ken Obbard, Jenny Nicholas and Rikke Sussgard-Vigon.
Editorial remarks
The opinions or views expressed in this abstract book are those of the authors and do not necessarily reflect the
opinions or recommendations of the British Pain Society or the publisher. The published abstracts have been typeset from electronic submission. Every effort has been made to reproduce faithfully the abstracts as submitted.
Dosages, indications and methods of use of products that are referred to in the abstract book by the authors are
not necessarily appropriate for clinical use and may reflect the clinical experience of the authors or may be
derived from professional literature of other clinical sources.
The investigators of these abstracts have stated in their submission documentation that prospective studies where
patients are involved have institutional and Ethics Committee approval and informed patient consent.
The British Pain Society. A company registered in England and Wales and limited by guarantee. Registered
address: Third Floor, Churchill House, 35 Red Lion Square, London WC1R 4SG. Registered No. 5021381.
Registered Charity No. 1103260. A charity registered in Scotland No. SC039583
Registration Programme
Annual Scientific Meeting
Liverpool
24 - 27 April 2012
Volume 7 Supplement 1 April 2013
Contents
Acute Pain
5-11
Assessment & Measurement
11-19
Cancer Pain
19-21
Education 21-25
Elderly 25
Epidemiology 25-27
Evidence & Guidelines
27-30
Experimental (Basic) Science
31-32
Interventional Pain Management
32-40
Management (Audit)
40-48
Management (Research)
48-49
Neuropathic Pain
49-53
Non-Pharmacological Pain Management
53-58
Other 58-61
Paediatric 61-64
Primary Care
64-66
Psychology 66-75
Reviews 75
Translational Pain Research
75-76
Index 77-86
466517
2013
BJP0010.1177/2049463713481587British Journal of PainLucas
Abstracts
British Journal of Pain
7(2) Supplement 1 576
The British Pain Society 2013
Reprints and permissions:
sagepub.co.uk/
journalsPermissions.nav
DOI: 10.1177/2049463713481587
bjp.sagepub.com
Acute Pain
001
A Follow-Up Pilot Study Looking At Pain Management
After Discharge, Following Major Surgery
Category: Acute Pain
Charlotte Halmshaw, Carsten Bantel, Stephen Ward, Tanya Carr,
Sarah Thomas
Chelsea and Westminster Hospital, London, UK
Background
discharge. In contrast, 87% of patients in the LG weaned their analgesics. However, weaning followed a different pattern with 36%
of the weaning patients reducing medication within 1, 36% within
2 and 28% between-2-6 weeks. This possibly reflects a better adaption of patients to individual needs in the LG. Further support is
provided by the finding that in the N-LG, 40% were still requiring
weak-opioids compared with 31% of the LG.
Interestingly, 2 patients of the LG accessed a GP-appointment,
compared with 1 patient of the N-LG. Since GP-appointments were
mentioned in the leaflet, again this likely reflects greater patient
autonomy.
Information received after surgery is essential for each patient in facilitating the transition from hospital to home (Suhonen et al, 2005;
Williams, 2008). Recent research has shown shorter recovery times
(Kehlet, 2009), reduced anxiety (McDonald et al, 2004), and improved
satisfaction of hospital care (Walker, 2007) when information was provided. However, studies so far have only looked at specific patient cohorts, such as orthopaedic or colorectal patients. There is limited data
available about the effect of leaflets on a generalised patient population
after major surgery. In addition, data is lacking on how patients manage
pain after discharge. Specifically, only scarce information is available
about patterns of analgesic consumption and weaning at home.
This pilot study aimed to explore whether providing an information leaflet on pain management after surgery, provided benefits to
patients. Secondly, it aimed to introduce a follow-up interview to
obtain evidence on general pain management after discharge.
Conclusion
Methods
A Survey On The Use Of Surgical Site Catheter Analgesia In The United Kingdom
A structured questionnaire-based interview was developed and trialled with initially 3 patients. The leaflet was subsequently revised to
its final version, which was then handed out to 20 patients. A random
sample was selected by reviewing day 1 post-operative patients after
major surgery. Verbal consent was obtained from 20 patients who
had been given the leaflet prior to discharge (leaflet group- LG), and
20 further patients who had not been given the leaflet (non-leaflet
group- N-LG). Epidemiological data and information about each
patient was taken from the patients notes. The period selected was
6th August 2012 to 17th September 2012, and the exclusion criteria was age <16 and non-English speaking. Data was collected 2-6
weeks after discharge from hospital. A 10 minute telephone followup interview was completed on all 40 patients. Having collected the
data, this was entered into a spread-sheet for the purpose of analysis.
Results
36 patients (mean age: 50+/-17) were finally included (N-LG: n=20;
LG: n=16) for analysis.
In the N-LG,-10% did not stop their analgesics compared to 13%
of the LG. Of the remaining 90% in the N-LG, 58% reduced their
analgesics within 1, 42% within 2, and none within 2-6 weeks after
This study shows that providing information leaflets may directly

influence the way patients manage their analgesics at home after
discharge from hospital. These findings emphasise that providing
information might improve patients ability to wean, or alternatively
take analgesics for longer. It therefore may help patients to adjust
treatment to their individual needs and seek help where necessary.
Hence, leaflets may enforce autonomy and subsequent patient satisfaction, and should be provided together with a follow-up after
major surgery. However, further research is needed to determine the
exact contents of information and the extent of follow-up required.
002

Mohammed Alousi1, Jonathan Yen2, Amod Manocha3, Brigitta
Brandner3
1Royal Free Hospital, London, UK, 2The Ottawa Hospital, Ottawa,
Canada, 3University College Hospital, London, UK
Background
Postoperative pain control is a major concern of patients, as well as affecting recovery, length of hospital stay, and overall outcome. Opioids
remain the main form of postoperative pain relief, but can cause numerous adverse effects such as nausea and vomiting as well as respiratory depression. Techniques such as neuraxial blockade and peripheral nerve blocks can be performed, but are labour intensive, require
expensive equipment, and can have technical failures. Surgical site
catheter analgesia (SSCA) involves inserting a multi-holed catheter
into the wound site, which allows the continuous infusion of local
anaesthetic and is a simple method of providing effective pain relief.
The purpose of this survey was to find out the number of NHS hospitals that provide SSCA and what the current state of practice was.
6
Methods
A one-page survey and a self-addressed stamped envelope were sent
through the postal system to the acute pain services of the 323 acute
care NHS hospitals in the United Kingdom. Respondents were
asked to answer to the questions raised above.
Results
146 surveys were returned, giving a response rate of 45%. Out of
the returned surveys, 70 acute pain services (48%) stated that their
hospital used a form of SSCA. The Painbuster system was used by
18 of the hospitals (26%), while 12 hospitals (17%) used an epidural
catheter and pump. 57% of respondents used Bupivacaine as the
local anaesthetic.
SSCA was used by 47% of respondents for orthopaedic cases and
by 44% for general surgical operations. Most patients (81%) were
looked after on the ward, while 17% were looked after in high dependency or intensive care unit.
The acute pain service was involved with looking after 80% of patients using SSCA, whereas the anaesthetist on-call was involved in
46% of cases. 66% of hospitals using SSCA had a protocol in place,
while another 10% of respondents stated that they were in midst of
implementing one.
Conclusion
Our survey shows that almost 50% of acute hospitals in the NHS
that responded are using a form of SSCA, using an elastometric system such as Painbuster or adapting the pumps used for epidural or
PCA systems. It is interesting to note that the acute pain service was
involved in looking after most of these patients, further showing the
need of the service in hospitals. A majority of patients with SSCA
were looked after the ward highlighting the safety and simplicity of
the delivery system.
003
Improving The Quality Of Analgesia After Shoulder
Arthroplasty Using An Analgesic Pathway.
Nigel Chee1, Elaine OShea1, Sav Wijesingha1, James Dinsmore2
1 Royal Bournemouth Hospital, Bournemouth, Dorset, UK, 2 Queen
Alexandra Hospital, Portsmouth, Hampshire, UK
Background
Royal Bournemouth Hospital performs approximately 60 shoulder
arthroplasties each year. In 2011 a service improvement project
was undertaken, examining the type of anaesthesia provided for
shoulder arthroplasty, postoperative pain scores and analgesia prescribed. As a result of this project, a standardised analgesic pathway
was developed with the aim of improving pain relief and to enable
patients to fully participate in rehabilitation exercises. Perioperatively anaesthesia is provided by an interscalene nerve block and
general anaesthesia with regular paracetamol and a non-steroidal
anti-inflammatory (NSAID). Postoperatively regular paracetamol
and ibuprofen are prescribed. Oxycontin is prescribed regularly,
with the first dose given at 20.00 on the day of surgery and continued 12 hourly for the first two postoperative days. Oramorph
is administered as required. Data was collected 12 months after
initiation of the pathway.
Methods
Between April 2011 and March 2012, 52 shoulder arthroplasties
were performed and the patient notes were analysed. Details of
British Journal of Pain 7(2) Supplement 1

anaesthetic and postoperative pain management were recorded.
Data collected included type of arthroplasty, type of anaesthetic, analgesia prescribed, pain scores at rest and on mobilisation, length of
inpatient stay and causes of delayed discharge from hospital.
Results
All patients (n=52) had an interscalene nerve block and general anaesthetic.
34 (65%) patients received a NSAID. 11 (21%) had a significant
contraindication to NSAID. 37 (71%) patients received Oxycontin, 5 (10%) patients were already prescribed an alternative opiate
medication preoperatively and this was continued.
9 (17%) patients had a pain score 9 on mobilisation on Day 1
compared with 10 (33%) n=30 before introduction of the pathway.
The mean length of stay was 2.9 days (range 1-12 days) compared to
3.4 days (range 2-9 days) pre pathway.
Conclusion
This shoulder arthroplasty pathway is now routinely used within the
trust. Whilst it was a local service improvement project with relatively
small numbers, it has demonstrated how the use of a pathway incorporating regional anaesthesia and multimodal analgesia can benefit
patients. There has been a 48% reduction in the number of patients
who had severe pain on mobilisation day one. We feel that the provision of improved analgesia has contributed to a shorter in-patient
stay. We would fully support expanding such pathways for other procedures and feel that by reducing variation within practice we can
improve patient experience.
004
Use of targinact (oxycodone and naloxone) in the management of acute post-operative pain: a preliminary case series
Arun Bhaskar, Shyam Mantha, Gemma Beirne, Sharon Cundy
The Christie NHS Foundation Trust, Withington, Manchester, Greater
Manchester, UK
Background
Post-operative pain is often undertreated due to poor assessment of
the pain as well as the reluctance to use strong opioids due to the misconception that this would delay discharge from the hospital due to
side-effects like constipation, nausea and vomiting. Patients are often
treated with weak opioids like codeine and tramadol even from day
three after being on an epidural following laparotomy. This not only
resulted in inadequate pain control and at higher doses patients were
not only complaining of constipation and nausea, but also found that
post-operative physiotherapy and mobilisation was being negatively
affected. We started using Targinact (Oxycodone-Naloxone combination) that is proven to reduce the incidence of opioid-induced constipation for the management of acute post-operative pain. We are
presenting the preliminary case series of patients who had undergone
surgery for cancer at The Christie NHS Foundation Trust.
Methods
We looked at patients undergoing major surgery including laparotomies for colo-rectal, gynaecological and urological malignancies as well as major reconstructive surgery following mastectomy
for breast cancer. Patients already on strong opioids and those with
prolonged post-operative stay in the critical care unit were excluded.
Data collected included pain scores (BPI) at rest, on coughing, on
movement and on straining for bowel movement. Patient satisfaction scores, time of first bowel movement, drinking and eating and
Abstracts
removal of nasogastric tube was recorded along with bowel function index. Mobilisation parameters like tolerance to physiotherapy,
walking to toilet and climbing stairs were noted. Side-effects like
constipation, nausea, vomiting, sedation and respiratory depression were also recorded till the day of discharge and any identifiable cause for discharge. The use of concommitant drugs like
paracetamol, anti-emetics, laxatives and neuropathic pain agents
were documented and patients had telephone follow-up to ascertain
analgesic usage and side-effects.
Results
In the preliminary series of 45 patients, all of the patients reported
significant reduction in their pain scores over days three to five as
compared to the previous standard, which was Tramadol at a dose
of 50-100 mg four times a day. Three of the patients had reported
constipation at day 5 and six patients had symptoms of nausea and
vomiting during their peri-operative period. Patients were using
less of oxynorm for rescue analgesia and had better satisfaction
scores. Bowel function index were favourable for ease of defecation
and for completion of evacuation, but were less reliably recorded
for rating of constipation as patients were finding it difficult to
quantify it. Patients also recorded better satisfaction scores about
their overall peri-operative experience. Patients gave varying duration of use of post-discharge analgesics. One patient died during
the observation period.
Conclusion
The use of adequate dose of a strong opioid was better in controlling
post-operative pain following major surgery compared to tramadol.
The addition of naloxone has effectively reduced the troublesome
side-effects of constipation and is an alternative to conventional opioids. The combination of oxycodone and naloxone (Targinact) has
been accepted by the surgeons as it effectively addresses the issue
of opioid-induced constipation that often delays discharge planning
and is currently incorporated in the Enhanced Recovery Pathway
as the opioid of choice for the management of post-operative pain.
More randomised controlled studies are required to validate the
findings of this audit.
Methods
A retrospective survey of all in-patients reviewed by the Acute Pain
Service (APS) at St Georges Hospital between April 2012 and October 2012 was done. Detailed information was collected via the
APS patient electronic database.
Data collected included: age, gender, specialty, operation, pain assessment, number of visits, type of pain, pain scores, side effects of
pain medication, medication started by the APS and patient satisfaction with their treatment.
Patients with a history of chronic pain were excluded. As this was
an observational study, no formal statistical analysis was undertaken.
Results
Over the six month period, 1318 patients were reviewed by the APS.
80 patients were excluded. Consequently, 1238 patient records were
analyzed.The mean age of the patients was 50 (range 5- 92) years.
52% of patients were male and 48% female.
123 out of 1238 patients were diagnosed with ANP, an overall prevalence of 11%. Out of the 123 patients with ANP, 120 were from
surgical specialties and 3 from medical specialties. The percentage of
ANP from surgical specialties was 10% (120/ 1222). The percentage
of ANP from medical specialties was 19% (3/16).
The four highest surgical subspecialties with ANP were: vascular
24% (8/34), neurosurgery 19% (9/47), trauma and orthopaedics
16% (40/ 253) and plastics 12% (7/ 60).
Conclusion
The prevalence of ANP in this survey was 11%, a higher percentage
than previously reported (2). ANP was more common in those surgical specialties with a predominant trauma case mix. The number of
medical patients was small, making it difficult to draw conclusions
on ANP rate. Thoracic surgery, perceived to be high risk for ANP,
had a low rate of 6%.
To our knowledge, this is the first report of the prevalence of ANP
in the UK.We have ascertained the high-risk groups for the development of ANP, this will help in the identification, recognition and
treatment for these patients.
005
Acute neuropathic pain: how prevalent is it in hospitalised patients?
Mae Johnson, Lenny Ng, Melissa Mellis, Jeremy Cashman
006
National inpatient pain study -using real time data
collection to measure the quality of inpatient pain
service techniques and identify variations in practice
Acute Pain Service, Department of Anaesthesia, St Georges Healthcare

NHS Trust, London, UK

Fiona Duncan1, Ruth Day2, Olga ONeill3, Jeremy Nightingale4,
David Counsell5
Background
1Manchester
Acute neuropathic pain (ANP) is defined as pain arising as a direct

consequence of a lesion or disease affecting the somatosensory system (1). It is a condition that is under-recognized, under-treated
and can progress to chronicity and disability.
ANP has been previously reported in approximately 2% of inpatients
reviewed by an acute pain service in a tertiary referral hospital in
Australia (2). It is not as common as nociceptive pain in the hospital
setting. The challenge is therefore to identify high-risk patients for
the development of ANP. There is evidence that the risk of progression to persistent neuropathic pain is high and that early intervention
may prevent this from developing (5).
The aim of this survey was to define the prevalence of neuropathic
pain at St Georges Hospital, a tertiary referral and major trauma
centre in the UK.
Metropolitan University, Manchester, UK, 2South Devon

Healthcare NHS Foundation Trust, Torbay, UK, 3Belfast Health and
Social Care Trust, Belfast, UK, 4Portsmouth Hospital NHS Trust,
Portsmouth, UK, 5Betsi Cadwaladr University Health Board, Wrexham, UK
Background
Pain management for patients in hospital is a major problem. Evidence of pain service impact has been lacking, there is significant
variation in care provision. Evidence is needed about the ways in
which pain services are organized in order to understand whether
these are linked to important differences in what happens to patients.
The National Inpatient Pain Study group (NIPPS) is a voluntary
collaborative venture of inpatient pain specialists working towards
building a national prospective research database.
Methods
Methods
The long-term aim is to improve the quality of pain management for

patients in hospital. The objectives are (1) to describe the case mix
of the inpatient pain population (2) to define and monitor the quality and side-effects of different techniques and identify variations in
practice.
The pilot clinical dataset is divided into six main sections and includes demographic data, surgical details if relevant, the primary
technique used to control pain (e.g. epidural, intravenous Patient
Controlled Analgesia, nerve block, intramuscular/subcutaneous and
oral analgesia), pain scores, adverse events, and a measure of effectiveness. We use ASA physical status as a general measure of comorbidity. Routine data is collected by members of the pain team using
handheld devices, and downloaded to a central site.
The pain service website is live, recording information about service
provision including staffing, hours of work, and the drugs and equipment used.
After institutional approval between April 2012 and June 2012

n=100 patients scheduled to have elective or emergency trauma and
orthopaedic surgery, or general surgery were randomly selected for
service evaluation. Pain intensity was assessed with a 5-point verbal
rating scale (VRS) and recorded immediately on first waking. Covariables thought to influence this outcome were determined from
analysis of anaesthetic, operation and recovery room charts including the patients healthcare records. Co- variables for preemptive and
preventive analgesic approaches were pain scores at first waking in
relation to; total morphine dose, total morphine boluses and total
number of preventive analgesics administered. Co-variables for risk
factors were; age, gender, previous history of pain, previous history
of surgery and open versus closed surgical procedures.
To determine how the independent variables predict the outcome
variable logistic regression was applied for the main analysis. A P-value of P<0.05 determined statistical significance during the analysis.
Results
Results
Results indicate that staffing varies widely from 0.5 to 8 nurses per
hospital site. 12% of hospitals do not routinely collect data. The main
workload is orthopaedic and general surgery based on data from 13
hospitals and 29,080 patients in 2011. 37% of patients reported a
pain score of moderate to severe pain on the first assessment, and
21% reported severe pain. Nausea and vomiting was the most frequent adverse event reported. Sixty-nine major adverse events were
logged, of which 64 documented respiratory depression. 29% of epidurals were reported as being stopped earlier than planned due to a
variety of technical reasons.
27% of patients were found to be experiencing pain greater than

mild at first waking. Pain experienced in the recovery room was more
likely to be treated than not. However, 30% of patients remained
untreated, which was carried over to the surgical wards. In general,
multimodal approaches were not sufficient enough to have a significant impact on pain scores.
However, a history of previous surgery was identified as a significant
predictor of pain at first waking. Patients with such a history revealed
a three times increased risk of waking in greater than mild pain at
rest. In contrast, age, gender, total morphine dose, number of morphine boluses, number of preventive analgesics administered, open
versus closed surgery or wound infiltration were not found to predict
post-operative pain scores.
Conclusion
We continue to develop and refine our outcome measures, and have
a rapidly growing accurate and meaningful database. This is an important step towards reducing variation and improving effectiveness.
Prospective longitudinal data has the potential to improve our understanding of variation in outcomes and establish future research
priorities.
007
Examining the effects of perioperative pain
management on pain at first waking in the recovery room
Stephen Ward, Charlotte Halmshaw, Dushyanth Gnanappiragasam,
Carsten Bantel
Imperial College, London, UK
Background
Pain outcomes immediately following surgery may be the result of
standardised approaches to preemptive and preventive analgesia,
risk factors associated with postoperative pain, or a combination of
both.1
However, it still remains unclear how these factors influence patients pain intensities in the real life scenario of busy theatres in
a major hospital and whether multimodal approaches are used sufficiently enough.
The primary aim of this study was to determine the quality of intraoperative pain management as assessed by pain-intensity scoring
on first waking in recovery. Royal College guidelines were used as
benchmarks.2
The second aim was to define predictors for the observed painscores on first waking through analysis of intra-operative management practice and determination of genuine patient factors.
Conclusion
This survey showed the management of immediate post-operative
pain following surgery continues to present challenges, and was frequently inadequately treated. Overall, analysis of clinical practice of
preemptive and preventive analgesia showed a trend towards artificial standardization with a shortage of individualized care.
In addition, this audit also identified a direct correlation between
previous surgery and post-operative pain intensity. However, whether
this correlation relates to all types of previous surgery or only to certain
procedures remains to be determined. Further research also needs
to be done to uncover the relationship of immediate post-operative
pain with physiological mechanisms and psychological factors.
008
Efficacy of patient controlled analgesia (pca)
for post operative pain for level 2/3 critical care
patients: does early connection make a difference?
Edward Todman, Amieth Yogarajah, Sian Griffiths, Tim Wigmore,
Paul Farquhar-Smith
The Royal Marsden NHS Foundation Trust, London, UK
Background
Failure to provide good post operative pain relief risks increased hospital stay, impaired quality of life and the development of chronic
pain, all of which have negative health economic implications. PCAs
have been used extensively and there is a good evidence base to
support their use. In our hospital, several anecdotal reports suggested in those patients going to level 2/3 care in CCU or overnight
Abstracts
recovery, post operative pain was more problematic if the PCA was
not connected before arrival in CCU compared to those who arrived
with the PCA connected. Therefore we retrospectively examined the
CCU electronic database (IntelliVue Clinical Information Portfolio
(ICIP)) to examine this question.
Methods
After gaining approval from our local Clinical Audit Committee,
data was collected retrospectively from ICIP on all post operative patients having an abdominal procedure (31/10/11 to 17/2/12) returning to level 2/3 critical care, who were prescribed an opioid PCA.
Pain numerical rating scores (NRS) at rest and on movement on first
arriving in CCU/overnight recovery were recorded and expressed as
means. The next NRS documented in ICIP was recorded to assess
the impact of pain management in CCU/overnight recovery. Connection (or not) of PCA prior to CCU/overnight recovery was documented. Results were also expressed as percentage of patients being
analgesed which was defined as a NRS of 2 at rest, and 4 on
movement. Prior PCA connection (before group) was compared to
connecting the PCA in CCU/overnight recovery (after group) for
pain scores (Mann-Whitney U) and if patients were analgesed or
not (Chi squared).
Results
91 patients were identified. Of those, 45 were connected before arrival and 46 after arrival. Overall, pain scores on arriving in CCU/
overnight recovery were 2.7 (rest) and 3.4 (movement). Pain scores
after intervention were 1.5 and 2.4.
NRS pain scores were significantly less if the PCA was connected
before arrival (before group) than if connected after, at rest (1.5
compared to 3.3, P<0.05) and on movement (2.6 c.f. 4.6, P<0.01).
Significantly more patients were analgesed in the before group
compared to the after group at rest (66% compared to 44%, P
<0.05) and on movement (77% c.f. 38%, P<0.02). Nevertheless, in
the after group, the number of patients analgesed improved to 69%
(rest) and 67% (movement) at the next pain score. One possible
confounding factor was the higher proportion of level 2 patients in
the before group possibly having less major surgery associated with
less pain.
Conclusion
These data demonstrate prior connection of a PCA is associated
with improved analgesia compared to connection after arrival to a
level 2/3 postoperative facility. Conceivably, prior connection minimises potential analgesic administration delay of having to connect
a PCA as one of the myriad of tasks on CCU/overnight recovery
arrival. This is a simple intervention with no cost implication that
potentially can improve post operative analgesia. Before this audit,
pain issues on arrival to CCU/overnight recovery had made connecting a PCA before transfer to level 2/3 care compulsory. A repeat audit has started now all PCAs are connected prior to arrival.
009
Pulsed radiofrequency electromagnetic field therapy
for menstrual pain, a double blind, randomized and
placebo controlled pilot study
Ian Rawe
BioElectronics Corporation, Frederick, Maryland, USA
Background
Primary Dysmenorrhea, commonly referred to as menstrual cramping, is a medical condition characterized by pain from contractions
in the lower abdomen occurring at the onset of menstruation in the

absence of an identifiable pelvic disease. Sharp pains in the lower
abdomen begin at the start of menstruation and may continue for
up to 5 days. The pain can range from mild to severe and can often
interfere with many normal activities. While the majority of women
who have menstrual periods experience some discomfort, an estimated 10% or more are temporarily disabled by the high level of
pain they experience. A miniaturized, lightweight and battery pulsed
shortwave radiofrequency electromagnetic field (PEMF) device has
been developed as a wearable pain therapy. The device operates at
the 27.12MHz radio frequency, 1000Hz pulse rate with a pulse
width of 100 seconds. The electromagnetic field is delivered by a 12
cm loop wire antenna.
Methods
A total of ninety-one (91) women were enrolled with moderately
to severe dysmenorrhea. Subjects self-reported perceived levels of
pain for each day of their menstrual cycle prior to participation
in the clinical trial were collected. Subjects were then randomly
assigned a number coded PEMF device, either active or placebo.
The energy from the functioning device cant be felt by the recipient so subjects were unable to determine device allocation
through use. The patients ranged in age from 18-34 years, with
an average age of 26.2. Forty-eight (48) patients were assigned
active devices while the remaining forty-three (43) received placebo devices. Subjects were asked to wear the PEMF device over
the lower abdomen, from the onset of their symptoms, for 24 hrs
per day for 5 days, and record their daily VAS pain scores on an
11 point scale (0 -10 scale). Subjects were not restricted in use of
pain medications.
Results
On average, pain was decreased significantly on a daily basis, with
the study group reporting a 31% decrease in pain compared to the
placebo group on day 1, 39% day 2, 42% day 3, 48% day 4 and
63% day 5. Average VAS scores for the 5 days of the study were,
day 1 control v study group 8.3 v 5.7, day 2: 7.9 v 4.8, day 3: 7.4
v 4.3, day 4: 6.5 v 3.4 and day 5 5.7 v 2.1. The result indicate that
over time 5 days the percentage of decrease in pain increases, suggesting that there is a strong correlation between duration of use
of the PEMF device and amount of pain reduction. Overall 77%
study group subjects reported a decrease in pain compared to 14%
in the control group. No significant adverse events were reported.
Conclusion
The pilot clinical study demonstrated that the PEMF menstrual pain
therapy is an effective and safe non-drug method for use in the treatment of primary dysmenorrhea. The results suggest that PEMF in
this form can be used as a drug-free treatment method for women
suffering from moderate dysmenorrhea. In more severe cases of
dysmenorrhea, it can be a possible adjuvant treatment allowing for
a reduction in the amount of oral pain medications used. Further
clinical study is needed to fully determine the effectiveness of this
therapy for primary dysmenorrhea.
010
Do pre-operative screening questions on pain predict a
worse post-operative pain experience? An exploratory
audit.
Andrea Magides1, Sophie Carter2, Ruth Day1, Douglas Natusch1
1Torbay
UK
Hospital,Torquay, UK, 2Nuffield Research Placement, Devonshire,
10
Background
011
There is interest in predicting patients likely to have a poor postoperative pain experience. Instinctively those with chronic pain and
opioid tolerance will present challenges. Identification of these would
allow pre-operative formulation of pain management plans and early
involvement of the inpatient acute pain service (APS). In Torbay,
all elective patients undergo nurse-led pre-operative assessment and
this is entered into a computer record. In the routine questionnaire
we included four questions thought to be predictive of a poor pain
experience. Data is collected on the Acute Pain Database (TIPPS) of
all patients seen by the APS. The two databases allowed us to compare whether the post-operative pain experiences of the patients seen
by the APS could have been predicted by the pre-operative questions
and if so, which questions, and whether 1, 2, 3 or 4 questions were
required. Data for 12 months of elective patients was retrospectively
reviewed.
An Audit To Evaluate The Efficacy Of Transversus

Abdominis Plane Blocks In Total Abdominal Hysterectomy In A District
General Hospital
Methods
The records of 908 patients assessed pre-operatively were reviewed.
Based on the Salford pain team questions (which were later incorporated in RADAR) the pain predicting questions were:1. Significant anxiety over post-operative pain
2. Previous experience of post-operative pain
3. Established chronic pain syndrome
4. On long-term opioid therapy
In patients regularly taking opioids, oral morphine dose equivalence
was calculated and the patient banded into high (>150mg), medium
(100-150mg) and low dose (<50mg). Patients taking anti-depressants or anti-convulsants for pain management were recorded.
The results were entered into an excel spreadsheet from the TIPPS
database. Data includes number of visits from the APS, number of
days under the care of the APS, pain scores at the time of the visit
and for the preceding 4 hours, the nurses assessment of efficacy of
pain management and patient satisfaction.
Results
Individual factors
30 (3%) of patients scored positively for significant anxiety over
post-operative pain.
19 (2%) of patients had had a previous bad experience of post-operative pain.
138 (15%) had a chronic pain diagnosis.
64 (7%) were on long-term opioid therapy, over 20 of which had a
pre-operative morphine equivalent dose of 50mg or more.
71 (8%) of patients seen by the APS were taking anti-depressant
commonly used for pain relief and 39 (4%) were taking anticonvulsants
Patients received an average of 1.5 visits with a range of 0 (not seen
due to insufficient time) and 33.
Further results and correlations will be presented on the poster.
Conclusion
Only a small number of patients (3% & 2% respectively) were
found to volunteer significant pain anxiety or a previous bad postoperative pain experience. Only 7% were on long-term strong
opioid therapy. The factor with the most significant pickup was a
previous experience of chronic pain which, at 15% would reflect
confidence limits for current population studies for chronic pain.
Correlations of the predictive value of the questions with a need
for APS input post-operatively are being undertaken and will be
presented.

Melanie Shuker, Andrea Magides, Ruth Day
Torbay Hospital, Devon, UK
Background
Trials have demonstrated the efficacy of transversus abdominis plane
(TAP) blocks in reducing opiate consumption for up to 48 hours
postoperatively, for various abdominal procedures, including total
abdominal hysterectomy (TAH). Carney et al. (2008) demonstrated
that TAP blocks in patients undergoing TAH reduced the mean (+/SD) total morphine requirements in the first 48 postoperative hours
from 55 +/- 17 mg with placebo block, to 27 +/- 20 mg with ropivacaine block. Our audit aimed to evaluate if TAP blocks affected the
cumulative dose of opiate received by patients in the first 48 hours
post TAH in our district general hospital. It was a service evaluation of a change in practice, introduced as a result of the enhanced
recovery program, which recommended TAP blocks for TAH as this
was considered best practice. It was suggested by the recovery nurses
who questioned the efficacy of TAP blocks.
Methods
We aimed to identify 50 patients who had undergone TAH without
receiving a TAP block and 50 who had undergone TAH and did receive a TAP block. A retrospective case note review was undertaken.
Data was ultimately collected for 56 patients who did receive a TAP
block and 32 patients who did not receive a TAP block. Those excluded were patients with a history of opioid tolerance and who underwent laparoscopic TAH. The data collected came from patients
who had had a TAH between January 2010 and January 2012.
Data collected included patient demographics, the dose of opiate
drugs received in the first 48 hours post TAH and other analgesics
received. Opiates received included intravenous morphine and fentanyl, oral morphine and codeine phosphate. These opiate doses
were converted to intravenous morphine dose equivalents and thus
cumulative opiate dose for the first 48 hours postoperatively calculated for patients in both groups.
Results
On analysis there was no difference in the variances between the 2
groups for age, weight, height or body mass index. Results showed
that the mean (+/- SD) cumulative opiate dose in the first 48h post
TAH was 45.8 mg (+/- 36.7) in the TAP block group versus 53.8 mg
(+/- 30.5) in the no TAP block group. This is a reduction of 8 mg (IV
morphine equivalent) which is approximately equivalent to a 15-20
mg dose of oral morphine. We felt this was not a clinically significant
difference and indeed the difference between the two groups proved
to not be statistically significant either (p=0.2959). Results also
showed that patients who received a TAP block received a higher proportion of the mean cumulative opiate dose in theatres recovery than
those patients who did not receive a TAP block (18.4% vs 10.5%).
Conclusion
TAP blocks for TAH did not produce a significant reduction in cumulative opiate dose in the first 48 postoperative hours. Translating
results of controlled trials into clinical practice is challenging. Some
11
Abstracts
disparities in the methods of delivering TAP blocks in our institution
and those used by Carney et al. were identified however, prompting
development of a departmental guideline to optimise the procedure.
It includes adopting a posterior ultrasound approach similar to that
used by Carney et al. and performing the block preoperatively. It
highlighted that not performing a TAP block does not necessarily
mean providing an inferior standard of care.
012
PARACETAMOL DOSAGE - ARE WE PRESCRIBING CORRECTLY?
AN EXPERIENCE FROM A DISTRICT GENERAL HOSPITAL
Ravi Kare, Kate OCallaghan, Heather Lynes, Udi Akhigbe, Coralie
Carle, Subhash Kandikattu
Anaesthetic Department, Peterborough and Stamford Hospitals NHS
Foundation Trust, Peterborough, Cambridgeshire, UK
Background
Paracetamol is widely used as an analgesic and antipyretic. Its recommended dose is weight dependent (BNF). Following reports of
accidental overdose of paracetamol the MHRA issued guidance on
Drug Safety Information in May 2010. The National Reporting
and Learning System identified 206 paracetamol related incidents
(44 neonates and 162 children) of them 2 had severe harm and 14
had moderate harm (NPSA Signal, Nov 2010).
These incidents were attributed to lack of awareness among various healthcare professions of neonatal and paediatric drug dosage regimens, poor documentation resulting in double dosing,
confusion between oral and IV Paracetamol drug doses and
calculation and prescription errors of IV Paracetamol.
This motivated us to review the paracetamol prescribing practices
within our hospital. This review involved three components: first
looked at anaesthetists understanding of paediatric dosing; second
focussed on peri-operative prescription (adults) and the third assessed
the knowledge of paracetamol prescribers in the wider hospital.
Methods
With appropriate audit permission, the initial component of our
review was carried out in June 2010. This involved a written questionnaire sent to all anaesthetists. We sought to establish the current practice of paracetamol prescribing in paediatric patients (dose,
dosing interval, maximum daily dose, errors). The results were
presented locally and the anaesthetists updated on key elements of
paracetamol prescribing.
We then re-audited Peri-operative paracetamol prescribing in July
2012.The notes, drug chart and anaesthetic chart of patients passing through the post anaesthesia care unit (PACU) were reviewed.
Details relating to paracetmol prescribing, including potential and
actual errors, were collected on a proforma. The findings were presented locally, the medical and nursing staffs were re-educated and
the audit repeated in September 2012.
The final component of our review involved a written survey establishing paracetamol prescribing practices of the hospitals physicians,
surgeons and paediatricians. This was carried out in August 2012.
Results
Our initial survey received a 70% response rate. The notable results
include: children < 10kg, 50% of anaesthetists stating an incorrect
treatment dose and 83% stating an incorrect maximum dose;
children 10-50kg, 50% of anaesthetists stating an incorrect max
dose; children >50kg, 70% of anaesthetists stating both an incorrect
treatment dose and incorrect maximum dose.
The PACU audit most significant finding was that in 50% of patients there was the potential for a second IV dose to be administered
within 4 hours. This error occurred in 6% of patients. Following staff
education, the re-audit revealed a reduction in both actual and potential errors.
Our survey of other specialities received a 20% response rate. The
notable results include: 70% doctors were not aware of the MHRA
guidance; 30% made no dose alteration for adult patients under
50kg; 20% stated an incorrect paediatric dose and; 15% stated an
incorrect adult dose.
Conclusion
The three components of our review highlight that errors in
paracetamol prescribing for both adult and paediatric patients is
widespread throughout the hospital. Despite improvements in
practice following staff education, 100% compliance with BNF and
MHRA guidance is not being achieved. It is important for us to be
vigilant while prescribing paracetamol doses and dosage intervals.
To prevent potential and actual errors we should communicate and
hand over carefully during the perioperative period. We should continue the cycle of education and re-audit to help in improving our
practice
013
Documentation Of Pain Observations Following Implementation Of The New Uhbristol Observation Chart
Category: Assessment & Measurement
Ben Welham2, Steven Lindley1, Nilesh Chauhan3
1Royal
United Hospital, Bath, UK, 2University of Bristol, Bristol, UK,

Hospitals Bristol, Bristol, UK
3University
Background
In 2008, the Chief Medical Officer advised that a pain score should
become part of the vital signs that are monitored routinely for all
inpatients . Previously at UHBristol NHS Trust, following the introduction of the early warning observation system, pain recording
did not feature on this form. A separate (Pain Observation Forms
(POF) was disseminated to encourage the recording of pain. An audit in 2009 found that there was poor uptake of this form and many
patients were left without adequate pain documentation. Following
this audit, space for pain observations was included as part of the
redesigned UHBristol Observation Chart (UOC). This form also included the Abbey Pain Scale for patients with cognitive impairment
and an action report for the recording of intervention of moderate
to severe pain.
Methods
Five patients were randomly sampled using a random number generator from each ward at UH Bristol. The Emergency Department,
ENT and Maxillofacial wards and the Intensive care unit were excluded as these wards used alternative charts to assess pain. Five
questions were asked of the form: 1. Is the UHBristol Observation
chart (UOC) used? 2. Is pain assessment filled in correctly 3? Is the
patient verbally able to communicate their pain? 4. Is the Abbey Pain
Scale employed? 5. Has an action report been recorded if pain is
documented as moderate or severe?
Results
A total of 132 patients were sampled which was similar to the initial
audit of 152 patients. Uptake of the UOC was 96%. 100% of patients with UOC documentation had pain recorded, compared to
only 50% (1% patients on medical wards 64% on surgical wards)
12
in the previous audit. 99% of patients had more than half correctly
entered pain recordings, compared to less than 40% on POF. There
was a very small take up of the Abbey Pain Scale with only 0.8% of
patients having this employed which likely represents a fraction of
patients with cognitive impairment (likely 1/3 of inpatients). 38%
of patients reported moderate to severe pain at some point, of these,
only 26% had action reports
Conclusion
The uptake of UOC compared well with the previous EWS observation chart. The use of the UOC for recording pain assessment was
exceptional, with the quality of entries representing an improved
chart. However, improvements can be made to the utilisation of the
Abbey Pain Score and freetext action-reporting.
This audit has shown the importance of pain assessment documentation on the same chart as an early warning system, we have shown
that by having two separate charts pain assessment is poor. With
the introduction of the National Early Warning Chart, which has a
minimal amount of pain assessment, this is threatened.
014
The Assessment Of Chronic Pain After Knee Replacement: A Systematic Review
Vikki Wylde1, Julie Bruce2, Andrew Beswick1, Karen Elvers1, Rachael
Gooberman-Hill1
1University
of Bristol, Bristol, UK, 2University of Warwick, Coventry, UK
Background
Total knee replacement (TKR) is a successful operation for relieving pain for the majority of patients. However, approximately
20% of patients experience chronic pain after TKR. Despite the
prevalence of this condition, there is no agreement in the research
literature about which measures should be used to assess chronic
pain after TKR. For clinical trials investigating efficacy of chronic
pain treatments, IMMPACT recommends that the assessment of
pain should encompass measurement of pain intensity, pain medication usage, pain quality and the temporal aspects of pain. The
aim of this systematic review was to determine which pain instruments and broader health-related measures incorporating pain
items were used in all original epidemiological and experimental
research articles published over a 10-year period. Within this literature we explored geographical and contemporaneous trends in
the use of pain-related outcome measures, and compared the pain
domains assessed within the measures to the recommendations
from IMMPACT.
Methods
Searches identified 8,486 articles with 1,164 eligible for inclusion.
MEDLINE, Embase, PsycINFO, Cochrane Library and CINAHL
databases were searched for research articles published in all languages between January 2002 and November 2011. Articles were
eligible for inclusion if they assessed pain at a minimum of 3 months
after TKR. Studies were excluded if they were case studies, conference abstracts, PhD theses, recruited less than 10 participants or did
not present original primary data. Abstracts or full text articles were
screened to determine if the article met the eligibility criteria. Data
extracted included study design, country, timings of assessments,
and outcome measures that contained pain items. For 184 articles
only accessible as abstracts, authors were contacted. Of 84 authors
with contact details, 36 provided full text articles or verified data
extraction.
Results
Studies used a variable number of measures that incorporated pain
items (range 1-14), with 17% of studies using three or more measures. A wide variety of composite and single-item measures were
used to assess chronic pain after TKR, with the American Knee Society Score being the most common. Other commonly used multiitem measures included the WOMAC, Hospital for Special Surgery
Knee Score, SF-36 and Oxford Knee Score (OKS). Comparison of
pain domains assessed within the measures to those recommended
by IMMPACT revealed that many measures failed to capture the
multi-dimensional nature of pain. Of measures commonly used, the
WOMAC and OKS provided the most comprehensive assessments
of pain. Geographical trends were evident, with nation-specific preferences for particular measures. Comparison of temporal trends
identified recent reduction in the use of clinically-administered tools
and an increase in the use of patient-reported outcome measures.
Conclusion
This systematic review found extensive variation in the outcome
measures used to assess chronic pain after TKR. A key finding was
that, despite a growing interest in investigating this condition, assessment has been inconsistent and predominantly orientated towards
pain severity, with little consideration of other key aspects of pain,
such as temporality and quality, as recommended by IMMPACT.
The review also highlights the presence of nation-specific preferences and conservatism in pain assessment within orthopaedic studies.
Standardisation and improvements in assessment has the potential
to enhance the quality and generalisability of research and facilitate
the establishment of a core outcomes set.
015
The Colour Of Pain: Can Patients Use Colour To
Describe Osteoarthritis Pain?
Vikki Wylde, Victoria Wells, Sam Dixon, Rachael Gooberman-Hill
University of Bristol, Bristol, UK
Background
Pain assessment is fundamental to management of osteoarthritis
(OA) pain and evaluation of the effectiveness of clinical interventions. While the subjective nature of pain means that self-report is
appropriate, some people experience difficulties in completing standardised numeric or descriptive pain measurement tools. This may
be because it can be challenging to define and explain pain experience through pre-defined questions and response options. In a clinical setting, patients ability to describe pain is a key component of
successful communication between patients and clinicians. Optimal
and diverse methods of pain assessment may help to facilitate communication and shared-decision making about treatment and management strategies. The aim of this qualitative study was to explore
patients views about the acceptability and feasibility of using colour
to describe OA pain, and whether they thought that colour was an
appropriate means of communicating about pain in clinical settings.
Methods
Seventeen patients with knee OA took part in one of six group interviews, each comprising 2-3 participants; groups were stratified by
gender. In each interview, participants were first asked to describe
living with OA, experiences of pain and management strategies, and
thoughts about using colour to describe pain. Next, 10 loose circles
of coloured card were placed in the centre of the table. Participants
13
Abstracts
were asked to describe and discuss whether they could relate the
coloured circles to OA pain, and if so how those colours related to
pain qualities and changes in pain intensity. Participants then used
coloured pencils to depict their pain on a body diagram, and were
encouraged to describe their choice of colours. Group sessions concluded with participants views about the potential to use colour in
conversations with healthcare professionals. Anonymised transcripts
were imported into NVivo version 9 and analysed using methods
of constant comparison.
Results
The group interviews revealed that while the idea of using colour
was generally acceptable, it did not suit all participants as a way of
describing pain. The majority of participants chose red to describe
high intensity pain; reasons given were its symbolic association with
inflammation, fire, anger, and its connection with a traffic light system. Colours used to describe absence of pain were those associated with positive emotional feelings, such as purity, calmness and
happiness. A range of colours was chosen to represent changes in
pain intensity. When describing aching pain, participants consistently
identified colours such as grey or black. In comparison, sharp pain
was described using a wider range of colours including yellow, white,
red and purple. The majority of participants thought that they would
be able to use colour to describe their pain to healthcare professionals, although issues around the interpretability and standardisation of
colour were raised.
Conclusion
This study suggests that presenting patients with a range of colours
and asking how they would use these colours to describe their chronic pain may be a useful communication tool. As evident from this research, this would not be appropriate for everyone, but some people
may find that engagement with colour provides a comfortable way to
initiate discussions around pain. Although not explored in this study,
colour symbolism varies between cultures and any such tool would
need to allow for diversity. Further research could establish the utility and possible impact of a colour-based communication tool in a
clinical setting.
016
Is confidence the key to accurate paediatric pain
assessment or is there more we need to learn?
Laura Angco1,2, Mansimran Cheema1,2, Carsten Bantel1,2, Helen
Laycock1,2
1Imperial
College London, London, UK, 2Chelsea and Westminster

Hospital, London, UK
Background
Children and infants experience pain1. Inadequate analgesia and the

experience of pain in children can lead to physical, psychological
and behavioural consequences in the short and long term2,3. Despite
the importance and moral obligations of healthcare professionals to
ensure a patients comfort, pain in hospitalised paediatric patients is
often poorly managed4,5.
Accurate pain assessment is key to pain management, both as a
screening tool and also a measure of effectiveness of analgesia. Pain
assessment in children should be completed with tools appropriate
for age, clinical situation and the childs ability to self-report6.
A previous hospital audit demonstrated over 75% children were not
assessed for pain using hospital recommended tools and 50% had
inaccurate pain assessments7. We aimed to explore, how nursing staff
evaluate their practice in pain assessment and its importance, to help

address the above discrepancy.
Methods
Over a two-week period, 20 paediatric nurses were approached on a
general medical and surgical paediatric ward in a Central London Teaching Hospital. No prior introduction to subject matter was
given and each was asked to complete a qualitative Likert scale questionnaire with additional areas for free text.
Questions were constructed to evaluate nurses confidence levels in
assessing pain and previous training. Additionally they were asked
about how to conduct pain assessments, the frequency with which
they perform them and average time taken to complete an assessment on the ward. They were also asked to list their top 3 responsibilities on the ward to assess the importance of pain / pain assessment.
Results
95% responder rate, 5% refusal. 84% felt confident or very confident
in their accuracy in assessing pain, with none feeling unconfident or
worse.
Only 42% felt children could accurately report pain, although
84% identified ability to do so was age related. There was a wide
range in average time spent assessing pain (3 seconds to 10 minutes, mean 2.6 minutes) and nurses were inconsistent in frequency
of pain assessment. Most identified that frequency depends on the
patient, but average frequency ranged from every 30 minutes to
once daily. Hospital guidelines recommend frequency should be
every 4 hours.
16% of nursing staff felt assessing pain was one of their top three
responsibilities. They found patient care, supporting family, running
the ward, managing staff, and keeping safe, clean environments more
important. Only 53% had received training in pain assessment, with
only 30% of those having received more than a one-day study course.
Conclusion
Despite previous evidence that pain assessments are inaccurate,
most staff were confident in their ability to assess pain. Many felt
children were unable to self report accurately and illustrated large
ranges of frequency and time take to complete assessments. This
suggests lack of training, which was confirmed by the questionnaire.
It is likely they exist in the unconscious incompetence stage of the
competency model of learning8 and a more standardised format of
pain assessment training could address this issue, leading to more
accurate assessments and a better standard of care.
017
Collecting patient reported outcome measures (prom)
using smart phone technology within a clinical setting
Andrew Vitiello, Dave Newell, Ahmet Ulusan, Maja Bjorn
Anglo European College of Chiropractic, Bournemouth, UK
Background
Mobile health (mHealth), and the use of mobile technology to enhance care, is an emerging debate. The model of the doctor knows
best has been questioned, whereas the involvement of the patient in
their care and management, including ongoing treatment decisions
and the development of a partnership between physicians and their
patients has been shown to impact outcomes and cost, particularly
in chronic conditions. 1,2
14
However, engaging patients in monitoring their health care and
managing their condition has remained a challenge.3 With the emergence of mobile technology considerable scope for innovation4,5 has
arisen with opportunities to improve patient self management and
experience of care, as well as potentially reducing unnecessary and
costly health seeking behaviour.6
We have developed a smart phone app7 that provides validated
PROMs on the patients phone together with the ability to provide
these outcomes to both the patient via a secure server to the clinician.
Methods
Code was written to enable the presentation of 2 validated PROMs
(Roland Morris Disability Questionnaire8 and Bournemouth Questionnaire9), in an appropriate format for smart phone screens as
well as web site to display PROM data to the clinician. The apps
were tested for face validity using a number of students and faculty
and feedback as to the ease of use, both as a potential clinician and
patient was obtained. A further pilot study was then carried out to
ascertain the experience, utility and practicality of 10 non specific
low back patients over the course of 7 days following the initiation
of treatment. Feedback concerning the use of the app and patients
experience was collected using a short questionnaire and in a smaller
sample, a semi structured interview.
Results
A smart phone app able to present two validated questionnaires with
daily notifications to the patients has been created along with a website to display PROM data from individual patients to their clinician.
The details of the app along with the results of the face validity and
pilot study will be presented at the conference.
Conclusion
The use of smart phone technology is an emerging area and has potential to impact favourably both in terms of providing valuable patient data concerning symptomatology as well as providing a platform
for feedback to the patient in attempts to encourage and support self
management. We have developed a patient friendly smart phone app
that enables the recording of PROMs directly from the patients phone
providing direct feedback to the patient as well as uploading this information to a secure central server for review and use by the clinician
018
Does the start back tool shortly after the initial visit compared to before better predict outcomes in lbp patients
Dave Newell1, Jonathan Field1,2
1Anglo European College of Chiropractic, Bournemouth, UK, 2Back2Health, Petersfield, UK
Background
Low back pain is common and costly 1. Most LBP is non-specific in
nature and identifying those individuals likely to respond to intervention has proved problematic. Research has attempted to identify
prognostic groups2 through the development of screening methods. 3
Hill et al 4 have developed the STarT Back, which has proved to add
utility beyond physiotherapist choice alone in determining treatment
for LBP patients by categorising into low, medium and high-risk
groups, with low risk given advice, medium, physical therapy and
high-risk physical therapy with a CBT component.
Recently5 we investigated whether the SBT could predict outcomes
in nsLBP patients undergoing chiropractic care and found no significant association between SBT risk groups and outcomes. Previ-

ous work in this population indicates early change may be associated
with favourable outcomes and we hypothesized that the SBT post
the initial visit as opposed to before may provide better prognostic
information.
Methods
Consecutive patients aged over 16 presenting with nsLBP to one of
six chiropractic clinics in the south of England are asked to complete
the SBT at baseline and within 2 days of their initial visit online, via
a web page. A Patients Global Impression of Change (PGIC) was e
mailed at 14, 30 and 90 days following their initial visit.
For this study, the primary outcome was the PGIC. Patients were
categorised into the three SBT risk groups using the method as described by Hill et al4. For each of the follow up points, all outcomes
were dichotomized with poor outcome defined as a score of <6 on
the PGIC 6
Any association between the SBT groups and outcomes were investigated using univariate logistic regression where SBT categorisation was the independent variable and the dichotomised outcome
(PGIC) was the dependent variable at each of follow up points.
Results
One hundred and eighty six patients with nsLBP filled out the baseline questionnaire, with 91% completing this via e-mail. Around
half were attending for a new episode of LBP and had not seen that
practitioner before. There were a slightly higher proportion of females with around half reporting pain for more that 30 days a year
with over 2/3 of patients reporting the back pain as a reoccurrence.
Twenty-eight and 12% reported pain in the leg above and below the
knee respectively.
Analysis of the odds of the SBT risk groups associated with outcomes (Table 1) revealed that the SBT neither at baseline or post the
initial visit was unable to distinguish between those that improved or
did not at any of the follow up time points of 14, 30 and 90 days. The
proportion of improved patients was therefore similar across the risk
groups for all follow up points
Conclusion
We hypothesized that those patients not experiencing improvement
might be better identified by the SBT if given immediately after the
initial consultation as opposed to at baseline before the patient attends their first visit. However, this was not the case and the SBT
performed as poorly as in our previous study that looked only at
baseline recorded SBT.
It is likely that the population of patients attending chiropractors
maybe different and the additional confounding effect of treatment
may have some impact on these results. Caution however, should
be used when extending this screening tool to other populations of
LBP patients.
019
Bapq: the development of an on line assessment tool
for adolescents who experience chronic pain
Lisa Austin, Chris Bevan, Christopher Eccleston
University of Bath, Bath, UK
Background
Chronic pain causes significant problems in the lives of many
adolescents, considerably affecting their physical, psychological
and social functioning. The assessment of the multidimensional impact of chronic pain is therefore an essential clinical
15
Abstracts
task. The Bath Adolescent Pain Questionnaire (BAPQ); is an
assessment tool designed specifically for use with adolescents
who experience chronic pain, developed by the Bath Centre for
Pain Research. The BAPQ offers a comprehensive way to assess
the widespread deleterious impact of adolescent chronic pain in
both a research and clinical setting. However, it is currently only
in paper version. New online technologies mean it is possible to
produce an online version, which is quick and easy to access anywhere and allows for immediate access of data for a distributed or
remote clinical team.
following strict aseptic precautions is of utmost importance. The

aseptic techniques need to be at par with what are followed in an
operating theatre environment.
In our Pain Clinic treatment room, we follow RCOA guidance
for performing central or peripheral nerve blocks. Operators wear
cap, mask, gown & gloves as a rule. Procedure site is cleaned with
Chlorhexidine 0.5% in ethanol spray & draped with sterile drapes.
This project was a quality assurance process to evaluate the adequacy of various aseptic techniques we routinely follow in the pain clinic
treatment room and improve or modify our techniques if deficiencies
were observed.
Methods
The questionnaire was replicated in full using standard web input
controls (free text entry, drop-down lists etc). Efforts were made
however to use each type of input mechanism appropriately in order
to sensibly limit the range of possible response to minimise ambiguity
wherever possible - e.g. if the range of possible answers are known,
a fixed drop-down list was used. It is thought this resulted in no loss
of resolution.
There was also a design decision to repeat the labels for each of the
likert-scale questions on each question (as opposed to just presenting them in a table with the labels shown only once at the top. This
was done to prevent the need for the user to scroll to the top to check
their response (e.g. 1 : never) and two, to allow for more physical
space between questions (mostly to increase selection accuracy on
touchscreen based devices).
Results
The online BAPQ is an HTML5 website that has been designed
to be usable in multiple environments. Efforts have been made to
ensure cross-browser and (more importantly in this day and age)
cross-device compatibility (website automatically adjusts for mobile
phone / tablet use / interface is usable on touchscreen-based devices
etc). All participant data is validated and verified before submission.
Data is non-personally identifiable and is stored securely on a UoBbased database.
A great advantage of the online BAPQ is that scores are calculated
automatically. The clinician is provided with these results immediately, which they can then print for further discussion with their patient. In addition, subject to ethical approvals, researchers can get
immediate access to the aggregate / anonymised data in a usable
form (MS Excel), with the BAPQ calculations already complete.
Methods
Service evaluation was approved by local research and ethics department. Microbiology department supported the project. Patients and
staff were consented for sampling. All patients received standard care
in the pain clinic. Staff were instructed to follow standard aseptic
precautions.
There were4 areas for evaluation:
Area 1: Swabs were taken from staff hands on 3 occasions (on
arrival from home, after 1st and after 2nd hand washing)
Area 2: Epidural injection group, where swabs were taken before,
during and post procedure from patients skin)
Area 3: Ultrasound guided procedures, where swabs were taken
before & after application of gel.
Area 4: Ultrasound gel (samples from sterile single use pouches
and refilled bottles)
As this project only aimed at quality assurance, only 4 sets of samples
were obtained from each area of interest. Microbiologic assessment
was performed to identify organisms and quantify as colony forming
units (CFUs)
Results
020
Area 1 Clinicians Hands: Two out of 4 samples from clinicians

hands grew pathologic organisms on arrival to the clinic. And after
1st Hand wash, only normal skin flora were cultured form the same
hands. No flora was cultured after subsequent hand washes.
Area 2 Epidural procedure: Two out of the 4 samples collected from
patients skin grew pseudomonas (opportunistic pathogens). But after cleaning with Chlorhexidine 0.5% (in 70% v/v ethanol) spray all
four samples showed no growth. Spraying the back with Chlorhexidine 0.5% eliminated all organisms.
Area 3 Ultrasound Blocks: One skin sample out of 4 grew non
staphylococcal gram positive cocci. No organisms were cultured after cleaning the same site with Chlorhexidine 0.5% & application of
ultrasound gel from refilled bottles.
Area 4 Ultrasound gel: Both gel from sachets and gel from refillable
bottles were cultured. Both did not grow organisms of any clinical
significance.
Service evaluation- adequacy of aseptic techniques in

pain clinic based procedures
Conclusion
Conclusion
The online BAPQ is currently being tested with clinicians in the
Royal National Hospital for Rheumatic Diseases in Bath. If deemed
useful in service settings, it will be being rolled out for wider clinician
and patient feedback.

Monica Chogle, Michael Stafford, William Campbell, David Miller
Ulster Hospital, Belfast, UK
Background
Asepsis plays an important role in any pain procedure. Operator
hands can be a significant source of bacterial contamination before
patient contact. In our Pain Clinic, where procedures are performed
in a dedicated treatment room on an outpatient basis, the role of
Microbiological snapshot data showed that adequate aseptic techniques were followed in our treatment room. In view
of results obtained from swabbing staff hands, importance of
regular hand washing needs to be emphasized to all staff in all
clinical areas. We obtained local data to show that seven step
hand washing is of utmost importance on arrival to a clinical
area from home. The microbiological data also reinforced that
Chlorhexidine 0.5% skin spray is an acceptable cleaning technique for a regional or central neuraxial procedure in an office
based environment.
16
021
and it can be adapted to meet the requirements of the Rasch model

which has statistical advantages.
Rasch analysis of the fatigue severity scale and an

examination of the relationship between pain and
fatigue in people with knee osteoarthritis
Bryan Moreton, Maggie Wheeler, David Walsh, Nadina Lincoln
Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
Background
There is growing evidence that fatigue interacts with pain experience in
osteoarthritis (OA) of the knee. Several questionnaires are available to
evaluate fatigue in musculoskeletal conditions such as the Fatigue Severity Scale (FSS). This questionnaire is composed of nine items which
assess the impact of fatigue (e.g., Fatigue is among my three most disabling
symptoms), and it uses a seven-point response scale where higher values
indicate stronger agreement. The FSS has been shown to exhibit good
measurement properties in other patient groups, but has not been fully
evaluated with people with knee OA. Rasch analysis permits an evaluation of a measurement scale. It can be used to refine a questionnaire
to improve its ability to measure variables of interest. We aimed to conduct Rasch analysis of the FSS with knee OA patients and to explore
the relationship between pain and fatigue in this condition.
Methods
Participants were recruited from hospital clinics and a group of people that had taken part in previous research. All participants had OA
of the knee, which was confirmed by examination of X-ray records,
and reported pain on most days for at least the past month. The exclusion criteria were another known arthritic condition (e.g., rheumatoid arthritis), knee joint surgery within the last three months and an
inability to understand English. Potential participants were sent an
invitation letter. Those interested in taking part were asked to complete a set of questionnaires, including measures of pain and fatigue.
Only data from the FSS and the Intermittent and Constant Osteoarthritis Pain (ICOAP) scale are reported. The questionnaires were
completed at home and returned by pre-paid envelope. Rasch analysis was conducted on the FSS and regression was used to determine
whether pain predicted fatigue controlling for potential covariates.
Results
Data from 171 participants were available for analysis. There were 89
women (52%) and the mean age of the group was 67 years (standard
deviation = 10). The FSS initially misfit the Rasch model (2 = 41.62,
df = 18, p = .001). One item had disordered response thresholds,
which means that the response options were not being used as they
should be. In addition, 14 participants and several items (1, 2, and 8)
deviated from the predictions of the model. Removal of items 1 and 2
considerably improved the fit statistics. The revised 7-item FSS exhibited good measurement properties. Data from this analysis was then
used to explore the relationship between pain and fatigue. Controlling
for age and gender, OA knee pain significantly predicted self-reported
fatigue accounting for just over twenty percent of the variance.
Conclusion
The study supported previous evidence that suggests an association
between OA knee pain and fatigue. There is a tendency for those
with more severe OA knee pain to report higher levels of fatigue,
which may be due in part to the impact that pain has on sleep. It is
therefore important that fatigue is considered when measuring pain
experience in this condition. The FSS offers a candidate measure to
capture fatigue in OA. It is brief, easy to understand and administer,
022
Elective major joint replacement- a comfortable
journey
Mei Foong Yeoh
Aintree University Hospital NHS Foundation Trust, Liverpool,
Mersey, UK
Background
Effective pain and nausea and vomiting management in the perioperative period improves patient outcome, reduces hospital stay and
prevents unnecessary distress. Pain and post- operative nausea and
vomiting (PONV) should be evaluated in partnership with patients
themselves and management tailored to individual experience. Patient satisfaction is the key indicator of efficient pain and PONV management. Our audits attempt to capture patients pain and PONV
experience in the first 24 hours post elective major joint replacement.
Methods
Data collection of the initial audit stretched from 15/11/2011 to
18/12/2011. Sample size was 56 patients. Patients were sampled
from the daily orthopaedic list at Aintree University Hospital. Patient questionnaires were used to evaluate patients satisfaction with
their pain management. A recovery proforma was used to identify
pain score on first eye opening, pain score at 30 minutes after eye
opening and management of pain in recovery. Data on choice of
perioperative analgesia, use of antiemetics and any surgical complications, if present, were obtained from patients notes. The results
were presented and change was implemented. A reaudit was carried out from 01/07/2012 to 31/07/2012. Sample size was 19 patients due to the reduced number of surgeries that month. The same
methodology was used with the addition of evaluating patients satisfaction with their PONV management using the questionnaire.
Results
Comparing the reaudit to the former, 94% (vs 89%) of patients had
a pain score of < 2 on first eye opening and 94% (vs 87%) of patients
had a pain score of < 2 at 30 minutes after eye opening. One hundred
percent (vs 92%) of patients were prescribed both regular and breakthrough analgesia and antiemetics prior to discharge to the ward. One
hundred percent (vs 89%) of patients felt that hospital staff did everything they could to control their pain while 10% (vs 16%) of patients
would opt for an alternative method of pain relief. In both audits, all patients received preoperative information on pain management and only
one patient from each sample was not satisfied with the information
received. However, only 73% of patients were warned about PONV.
Conclusion
There has been significant improvement with patients pain management during the perioperative period. Other areas of improvement were reflected in the judicious prescription of both regular
and breakthrough analgesia and antiemetics for the post operative
period and the prompt response to patients complaints of pain. An
area that still needs addressing is informing patients about PONV
and treatment available post operatively. Suggestions made included
warning patients about PONV and discussing antiemetic regimes.
The audit should be repeated after the Aintree University Hospitals
elective joint replacement perioperative analgesia and antiemetic
protocol commences.
17
Abstracts
023
Nurses views about assessing pain in nonverbal
patients by using behaviours parametric pain scales in
the intensive care
024
Pain clinic - patient satisfaction survey
Arindam De, Nick Roberts

Nai-Huan Hsiung1,2, Graeme Smith1, Jennifer Tocher1
Kettering General Hospital, Kettering, UK
1The University of Edinburgh, Edinburgh, UK, 2Tzu-chi College of Technology, Huailien, Taiwan
Background
Background
The inadequate treatment of pain in adults with speech impairments
could be due to professional caregivers failure to assess and manage
pain effectively. It is recognized that effective pain assessment would
lead to more satisfied patients and families. Despite the availability of
the evidence to guide pain management practices, practices are often
suboptimal with patients experiencing from moderate to severe pain
in critical care. Limited theoretical knowledge and lack of objective
instruments for assessing pain have been suggested reasons for this.
This study, then, is to explore nurses views on the use of pain assessment tools in an intensive care (ICU) setting.
Methods
This paper present data from three modified focus groups undertaking as part of a large study by exploring pain assessment practices in
five hospitals in Taiwan. The researcher first introduced various pain
assessment scales for measuring pain in patients with communicative
difficulties, such as the BPS (Behavioural Pain Scale), the CPOT
(Critical-care Pain Observation Tool), and the FRPS (Facial Rating
Pain Scale). Before the study, twenty two nurses were taught how to
appropriately assess patients by using the three scales. After practicing with them for more than half a year, fifteen nurses took part in
the focus groups and were asked questions about their views on the
satisfaction and remarks of using three instruments in pain assessment within the ICU.
Results
The regional Research Ethic Committee in Hualien, Taipei, and
Chiayi approved the study (approval no.IRB100-23, B10002014,
00-IRB-006-M). All participated nurses agreed that the introduction
of pain assessment tools would improve documentation. Nurses also
felt full theoretical knowledge on overt expressions of pain behaviours
is necessary to objectively explore pain in patients with speech impairment. Therefore, almost three-quarters of nurses preferred BPS
for assessing pain in their clinical practices. When nurses were asked
how much time they need and how easy they felt for completing these
tools, all of them agreed that each patient assessment was the easiest
and took minimal time to use FRPS. However, eighty percent considered that the most effective pain reactions during nociceptive procedures had been assessed by using BPS. Even though all stated CPOT
provides a detailed item-description about pain behaviours, there is
also main obstacle to use because of its ambiguous indicators.
Conclusion
The variety of pain assessments used by nurses in this study opens
an avenue for further investigating through the linkage between
underlying conceptions of pain behaviours and the effectiveness of
nurses assessments of pain in patients without verbal communication by using an objective pain measurement. The inconsistencies
in these replies could reflect the conflicting demands between the
need to use a validated measures of pain for nonverbal patients while
managing a heavy workload in ICU.
Pain Clinic - Patient Satisfaction Survey was developed as a unique

patient centered reflective feedback loop at Kettering General Hospital Pain Clinic. More than 3000 chronic pain patients were seen in
clinic last year and offered consultation for over 1000 new referrals
in last one year. We offer the best available management for Chronic
Pain based on recent advances and available evidences. But effectivity of our service was only endorsed recently by patients following
this survey.
Methods
Prospective survey recruited 100 new patients over 3 months, who were
requested to fill the questionnaire.The questions covered the following:
The reason for consultation and their expectations from the clinic,
choices include Someone to listen
Diagnose the problem
Further Investigations
Medication
Injections
Acupuncture
Alternative therapies (TENS)
Cure
Coping skills
Improve quality of life
They were also asked where would they like the consultation - either
at the hospital or at the GP / PCT and how far they were prepared
to travel for this.
The duration of the consultation and the information given were
satisfactory or not.
Patient understanding of the management plan and professionalism
of both the doctors and the nurses were in the questionnaire.
Finally they were requested to value their appointment by putting
a number between 0 to 10; 0 being waste of time to 10 being most
satisfactory. Patients were also requested to add comments regarding
consultation.
Results
Out of 100, 6 refrained from valuing, 3 did not reply.
> 70% patients expected someone to listen, diagnose a problem, investigate and offer medications and injections.
Majority did not expect cure but wanted a better quality of life.
80% expect consultation at local hospital.
90% were happy with timing of referral and the length of consultation where they understood the given information, except for the
leaflets. Patients rated doctors and nurses as professionals.
Value of the appointment mostly had high scores, which then plotted
in Net Promoter Score (NPS) chart.
NPS is a customer loyalty model of Harvard Business School to
improve services, which correlates with revenue growth. NPS seeks
votes on a scale 0-10 for a service; where 0-6 detractors, 7-8 passives
and 9-10 are promoters. NPS is calculated as (% promoters) - (%
detractors). NPS maximum score can be 100 (everyone promoter),
NPS +50 is excellent. Our survey yields NPS of 82.
18
Conclusion
026
Patients highly valued the service provided. NPS should be included

as a regular feedback programme at all patient care delivery level.
In reflection of this survey we concluded that the patients still want
the services to be delivered at secondary care level and chronic pain
consultants were most valued among the team. Long waiting time
remained as a challenge. But overall pain clinic based delivery of
the chronic pain management programme was highly valued by this
patient endorsement survey.
Is the brief pain inventory (bpi) a useful patient

reported outcome measure (prom) to assess change in
patients with chronic pain following input from a specialist pain management physiotherapist?
025
The intermed system: an exploration of changes in
case complexity from 2008-2012 at wirral university
hospitals nhs trust pain management clinic
Emma Bain, Peter Williams
Wirral University Teaching Hospitals NHS Foundation Trust, Upton,
Wirral, UK
Background
There is concern about the increasing complexity of cases presenting to the Chronic Pain Management Clinic over time, and there is
indeed need to assess this and allocate resources accordingly. The
ageing population is one of the factors contributing to an increase
in presentation of patients with complex medical, psychological and
social needs to Pain Management Services.
The INTERMED system provides a simple and rapid assessment of
case complexity based upon patient interview. It includes an assessment of history (past 5 years), current state and prognosis. It involves
the evaluation and scoring of biological, psychological, social and
health care needs. There is a maximum score of 60 and an overall
score of greater than the cut off of 21 is considered significant and
deemed as a complex case.

Christopher Carter, Kevin Dewell, Gary Ferguson, Richard Hughes,
CRD Laird
County Durham and Darlington NHS Foundation Trust, County Durham, UK
Background
The National Pain Audit has been set up to look into pain management around the UK over the next 3 years. The BPI is one PROM
being used and consists of a simple, short, self-administered questionnaire that uses 0 to 10 numeric rating scales (NRS)to measure
pain intensity as well as the degree to which pain interferes with
function.Since pain can be quite variable over a day, the BPI asks
patients to rate their pain at the time of responding to the questionnaire (pain now), and also at its worst, least, and average over the
previous week. Evidence for the validity and reliability of the BPI
comes from several studies using the instrument with cancer patients
and patients with other diseases who had pain (Cleeland & Ryan
1994; Keller et al 2004).It has several applications, including efforts
to assure the quality of pain management.
Methods
From 2008 to 2012, the INTERMED score of 804 patients presenting to the Chronic Pain Management Service was collected. Scoring
was performed at interview on clinic assessment. The total number
of patients scoring greater than 21 per quarter of each year was recorded and mean INTERMED score per quarter were calculated.
The BPI has been used as part of a service evaluation to investigate

the impact of specialist pain management physiotherapy on patients
with chronic pain attending the University Hospital of North Durham (UHND). Specialist physiotherapy intervention consisted of
education,acupuncture,graded exercise, class based exercise, problem
solving and progressive goal setting.Significant change was deemed to
be any change of two points or more on the NRS (Farrar et al 2001;
Farrar et al 2009; Salaffi et al 2004). Over a 6-month period a total of
126 patients were asked to complete a BPI pre and post physiotherapy
intervention. The data was then compared and any significant change
in any of the domains on the BPI noted. The working hypothesis was
that specialist physiotherapy intervention would have more impact on
the more physical domains as it aims to restore normal movement and
reduce fear avoidance (Main, Sullivan & Watson 2008).
Results
Results
There was an increase in the number of patients presenting with

INTERMED score of greater than 21 over time and an increase in
mean INTERMED score from 18.4 in the first quarter of 2008 to
21.1 in the third quarter of 2012. The percentage of patients presenting with INTERMED score of more than 21 had increased from
32.9% to 42.9% in 2012. Mean INTERMED score had risen over
time to above the cut off of 21.
The pre and post data on the 126 patients showed nearly a third,
29% of patients with chronic pain showed significant improvement in
worst and least pain experienced.Just over a quarter, 27% showed significant improvement in the average pain experienced. Exactly a third
of patients, 33% showed a significant reduction in their pain at that
exact moment in time (pain now). The physical domains on the BPI
that were expected to change significantly following specialist physiotherapy input included general activity, walking and normal work
(including housework), these improved significantly in 44%, 37%
and 34% of patients with chronic pain respectively. Interestingly the
BPI domains that showed significant improvement in most patients
following specialist physiotherapy were not the physical domains as
expected, but indeed the patients mood and enjoyment of life which
significantly improved in nearly half of the 126 patients, 46% and
49% of patients respectively.
Methods
Conclusion
There has been an increase in case complexity presenting to the
Chronic Pain Management Service as scored by the INTERMED
system from 2008 to 2012. This has significant implications for
allocation of resources needed to manage these increasingly complex
patients. In particular psychosocial comorbidities are known to affect
outcome and prognosis of medical and psychiatric disorders. The
need for access to integrated care with medical specialities, psychiatric services, physiotherapy and occupational therapy will increase
over time. An increase in allocation of resources to Pain Management
services will be required in order to manage these cases effectively.
Conclusion
The results show that the BPI can be used as a PROM to assess change in patients with chronic pain following input from
19
Abstracts
a specialist pain management physiotherapist. Although the results
did not prove the working hypothesis, nearly 1 in 3 patients showed
significant improvement in the physical domains on the BPI directly
associated with physiotherapy intervention. These results must be
interpreted with caution as pain management is not uni-modal and
other interventions from within the wider multidisciplinary team
(MDT) may have taken place during this same period, therefore a
further study is needed to address this issue.
027
PERCUTANEOUS CERVICAL CORDOTOMY FOR CANCER RELATED
DEAFFERENTATION PAIN
Category: Cancer Pain
Manohar Lal Sharma, Heino Hugel, Manish Gupta
Walton Centre NHS Foundation Trust, Liverpool, UK
Background
Percutaneous cervical cordotomy is accepted treatment for mesothelioma related medically refractory cancer pain. Its role is also established for nociceptive cancer pain which is refractory to conventional
medical management. However, there is some controversy relating to
use for this neuroablative technique for cancer related deafferentation pain.
Methods
We describe three cases of brachial plexus infiltration related cancer pain treated by Percutaneous cervical cordotomy. All patients
derived excellent reduction in pain and analgesics consumption
after this procedure. All of these patients had numb, painful and
paralysed upper limb. This was related to spread of cancer to axilla
and impaired function of brachial plexus. All patients were treated
by application of radiotherapy and chemotherapy to control the
spread of cancer. Pain was difficult to control with combination of
strong opioids, anticonvulsants, antidepressants and conventional
analgesics. All patients were assessed by Joint Palliative and Pain
team. Patients were usually admitted at Woodlands hospice for pre
and post procedure care and procedure was carried out at Walton
Centre.
Results
All patients reported excellent analgesia post cordotomy. There
were no major complications. Usual side effects of headache, neck
pain and general malaise were noticed for 2-3 days. There was considerable reduction in analgesic use post cordotomy. Another useful observation during sensory stimulation while undertaking cordotomy was that all patient felt spinothalamic sensation in numb
and paralysed limb (sensation of heat and cold). Before undertaking Cordotomy, authors were not sure whether this will be possible.
Perception of spinothalamic sensation in painful area on sensory
stimulation is positive predictor of success from percutaneous cervical cordotomy.
Conclusion
In our opinion and experience, percutaneous cervical cordotomy has
useful role in medically refractory cancer related deafferentation type
upper limb pain caused by infiltration of brachial plexus. However,
we understand that our results cannot be extrapolated to all patients
suffering from this type of cancer pain. This though remains a possibility if the pain was to be poorly controlled with conventional medical management.
028
Pain screen and treat: a randomised controlled trial
to assess the effect and cost- effectiveness of routine
screening and treatment of pain in cancer patients
John E. Williams1, Janet Peacock2, Anthony Gubbay1, Rose Ellard1,
Julia Riley1, Odile Sauzet3, Joy Ross1
1Royal
Marsden Hospital, London, UK, 2Department of Primary care

and Public Health Sciences, Kings College London, London, UK, 3Department of Statistics, University of Bielefeld,, Bielefeld, Germany
Background
Cancer pain remains a major public health problem affecting as many as
one in two patients attending oncology outpatients departments (1,2,3).
Reports from the American and British Pain Societys have recommended a proactive approach to pain management, including regular assessment of pain and use of evidence-based treatment protocols, integrated into routine oncological practice.
We aimed to explore whether a new proactive screening and treatment
system for pain, which incorporates these recommendations, is effective and cost effective when compared with usual care.
Methods
We screened patients routinely attending outpatients for pain using
a single question. Patients scoring >4 on the BPI-NRS worst pain
in past 24 hours were approached for inclusion and randomised to
intervention or usual care.
Intervention included immediate (on-the-day) access to pain treatment advice according to individualized protocol algorithms, follow
up, reassessment and patient education.
The primary outcome was difference in pain scores (BPI) at one, two
and three months.
Secondary outcomes included pain interference with activities
(BPI), adequacy of pain management (PMI), quality of life (EQ5D), patient satisfaction (0-6 Likert scale) and anxiety or depression
(HADS).
Data was prospectively collected to evaluate healthcare costs.
Results
From January 2011-July 2012 we screened 1087 patients (2212 visits).
We recruited 156 patients, mean age (SD) 58.1 (10.6) years, 64.7% male.
The most common diagnoses were thyroid 18.6%, tongue 17.9%,
tonsil 10.9%, and parotid cancer 7.1%. Average (SD) pain scores at
baseline were 6.4 (1.6).
Conclusion
Final data will be available March 2012 and full results presented at
this meeting.
029
Invasive neurodestructive procedures in cancer pain
(inpic): development of a cordotomy registry.

Nicholas Campkin1, Matthew Makin2, on behalf of INPiC pilot study
group3
1Portsmouth Hospitals Trust, Portsmouth, UK, 2The Marie Curie Palliative Care Institute, Liverpool, UK, 3INPiC pilot study group, INPiC, UK
20
Background
The Marie Curie Palliative Care Institute Liverpool Pain Group
and NRCI Palliative Care Studies Pain Group established a working party to examine the role of Invasive Neurodestructive Procedures in Cancer Pain (INPiC). The initial focus has been on cordotomy (INPIC Pilot study) The aims and objectives of the INPiC
Pilot study were:
To produce national guidelines for the use of cordotomy in mesothelioma-related pain management
To provide a benchmark for the availability of cordotomy for
mesothelioma-related pain in the UK
To establish a National Registry for cordotomy
As a pilot, if successful, to be repeated in other interventional approaches in cancer pain management
Methods
Three phases to the project were identified:
Systematic Literature Review:
Is cordotomy a safe and effective treatment for mesothelioma-related
pain?
Consensus Study
Ser vice Sur vey/ Screening identifying UK centres providing
cordotomy
Delphi Study measuring consensus regarding: place of cordotomy
in mesothelioma-related cancer pain; benefits vs risks; evidence base;
appropriate uptake and timing of referral for cordotomy; use in nonmesothelioma cancer pain.
Nominal Group Technique - developing consensus using case scenarios
at Palliative Care Section, RSM October 2011 following presentation
of outcomes of Systematic Review, Service Survey and Delphi Study.
Registry Study:
Meeting of INPiC group and Dendrite Clinical Systems Ltd. March
2012 to initiate registry study, agree data set by consensus and commission registry of all cordotomies in UK. Data set and site development online by clinical / IT group.
Funding for project provided by NCRI SuPaC Lung Cancer Research Grant approved June 2008
Results
Literature Study:
Evidence base for cordotomy in mesothelioma pain limited - case
series
Percutaneous fluoroscopic technique most commonly used
Studies demonstrate good pain relief in most patients
Life-threatening complications rare
Minor side-effects common
Consensus study:
160 Interviewed;136 entrants into Delphi; 101 completed First Round;75
complete data sets.
Cordotomy has place in managing mesothelioma cancer pain?
YES
Potential benefits of cordotomy far outweigh risks of procedure? YES
Evidence-base for use of cordotomy in mesothelioma pain is robust?
UNCERTAINTY
Are patients with mesothelioma in the UK who could benefit from
the procedure referred for cordotomy? NO
Are patients with mesothelioma in the UK who could benefit from
cordotomy referred at appropriate time? NO
Cordotomy should only be considered for mesothelioma-related
pain? NO

Registry study:
Data set agreed, pilot site tested,now live. Online UK registry includes demographics, baseline pain, medication and interference
scores, procedure data, post-procedure outcome data etc.
Conclusion
Consensus methodology is useful for collating information and expert opinion where published evidence is limited for priority setting
and guideline development. Our findings indicate:
Cordotomy has a place in the management of mesotheliomarelated cancer pain.
The potential benefits far outweigh the risks of the procedure.
Not all patients with potential for benefit are referred.
Patients are often referred late.
Cordotomy should be considered for unilateral cancer-related
pain from other causes.
A National registry has been developed with the aim of standardising
and improving outcome data across the UK and ensuring safety and
efficacy of cordotomy.
030
Pain screen and treat: the feasibility of regular
screening for pain in a busy oncology outpatient
department; an update on the ongoing service evaluation study.
John Williams1, Janet Peacock2, Anthony Gubbay1, Rose Ellard1,
Julia Riley1, Odile Sauzet3, Joy Ross1,4
1Royal
Marsden NHS Foundation Trust, London, UK, 2Kings College

London, London, UK, 3Universitt Bielefeld, Bielefeld, Germany, 4Imperial College, London, UK
Background
Pain in the cancer patient is seen in nearly half of attendees to oncology outpatient departments [1,2,3]. Recommendations from the
American and British Pain Societies outline the need for a more
proactive approach to cancer pain management involving regular assessment and early, individualised treatment using evidence-based
protocols [4,5].
Screening for clinical signs and symptoms such as fatigue, distress
and depression in general or oncology outpatient departments is
common [6,7]. However, screening for pain is less so. At the Royal
Marsden Hospital, one of the largest tertiary referral cancer centres
in the United Kingdom, a new proactive screening and treatment approach for pain is being explored for its effectiveness when compared
to usual care with findings due to in 2013.
Part of this research involves investigating the feasibility of regularly
employing this proactive screening and early treatment approach in
a busy oncology department.
Methods
Patients attending the outpatient department at the Royal Marsden have been screened for pain over the last fourteen months. A
screening form asking the attendee to score their BPI-NRS worst
pain in past 24 hours between 0 and 10 is handed out at the reception. Once filled in, the forms are given to their clinic nurse.
If their pain score is 4/10 (a positive score), the nurse will offer
the patient an immediate assessment by the pain team or a pain
clinic appointment. The patient can also chose to remain under
the supervision of an alternative clinician e.g. oncologist or GP,
or can decline.
21
Abstracts
Quantitative data is collected on the number of patients attending,
forms distributed and returned, pain score and treatment choice.
Positive scores without documented treatment choice are also recorded. Qualitative information from the outpatient clerical and
nursing staff has been collected during two focus group meetings.
Recommendations:
Results
032
From October 2011 to date, over 1400 outpatients have been

screened for pain from approximately 3000 attendees. Almost
70% of screening forms have been distributed to patients on arrival by clerical staff with approximately 50% returned for collection.
Of those attendees screened, 20% of patients complain of pain that
scores 4/10. 12% of these patients requested immediate pain service attention in the form of an assessment or clinic appointment.
The remainder chose for another party to manage their pain. However, over 30% of positive forms (i.e. pain that scores 4/10) did not
have a treatment option documented.
Qualitative focus groups meetings and relevant communication with
the outpatient staff and clerical staff are currently being analysed.
Noted topics of discussion range from the need to screen cancer
patients for pain and preferred methods of screening at the Royal
Marsden.
Conclusion
This study into regularly screening outpatients for pain will be completed by early February 2013. Remaining quantitative and qualitative data will be collected, analysed and finalised and further dissemination of results will take place at that time.
031
Survey of paediatric chronic pain training in uk
Category: Education
Senthil Vijayan
Chelsea and Westminster hospital, London, UK
Background
1. To assess the delivery of paediatric chronic pain training for advanced pain trainees in UK. 2.To improve the delivery of paediatricchronic pain training for APTs.
Delivery of pain training is not uniform within United Kingdom and
different deaneries have different modes of pain training delivery.
The aim of this survey is to assess the delivery of paediatric chronic
pain training within UK to address the issues, improve the delivery
and bring uniformity in pain training [1].
Methods
Survey was conducted among all the advanced pain trainees on UK
via the internet tool survey monkey.
Results
The survey was sent to all advanced pain trainees in UK. The response rate was 80%. Only 10% had attended more than 10 sessions
of acute ward rounds. 100% agreed they need to have access for a
module in paediatric chronic pain. 10% have attended more than
10 outpatient sessions. Only 10% managed to achieve their recommended competencies in paediatric chronic pain training.
1. Uniformity in training should be rolled out across the country.

2. Paediatric chronic pain training should be delivered as a continuous module rather than random clinics.
Using social media to assess public perception of

FIBROMYALGIA
Category: Education
Rajiv Malhotra, Sara Kelly
Royal Liverpool University Hospital, Liverpool, UK
Background
Fibromyalgia is a common chronic pain syndrome associated with
adverse symptoms of cognitive, behavioural, and emotional dysfunction. It has a prevalence of 0.5-5%. However, public knowledge has
been shown to be poor, with false perceptions regarding the medical
basis of the condition being widely believed. Social media platforms
have been rapidly expanding in recent years and often involve discussions on medical topics. We sought to access various social media
sites to gauge current public perception of fibromyalgia.
Methods
A search of YouTube, Facebook and Twitter was performed on
27/11/12 with the terms fibromyalgia, fibromyalgia syndrome and fibrositis. The 20 most-viewed videos on YouTube were selected, with
the top 10 comments for each being reviewed. The 10 most recent
comments on the top 20 Facebook webpages were reviewed. The 20
most recent tweets on Twitter were also included. Each comment was
graded as sympathetic, neutral or derogatory. Comments that
questioned the validity of a diagnosis of fibromyalgia were identified.
Results
A total of 21,100 hits were obtained on YouTube, with the top 20
videos having an average 39, 887 views and 44 comments. The top
20 Facebook webpages had an average of 22 211 likes. The 20
most recent Tweets had an average of 4 replies.
Sympathetic responses: 72% YouTube, 92% Facebook, 82% Twitter
Neutral responses: 18% YouTube, 7% Facebook, 13% Twitter
Derogatory response: 10% YouTube, 1% Facebook, 5% Twitter
Question validity: 1% YouTube, 1% Facebook, 0% Twitter
(Displayed as a graph, not included)
Conclusion
The expansion in social media has resulted in a significant amount
of public discussion regarding fibromyalgia. The majority of comments were sympathetic in tone, with only 6.6% of total comments
assessed being derogatory. There is still a small percentage of the
public that questions the validity of a diagnosis of fibromyalgia, in
accordance with previous studies. Enhanced public education, utilizing the social media network, may improve awareness of this common condition.
033
Independent healthcare: the knowledge and attitudes
of nurses towards pain management
Conclusion
Category: Education
Katharine Wall1
The survey clearly illustrates lack of uniformity in paediatric chronic pain

training and the main reason being difficulty in access to such module.
1HCA Healthcare International, London, UK, 2The Wellington Hospital,

London, UK
22
Background
034
Evidence supports continuing education to improve knowledge,

attitudes and understanding towards pain management 1.
At a large Independent Healthcare facility with 6 hospitals and an
infant pain service, a corporate pain group was conceived, who devised a pain training programme using an adapted knowledge and
attitudes to pain questionnaire 1.
The content of the programme was based on local audit results2
showing that only 67% of pain assessments were accurate when
documented pain scores were compared with the patients report.
Physiology and pharmacology were taught with emphasis on pain
assessment and also assumed gaps in knowledge regarding addiction
and opioid use 3.
Intermediate level pain training - survey of sesa

trainees
Methods
The delegates (n=179 ) were asked to complete the questionnaire
prior to the training session and the data was collated and analysed
to examine trends in attitudes and gaps in knowledge, specifically
looking at beliefs of patient over-reporting of pain. The mean correct response rate was 71%
The questions were answered and discussed during the first 3
sessions of the study day and the amount of correct answers
increased even during that short space of time with intense
teaching.
The speciality of pain has been significantly highlighted over the
previous 18 months with the advent of a Pain Clinical Nurse
Specialist and heightened the awareness even before the formal
teaching and this is evident when comparing the data to previous
studies.
Results
Ambivalence was observed toward pain assessment and treatment when faced with 2 identical patients reporting severe pain;
stoical patient A; patient B exhibiting behavioural manifestations
of pain.
Patient B received adequate analgesia 62% of the time. This finding
is an improvement in comparison 4 (45.1%). The stoical patient was
under scored (24%) and received inadequate analgesia (53%).
94% correctly identified the patient as the most accurate judge of
their pain but, 47% believe that the patients exaggerate their report
of pain.
Poor opioid knowledge (31% identified respiratory depression as
rare in opioid tolerant patients), and opioid addiction misconceptions (62% identified <1% of patients will become addicted
when pain treated with opioids, compared with 30% 5), may account for the poor vignette choices. This lack of knowledge does
not clarify the philosophy that patients must demonstrate visual
pain behaviours before we are more likely to believe their report
of severe pain.
Conclusion
Nurses inability to effectively titrate opioids has been identified as a
central cause for the under treatment of pain 6. Several authors have
listed the possible reasons why nurses consistently choose dosages
which do not correlate with patients self-report of pain including:
fear of overmedicating patients with opioids; personal beliefs regarding patients pain scores.
The majority of respondents (87%) correctly indicated that subsequent doses of opioid analgesics should be adjusted according to
individual responses, however clinical application of this belief was
not reflected in the patient case vignettes and the stoical patient remained poorly managed
Category: Education
Fauzia Hasnie
Guys & St. Thomas NHS Foundation Trust, London, UK
Background
Pain Medicine is a compulsory part of Anaesthetic training. Trainees must undergo basic and intermediate level training in Pain
Medicine in order to achieve the core competencies required for
the CCT in Anaesthesia1. Intermediate competencies, which are
usually achieved during the Specialty Registrar (StR) Years 3/4 of
training, build on those acquired during basic level training as a
Core Trainee (Years 1/2). They include competence in the assessment and management of acute, chronic and cancer pain; understanding of the importance of managing acute or chronic pain in
a timely manner; and competence as an effective member of the
acute pain team. It is preferable that this training is gained as a
dedicated block. This survey details the training experiences of
trainees in the South East School of Anaesthesia (SESA) and highlights areas for training improvement when compared to requirements in the Royal College of Anaesthetists (RCoA) 2010 Curriculum2.
Methods
SESA trainees StR3 and above who had completed their intermediate level pain training by end of September 2012 were invited via
e-mail to participate in an online survey consisting of 8 questions
relating to their training experience. The 2010 RCoA Curriculum
for a CCT in Anaesthesia was reviewed, specifically with regard to
those competences that relate to acute pain and those that relate
to chronic pain. A comparison was then made between curriculum
requirements and survey findings to identify any training areas that
could be improved.
Results
Of the 190 SESA Trainees StR3+ who were contacted, 42 responded
(response rate 22.1%). 97.6% undertook intermediate level pain
training as a dedicated block. Acute pain ward rounds were attended
by 88.1% of trainees; whereas, chronic pain ward rounds were attended by 45.2%.83.3% of trainees spent less than of their time
in acute pain, whilst only 4.8% of trainees spent at least 50% of their
time in acute pain. 54.7% of trainees spent <50% of their time in
chronic pain clinic compared to participating in theatre lists. 7%
spent <25% of time assessing and managing patients in clinic during
their pain module. Median confidence score in assessing and carrying out basic management of chronic pain in adults was 3/10. 60%
of trainees had confidence levels of <50%. 85.7% of trainees felt that
their pain module was well organised and with adequate sessions.
However, the majority were not interested in furthering their pain
training.
Conclusion
The RCoA 2010 Curriculum for Intermediate Level Pain training
outlines an equal weighting in competences that relate to acute pain
and chronic pain. It further stresses the importance of achieving
competency in the basic assessment and management of chronic
pain patients, best accomplished in the clinic environment, rather
than attaining practical skills in theatre. This survey highlights areas
for improvement in training needs: (1) Pain training should be
23
Abstracts
performed as a dedicated block; (2) More Acute Pain sessions including ward rounds; (3) More sessions in chronic pain clinic, rather
than in theatre to allow a more balanced training experience.
035
Why not a career in pain medicine?
Category: Education
Bence Hajdu, Mohjir Baloch, Ann Hatch
Frimley Park Hospital NHS Foundation Trust, Camberley, Surrey, UK
Background
In our region, London & KSS Deanery, we have noticed consistently
low numbers of trainees wishing to pursue a career in pain management, with pain training posts being undersubscribed. The aim
of our survey was to find out what may be the reasons why junior
specialist anaesthetic trainees (ST3/4) decide not to pursue pain
training.
Methods
A pre-formatted scannable survey consisting of five questions was
distributed to a group of ST3/4 level anaesthetic registrars appearing
at a regional training day on Anaesthesia for cancer surgery. It was
organised by the London and KSS Deaneries, in Guildford.
The survey consisted of two main parts. In the first we identified the
exact training level & experience gained in the field of pain medicine
using multiple choice questions. This was intended to identify the
context for the second half of the survey where trainees were asked
to give free text answers about their career choices and the reasons
why they decided against pain medicine..
Results
23 out 29 (79%) participants completed the survey in. Out of the
23 responders 3 were other grades than ST3/4, 3 were ST4s and 17
ST3s. 13% had finished the intermediate pain training already, and
61% had started intermediate pain training since August 2012. The
range of exposure to the domains of training were3-5 pain clinic
sessions, 2-4 acute pain round sessions, 2-10 theatre block lists..
100% of ST4s (3) and 24% of ST3s (7) have already made a decision on their career. 4 trainees chose ICM, 2 Obstetric anaesthesia,
2 Pain medicine, 1 Regional anaesthesia, 1 Paediatric anaesthesia.
Reason for not choosing pain medicine were:
interested in something else (10)

not interested pain medicine, but no other preference(5)
clinics are difficult(4)
not enough exposure to pain medicine as yet (3)
doesnt feel trained in managing personality/psychological issues (1)
Conclusion
This small survey of ST3 & 4 trainees shows that the ST3 trainees
come to a decision by the end of the academic year, hence their
exposure in this year could be crucial in their decision. Exposure
seemed to be the factor driving these decisions and the experience
gained in clinics seem to be a major determinant in deterring trainees from seeking a career in pain medicine. A larger scale survey
would be necessary to be able to generalise these findings.
036
But how do you feel about morphine doctor?
Category: Education
Helen Laycock1,2, Emma Casely1, Carsten Bantel1,2

1Chelsea
and Westminster Hospital, London, UK, 2Imperial College,

London, UK
Background
Pain in hospitals continues to be managed insufficiently (Hefand
2009). Causes are multifactorial, but include doctors prescribing
habits. The process of prescribing is influenced by the patient, traditions, guidelines and cost (Ljungberg 2007), but may also involve
highly sophisticated learning and memory schemas, which generate
certain concepts or values about specific therapies (Higgins 2005).
Moderate and severe acute pain is commonly treated with opioids.
Barriers leading to ineffective opioid prescribing include safety concerns and fear of addiction or abuse (Murnion 2010). However
terminology used to describe these barriers appears to be similar
to those associated with value judgments. Therefore are value judgments a barrier in opioid prescribing and can they be modified?
This study aims to evaluate if a dedicated teaching session on opioid
use in acute pain improves newly qualified doctors confidence and
reduces perceived difficulty in dealing with acute pain, whilst also
altering individual value judgements regarding morphine.
Methods
Newly qualified doctors completed questionnaires before and after
a teaching session.
The teaching session was Consultant led and focused on intravenous
morphine use in severe acute pain. It included a video based clinical
scenario, tips on opioid use, complications, side effects and time for
questions.
The questionnaire included a written case describing a patient in
severe acute pain requiring immediate management. Doctors then
evaluated confidence and case difficulty by marking on 100mm visual analogue scales (VAS) anchored with easy / difficult and
unconfident / confident. A further two pages were headed with either
30mg mophine or 1g paracetamol, with ten 100mm VAS lines
underneath. Each VAS was anchored with value judgment words
with opposite meanings. Five word pairs came from a junior doctor generated word database describing morphine and paracetamol.
The remaining five word pairs were synonyms of the original pairs
included to ensure inter-individual scoring validity.
Results
100% responder rate (n=18).
Mean difficulty VAS scores changed by 20mm towards the easy
anchor and the range of individual scores reduced by 30mm following teaching. All doctors scored the case easier to manage following
teaching.
Mean confidence VAS scores improved by 17mm following teaching
and 94% of doctors had improved confidence following teaching irrespective of original confidence.
Two VAS were removed from the value judgment section due to lack
of scoring consistency. The remainings mean VAS scores prior to
teaching showed morphine scores trended towards potent, apprehensive, excessive and dangerous anchor words, whereas paracetamol
scores trended towards weak, unconcerned, inadequate and safe. All
mean VAS scores following teaching were within a few millimetres
of the pre teaching scores, except paracetamol, which scored as increased risk following teaching.
Conclusion
Newly qualified doctors reported increased confidence and ease in
dealing with an acute pain scenario, following a dedicated teaching
session on opioid use in acute pain. This session focused on improv-
24
ing knowledge but this single educational intervention did not alter
individual value judgments regarding morphine, these remained unchanged. This may indicate that value judgments are not influenced
by improved technical knowledge. Therefore if value judgments are
important in influencing junior doctor prescribing of opioids, teaching needs to be focused on altering these aspects in addition to improving knowledge.
037
Does attendance at a pain special study unit significantly improve medical students knowledge of pain
at peninsula medical school?
Category: Education
Anand Mehta0 ,2, Mark Taylor1, Suzanne Blowey1, Roy Powell0 ,2
1Plymouth Pain Management Centre, Derriford Hospital, Plymouth, Devon, UK, 2Peninsula College of Medicine and Dentistry, Exeter, Devon, UK

students who had not attended a pain SSU obtained a median score
of 27%. Students in all years had a tendency to under-estimate pain
and prescribe inadequate analgesia. 96% of respondents felt they needed
more pain teaching. All results were statistically significant (p<0.001).
Conclusion
This study shows that attendance at a Pain SSU significantly improves medical students knowledge and understanding of pain management. Despite the benefits, it is worrying that only 10% of medical students attended this optional pain SSU, considering 100% of
PMS students are likely to encounter patients experiencing pain at
some point following graduation. Additional pain teaching should be
provided to meet current competencies expected of them as junior
doctors [2]. The pain tuition given in this SSU should be integrated
into the compulsory undergraduate curriculum, rather than merely
an optional study unit for a minority of medical students to attend.
038
Background
A previous study in South West England showed a lack of knowledge
amongst junior doctors regarding post-operative pain management
[1]. At the Peninsula Medical School (PMS), in South West England,
medicine is taught in a patient-centred approach. Students are in
contact with patients throughout the five years of their undergraduate studies. Medical students regularly see patients who are in acute
or chronic pain. As a Foundation Year 1 doctor, PMS graduates will
have to meet competency standards in pain assessment, prescribing
adequate analgesia and re-evaluation of patients experiencing pain
[2]. Therefore, it is essential medical students appreciate the various
forms of pain, can adequately assess patients who are experiencing pain and understand how such patients should be managed. At
PMS, medical students can choose from various optional special
study units (SSU) to enhance their understanding of various subjects. We wanted to know if a Pain SSU significantly improves pain
knowledge among medical students.
Methods
To determine if this is the case, following ethical approval and a pilot
study, we developed a questionnaire based on the Outline curriculum on Pain for Medical Schools produced by the International Association for the Study of Pain (IASP) [3]. Our questions tested medical students knowledge of the definition, assessment, physiology
and pharmacology of pain plus pain management in various clinical
scenarios. Questionnaires were given to 1st - 5th year undergraduate
medical students at PMS. One of the questions asked participants
to reveal if they had attended a pain special study unit - an optional
course available to medical students. A statistician analysed the data
utilising non-parametric (Kruskal-Wallis and Mann Whitney U)
tests and SPSS. Statistical analysis was undertaken to establish if
there was a significant difference in the number of correct answers
from students who had undertaken a Pain SSU, compared to students who had not undertaken a Pain SSU.
Results
Analysis of student scores from completed questionnaires showed
the percentage of questions answered correctly improved sequentially between 1st - 5th year PMS students. Median scores improved from
7% correct in year 1 cohort, to 27% in year 2, 40% in year 3, 47%
in year 4 and 53% correct in the Year 5 cohort. This shows students
understanding of pain improved as they progressed through medical
school. However, there are clear discrepancies between what they
should know [2-3], compared to what they actually do know.
Thirty nine medical students who attended a Pain SSU obtained a
median score of 47% correct answers in the questionnaire. 387 medical
Opioid prescribing practice among general practitioners: a survey

Category: Education
Senthil Vijayan
Imperial school of Anaesthesia, London, UK
Background
Chronic non malignant pain is a huge burden on the society. Opioids
have a significant role to play in the management of these patients.
There is a huge variation in the practice of opioid prescription in the
primary care. The reasons include fear of addiction and lack of proper
knowledge and understanding of the pharmacology and side effects.
Aim:
To identify the opioid prescribing practice among GPs in the Ealing,
Harrow and Hillingdon boroughs of West London. To ascertain the
training, knowledge and understanding of opioids among GPs.
Methods
The survey was done using the online tool survey monkey among the
GPs in West London
Results
The survey was sent to 89 GPs. The response rate was 75%. Only
20% had some training about opioid prescription. 70% agreed they
are reluctant to start patients on opioids. 62% do not have any ceiling for the opioids. 90% agreed opioid are useful in the management
of chronic non malignant pain
Conclusion
The survey clearly shows there is wide variation of opioid prescription in the primary care. The results show there is a need for education and training about opioids among GPs. If patients do not achieve
useful relief of pain when titrated to doses between 120- 180 mg morphine equivalent per 24 hours, referral to a specialist in pain medicine is
strongly recommended. 80% of patients taking opioids will experience
at least one adverse effect
039
An exploration of religious faith and the management
of pain among older people
Category: Elderly
25
Abstracts
Jill Edwards1, Michelle Briggs2, Karl Atkin4, Ganesa Baranidharam3,
Mike Bennett1, Chris Swift3, S. Jos Closs1
1University
of Leeds, Leeds, UK, 2Leeds Metropolitan University, Leeds,

UK, 3Leeds Teaching Hospitals NHS Trust, Leeds, UK, 4University of
York,York, UK
Background
While social influences have been acknowledged as important in

the experience of chronic pain, they comprise a relatively under-researched area. In particular, little attention has been paid to the influence of religious faith on how pain is experienced and expressed
by individuals, and how it may influence the communication and
self-management of pain. The intersectionality of attributes such
as ethnicity, language and faith make them a challenge to study
and the different ways in which these factors may impact on health
service usage is not well understood. To date, ethnicity has been
the major cultural lens through which disparities in healthcare have
been viewed and little attention has been given to how different
faiths may induce differences in the management of pain. This
study aimed to explore how the five most common faiths in the UK
influence the experience and expression of pain in older people.
Methods
Qualitative interviews were undertaken with people aged 65 years or
above. Three main issues were explored:
1. The nature of pain, its location, beliefs about the cause of the pain
and familial, social and spiritual meanings of the pain.
2. Expectations and experiences of the NHS concerning pain, including consultations with their GP, community-based nurses,
episodes in hospital, and any others.
3. Attitudes towards pain treatments in terms of prescribed analgesics, other NHS initiated interventions, over-the-counter remedies,
CAM and any other self-management strategies.
A theoretical sampling frame included Christians Jews, Muslims, Sikhs,
and Hindus. We aimed to include equal numbers of men and women as
well as key minority ethnic groups. Recruitment was undertaken through
the local hospital chaplaincy and >70 community groups with a focus
on specific faiths or ethnicity; and individual contacts. Ethics committee
and R&D governance approvals were negotiated via the NHS IRAS.
Results
Forty-four interviews were completed, including all the intended
faith, ethnic and gender quotas. Audio-recorded interviews were transcribed verbatim. Data were initially organised using the qualitative
software NVivo, then thematic accounts were developed from the
data using framework analysis. During the analysis regular meetings
were held between members of the research team to discuss emergent
themes. Inter-rater reliability was maximised by ensuring that a second researcher coded 10% of all transcripts. Any discrepancies in coding were discussed by two researchers until agreement was reached. A
broad framework was generated, with four preliminary themes. These
were: Nature of pain, Faith and pain, Interactions with health professionals, and Patients responses to pain. In-depth analysis is ongoing.
Conclusion
Fiona MacKichan1, Joy Adamson0 ,2, Rachael Gooberman-Hill1

1University
of Bristol, Bristol, UK, 2University of York,York, UK
Background
People draw on diverse explanations for the existence of chronic pain,
and seek to make sense of (and give meaning to) pain within their life
history. This explanatory model informs a persons expectations of
pain, and their responses to it. One way in which people may explain
their experience is by drawing on their observations of the experiences of family members. These reflections have been found to be important in peoples understanding of ageing and their own experience of
ageing, but little research has explored how family history contributes
to an individuals explanatory model of chronic pain.
Methods
These data are drawn from a larger investigation of older peoples
management of chronic pain. A qualitative in depth interview study
was conducted as part of a mixed methods doctoral project, which
received ethical approval from the South West Multicentre Research Ethics Committee. A total of thirty-one older adults (age 67
- 92) were interviewed about their experiences of living with pain
in older age. Participants were purposively drawn from an earlier
cross-sectional community-based survey (n = 583), based in South
West England. The qualitative sample was demographically diverse.
Interviews, in participants own homes, were audio recorded and
transcribed verbatim. Data collection and analysis were conducted
simultaneously. Analysis followed the constant comparative method,
inductively generating a thematic account of the data. Data presented reflects a segment of findings, specifically concerning the inclusion of family history in explanatory models of chronic pain.
Results
All participants sought to construct a coherent explanation for chronic pain, and this often included observations about family members,
particularly parents. Understandings of pain were enmeshed with
views of ageing and this was important to peoples incorporation of
family into their own account; if parents had experienced pain at an
equivalent age, then pain was more likely to be normalised. The behaviour of family members, and outcomes, were linked with participants behaviour. For example, some described seeing their parents
decline in older age and felt that they needed to respond to pain in
a different way, such as being more active. A number of participants
also held the view that chronic pain, or painful conditions, could be
hereditary. This gave rise to a sense of inevitability in some accounts,
with participants describing having expected to develop conditions
such as osteoarthritis.
Conclusion
The findings show that older people draw on family history to make
sense of chronic pain and ageing, and the relationship between these.
People may view chronic pain conditions as inherited/transmitted
through generations, which may influence perceptions about the significance of pain, and subsequently perceptions of risk and health
behaviours such as seeking help. Greater understanding of the influence of family history on pain behaviour can inform public health
interventions to improve outcomes in people with chronic pain.
Conclusions will be generated on completion of the data analysis.

041
040
Just like mum: the place of family history in older
peoples explanations of chronic pain
Publication bias, heterogeneity and quality assessment of research on the prevalence of chronic pain.
A meta-analysis.
Category: Elderly
Category: Epidemiology
26
Raga Elzahaf
Methods
Leeds Metropolitan University, Leeds, UK
A systematic search of ten electronic databases (including Medline

and EMBASE) was undertaken in March 2012 to identify observational studies of widespread musculoskeletal pain and mortality.
Studies were excluded if the outcome was not death from natural
causes (e.g. suicide) or if they focussed on non-musculoskeletal pain
(e.g. cancer pain), musculoskeletal conditions (e.g. osteoarthritis) or
location specific pain (e.g. back pain). Identified studies were assessed for methodological quality by two independent reviewers using a validated instrument. A meta-analysis of the identified studies
was conducted using a random effects model. The pooled effects for
an association between widespread pain and (i) all-cause mortality, (ii) cardiovascular disease mortality, (iii) cancer mortality and
(iv) respiratory disease mortality were calculated and presented as
pooled Standardised Mortality Ratios (SMR) and Mortality Rate
Ratios (MRR) or MRR only with 95% confidence intervals. The
proportion of variance across the studies attributable to heterogeneity (I2) was also assessed.
Background
A systematic review without a meta-analysis by our team concluded that there is insufficient reliable data to estimate the prevalence
of chronic pain in countries with a Human Development Index
(HDI) <0.9 (Elzahaf, et al., 2012). This highlighted the need to
improve the methodological quality of epidemiological surveys.
The aims of this secondary analysis were to assess the quality of
surveys of chronic pain using a meta-analytic approach to evaluate
the sources of heterogeneity and to estimate the risk of publication bias.
Methods
Two reviewers assessed the methodological quality of 65 surveys
from 34 countries (19 study reports) identified in a review by
Elzahaf et al. (2012) by using criteria developed by Lonely et al
(1998). Assessment of publication bias was performed using Eggers
test and a funnel plot of standard error by logit event rate (e.g. the
proportion of people with chronic pain). Forest plots were produced
and the I2 test used to determine heterogeneity. All analyses were
performed using Comprehensive Meta-analysis Software.
Results
All studies scored >5 or more out of a maximum of 9 points on quality assessment. All investigators reported using random sampling
with 18 out of 65 surveys used at least a sample size of 600. However, only 16 surveys reported using unbiased sampling frames like
electoral register and telephone directory. A funnel plot indicated a
high risk of publication bias (P<0.001, Eggers test) and heterogeneity was large (I2=99.37, P<0.001).
Conclusion
Studies estimating the prevalence of chronic pain had a large amount
of heterogeneity suggesting that any attempt to pool this data should
be interpreted with caution. The heterogeneity is likely to be due to
differences in survey methodologies, characteristics of target populations and categorisation of chronic pain. There was a greater risk of
publication bias in favour of surveys reporting higher chronic pain
prevalence.
Results
15,057 papers were identified through the electronic search. Following application of inclusion and exclusion criteria, six papers were
selected. All were assessed to be of good methodological quality. An
association between widespread pain and all-cause mortality was
reported in three studies. Five papers reported an association with
cause specific mortality, particularly from diseases with links to
lifestyle factors (e.g. cancer and cardiovascular disease).
The meta-analysis indicated a trend toward an increased risk of allcause mortality in people with widespread pain although not statistically significant (MRR and SMR combined = 1.11; 95% CI
0.91 to 1.35, p=0.305, MRR only = 1.12; 95% CI 0.87 to 1.45,
p=0.375). There was evidence of statistically significant high heterogeneity (MRR and SMR combined I2 =73.4%, 2=18.80, p=0.002,
MRR only I2 =82.4%, 2 =17.01, p=0.001). No significant results
for cause-specific mortality were found although an increased risk of
cardiovascular disease and cancer mortality was indicated.
Conclusion
042
This study identified that mortality from diseases with links to lifestyle factors are associated with widespread pain. However, in the
meta-analysis there was no confirmation of a significant pooled association between widespread pain and mortality. This may be due to
the low number of identified studies and high heterogeneity between
them. Further research is necessary to explore the link between
widespread pain, morbidity and mortality.
Widespread pain and mortality a systematic review

and meta-analysis
043
Diane Smith, Ross Wilkie, Olalekan Uthman, Joanne Jordan, John
McBeth
Demographics and referral patterns of non attendees for new appointments to the pain clinic.
Keele University, Staffordshire, UK
Parveen Dhillon1, Arun Sehgal1, Ravi Kare2
Background
1Peterborough and Stamford Hospitals NHS Foundation Trust., Peterborough, UK, 2Norfolk and Norwich University Hospital, Norwich, UK
Pain is common in older adults with two thirds of those aged 50

years and over living in the community reporting pain that lasts
for a day or longer during a one month period. The impact of pain
increases with age however it is unclear if there is an association
with mortality. Focusing on widespread pain may provide clearer
evidence of an association. The objectives of this systematic review
are to (i) determine the strength of the association between widespread pain and mortality and (ii) identify potential mechanisms of
this relationship.
Background
Non attendance at Outpatient clinics in NHS has clinical implications for non attendees and other patients on the waiting list. This
also results in wastage of resources and can be very frustrating for
the clinicians. There appears to be no published data for incidence
and demographics of non-attendees in pain clinics. The rate of
non-attendance in outpatient clinics for other specialities worldwide has been reported to vary from 15% to 25% . It is recognised
27
Abstracts
from historical data that patients who are young, with low socioeconomic background, unstable families and previous history of nonattendance are more likely not to attend. The aim of this anonymised
survey was to identify the demographic and referral factors influencing non-attendance in the outpatient pain clinic in our district
general hospital.
to investigate the Prevalence of NeP in our clinic. Since the majority

of our patients have spinal pain, we chose the painDETECT (PD-Q)
questionnaire to measure this. This PD-Q is well validated for use in
patients with low back pain. It has high sensitivity (85%), specificity
(80%) and positive predictive accuracy (83%) .
As a secondary outcome measure we also looked at the percentage of
patients on regular drugs for treatment of neuropathic pain.
Methods
We surveyed Non attendees (DNAs) over a period of 6 months who
were scheduled for their first/initial consultation with a pain consultant in the Pain clinic at Peterborough and Stamford Hospitals. After
the approval from Clinical governance department at our hospital,
we collected the data retrospectively for all DNAs for new referrals
over 6 months from January to June 2012 using the e-TRACK system. We looked at patients age, gender, duration and type of pain
and source of referral. For further comparison, we collected the similar data for all the patients with new outpatient appointments over 2
months (March, April 2012).
Methods
We surveyed 51 consecutive patients attending the pain clinic at University Hospital of North Staffordshire over a period of 4 months. Patients were briefed and given the PD-Q to complete in the waiting area
by outpatient nurses prior to the consultation with the pain physician.
In addition to the PD-Q we collected demographic data, site of pain,
diagnosis, duration of pain and current medications.
All the PD-Q were evaluated for the scores as per the PD-Q scoring
(0-12 for Nociceptive pain, 13-18 for unclear and 18-35 for NeP).
Results
Results
Data collected for the 271 new referrals over 2 months demonstrated
overall referral pattern to pain clinic. 39% patients were male, 17%
were less than 40 yrs age and 50% patients had pain for over 4 yrs.
71% patients were referred with spinal pain and 88% of referrals
were received from primary care settings.
Over 6 months period, we had 848 new appointments of which 54
patients missed their appointments (6.4%). 54% of non attendees
were male (39% of all new referrals). 45% of DNAs were under
40yrs of age (account for only 17% of all referrals). 28% of DNAs
had pain for less than 2 yrs (22% of all referrals). We found that 11%
of DNAs were referred with abdominal and pelvic pain (6% of all referrals ) and 6% with CRPS (1% of all referrals). For 24% of DNAs,
referral was sent by secondary/tertiary care settings.
All 51 PD-Q questionnaires returned were completely filled. We had

31.4 %(n=16) male and 68.6 %(n=35) female patients. The age
group was between 21 to 87yrs old with a mean age of 55yrs. The
average duration of the pain was 10yrs. The most common diagnosis was Low Back Pain (LBP) with 70.6 %(n=36) followed by wide
spread body pain 9.8% (n=5) and joint pain 5.9% (n=3).
The overall prevalence of NeP was found to be 51% (n=26). The
prevalence of NeP in the LBP group was 50 %(n=18).
We found in patients attending our pain clinic that 43.1% (n= 22)
were on regular anti neuropathic medications. These include patients
on either or combination of Amitriptyline, Duloxetine, Pregabalin
and Tramadol. In patients identified with NeP, 50 %(n=13) were on
anti-neuropathic medications. This was in comparison to 36 %(n=9)
in patients not identified with NeP.
Conclusion
Conclusion
The survey has identified groups of patients who have a significantly

higher incidence of non attendance at the pain clinic like patients less
than 40 years age and patients with history of abdominal and pelvic
pain. Targeted interventions may improve attendance and utilisation
of health care resources. Currently we provide Choose and Book
service, 2 mobile phone text reminders and recently introduced
Cronos system for sending automated phone calls. Further improvement can be made by early patient education with an information leaflet about the local pain services given to patients particularly
from the high risk groups when appointment is booked.
We found a high prevalence of the NeP in our outpatient pain clinic.

Our findings were similar to that found in an Arabian study which
measured the prevalence (55%) of NeP in patients with chronic
LBP4. In contrast, our findings were higher than that found by a
German multi-centre study using PD-Q with prevalence of 37%.
Our study also revealed that only half the patients with NeP were
receiving regular anti neuropathic medications.
We will advocate using the PD-Q as a screening tool in early diagnosis and initiation of appropriate medications for the management
of NeP.
044
045
The high prevalence of neuropathic pain detected in a

secondary pain clinic using the paindetect
questionnaire.
A SURVEY OF PAIN MEDICATIONS AT A SECONDARY CARE PAIN

SERVICE AND TREATMENT RECOMMENDATIONS.
Vivekanand Eli, Harnarine Murally, Arif Hasan
University Hospital of North Staffordshire, Stoke on Trent, UK
Category: Evidence & Guidelines

Lorraine Harrington1, Jane Timperley2, Steve Gilbert2 ,3
1South
East Scotland School of Anaesthesia, Edinburgh, UK, 2Fife Integrated Pain Management Service, Dunfermline, UK, 3Healthcare Improvement Scotland, Edinburgh, UK
Background
Neuropathic pain (NeP) develops as a result of damage to, or dysfunction of the nervous system that signals pain. It is often difficult
to treat because it is resistant to many medications and/or because of
adverse effects associated with effective drugs. Early recognition is a
key to the successful management.
The exact prevalence of NeP in the UK is unknown. It is likely to be
higher in patients attending secondary care Pain clinics. We wanted
Background
Prescribing costs represent a significant expenditure for NHS trusts.
All clinicians have a responsibility to ensure that the medications
they are prescribing are both economically and clinically effective
and repeat prescriptions should be reviewed regularly. In addition,
concern has been raised nationally regarding the large increase in
the number of prescriptions issued for strong opioids without clear
28
evidence of benefit1,2. A review of the pain section of the Fife Formulary has been undertaken over the past year with clear recommendations made for 1st, 2nd and 3rd line drug treatments for chronic
pain. Concerns have been raised regarding the high costs to NHS
Fife of pregabalin and oxycodone prescriptions. In line with SMC
guidance pregabalin is placed as a 3rd line drug for management of
neuropathic pain. The Fife formulary choice for 1st line strong opioid
is Zomorph.
Methods
Our survey recorded all pain medications being taken by patients at
their first assessment in the NHS Fife secondary care pain service
and also recorded what prescription changes were recommended by
the clinician seeing the patient. Information relating to 159 consecutive patients was collected from November 2011 to February 2012.
Although data relating to all medications prescribed for pain were
collected and analysed, particular attention was paid to prescribing
of gabapentinoids and strong opioids.
Results
Patients were taking a variety of medications. 13% were taking 4 or
5 different medications for pain and the average number of different
medications was 2.14.
Gabapentin was being taken by 35 patients and pregabalin by 36,
not all of whom had had gabapentin. Only 1 patient had pregabalin
initiated in secondary care and gabapentin was initiated in 9 patients.
Strong opioids were already being taken by 18% of patients and adherence to Fife formulary choice was poor (11 patients on zomorph
and 18 patients on other strong opioids).16 patients were taking Tramadol and a Codeine based analgesic in combination , equivalent to
being on strong opioids. This equates to 28% of patients. As shown
in the graph below the opioid dosage was recommended to be reduced at first consultation in the majority of patients. One patient,
newly commenced on zomorph had previously been on a higher
dose of oxycodone.
Conclusion
We found that many patients are taking strong opioids when they
attend a pain clinic. In addition to these patients, 16 were taking
combinations of weak opioids.No strong opioids were initiated
and in the majority, a recommendation was made to reduce. In
many patients with chronic pain, neither analgesia nor quality of life
are improved by the use of opioids3.
In the majority, guidance4 was being used appropriately. Many medications were of limited effectiveness, reflected by recommendations to
reduce. Regular assessment of medication could reduce the amount that
patients are taking, reducing drug costs and adverse drug effects.
046
Psychological therapies for the management of
chronic and recurrent pain in children and adolescents
Emma Fisher1, Christopher Eccleston1,2, Tonya Palermo3, Amanda
Williams4, Amy Lewandowski5, Stephen Morley6, Emily Law5
1Centre
for Pain Research, University of Bath, Bath, UK, 2Cochrane Pain,

Palliative and Supportive Care Review Group, Oxford, UK, 3Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington,
USA, 4Research Department of Clinical, Educational & Health Psychology, University College London, London, UK, 5Seattle Childrens Research
Institute, Seattle, Washington, USA, 6Leeds Institute of Health Sciences,
University of Leeds, Leeds, UK

Background
Chronic pain is a common problem for children and adolescents, commonly located in the abdomen, head, and limbs. These children report
that their pain to be severely debilitating, and affects all areas of their
lives, which can later extend into adulthood. This also impacts on other
family members lives, particularly the parents. Psychological therapies
are used to treat such children with an aim to improve these outcomes.
We aimed to update a previous Cochrane review that investigated the
effectiveness of psychological therapies to reduce pain and disability and
improve the mood of children with chronic pain (Eccleston, in press).
Methods
EMBASE, MEDLINE, and PsychINFO were searched for studies
from 2009 to March 2012. To be included, studies had to be randomized controlled trials (RCT), and use a psychological therapy
to treat children (<18 years) with a chronic pain condition. Pain,
Disability, and Mood outcomes were extracted at post-treatment
and follow-up. The pain conditions were split into headache and
non-headache pain. Headache studies measured pain dichotomously, therefore numbers-needed-to-treat-to-benefit (NNT) was calculated. Continuous data were used for disability and mood outcomes.
Results
The updated search added a further eight studies to the previously
identified 29 studies included in the 2009 version of this Cochrane
Review. This raised the total number of participants to 1938, 506
more than previously. From the 37 studies, 21 investigated psychological therapies for headache (including migraine), seven addressed
abdominal pain, four used a mixed pain sample (including headache pain), two used fibromyalgia patients, two delivered treatment
associated with sickle cell disease, and one for juvenile idiopathic
arthritis. Results revealed five significant effects. Pain was found to
significantly improve for both headache (NNT = 2.72; CI 2.32 to
3.29) and non-headache groups at post-treatment, and for headache
groups at follow-up (NNT =2.01; CI 1.62 to 2.64). Disability significantly improved for non-headache groups at post-treatment, and
mood significantly improved for headache groups at follow-up.
Conclusion
Psychological therapies are an effective treatment for the management of headache. 49% of children who received therapy improved
on pain outcomes compared to 17% in the control group. There
is, however, limited evidence for disability and mood outcomes for
headache groups at post-treatment and follow-up. For children and
adolescents with non-headache pain, therapies significantly improve
their pain symptoms and disability at post-treatment, but these effects are not maintained at follow-up. Further to this, therapies do
not improve of their mood when receiving such treatments. Future
studies should concentrate on increasing sample sizes and tailoring
treatments for conditions and individuals.
047
Percutaneous lumbar epidurolysis by racz catheter
technique: are we doing the right thing?
Devendra Tilak, Anthony Ordman, Riaz Khan
Royal Free Hospital, London, UK
Background
Managing persistent pain from epidural adhesions following lumbar
decompression is challenging. Patients with epidural scarring are at
29
Abstracts
particular risk of recurrent radicular pain(2). Nerve roots encased in
collagenous tissue may be tethered, causing neural tension, restriction of arterial supply and venous return. Nutrient and axoplasmic transport may also be impaired. Epidural adhesions are best
diagnosed by performing an epidurogram, with adhesions identified
as filling defects(3).
Epidural steroid injection is a common treatment for such pain, but
outcome studies have not been reported. Secondary, open surgery
for removal of epidural scarring has had limited success, with longterm benefit seen in only a small number of patients(1,3).
Percutaneous lumbar epidural adhesiolysis (PLEA) is a technique
described for the management of radicular leg pain caused by epidural adhesions. It was first described by Gabor Racz et al as a threeday treatment, and modified by Manchikanti et al. to a 1-day procedure (4).
Methods
We audited our current practice of Racz PLEA. Patients with epidural adhesions as a cause of radicular pain who had failed other
treatments, received 1-day PLEA as a single procedure. 23 patients
undergoing 26 epidurolysis procedures from January-2011 to July2012 were included. Data was collected retrospectively from patients notes, outpatient clinic letters and telephone reviews. We
documented % reduction in pain, and improvement in function following epidurolysis, as reported by the patients.
The epidural space was accessed via the caudal route using
Epimed-(COUDE(R)Epidural needle) needle and Epimed(BREVI(STF)Epidural catheter) catheter, guided to the appropriate level under fluoroscopy. Epidurography was performed to
identify the location of scar-tissue. 0.5-1% lidocaine, 0.9% saline,
40-60 mg triamcinolone acetate and 750-1500 units of hyluronidase (total volume 15-20 mls) were injected. Three patients had
two procedures.
Patients were telephoned after 8 weeks, and seen in clinic up to 5
months post procedure.
Procedures should be performed upto 4 times(4,7) in the first year

to achieve sequential improvements in pain and function(4,7).
048
Good practice in opioid prescribing for persistent
pain: a survey of prescribers based on bps guidelines
Category: Evidence & Guideline
S Prit Anand Singh, Usman Bashir, Margaret Cullen
Western General Hospital, Edinburgh, Midlothian, UK
Background
In 2010, the British Pain Society (BPS) published a comprehensive
document (Opioids for persistent pain: Good practice) providing
detailed guidance on the prescription of strong opioids for all
practitioners in the UK. The guidance included recommendations
on the dosage & formulations of opioids, frequency of review and
the need to discuss short and long term adverse events with patients
at the time of prescribing.
The objective of the survey was to review adherence to the BPS
guidelines by local General Practitioners.
Methods
Initially a paper based pilot survey was carried out followed by
an online survey (Surveymonkey.com) with questions based on
various aspects of opioid prescribing as per the BPS publication.
The online survey web link was forwarded to the local GP
administrator who distributed it to all the local GPs. The survey
was kept open for a period of 4 weeks with a reminder sent after
a fortnight. There were 10 objective questions in the survey with
areas for free comments where required. A total of 124 responses
were received.
Results
Results
15 patients were male, 8 female, with mean age 56.5 years. Previous
lumbar surgery was the cause of epidural adhesions in 22/23
patients, while 1 patient had history of tuberculosis of spine. 20
patients had previous open surgical decompression and 2 patients
had microdiscectomy.
20/26 (74%) patients reported some pain relief.
12/26 (46 %) patients reported > 50% reduction in pain for over 2
months, while
4/26(15.3%) reported 20-50% and
4/26 (15.3%) reported < 20% reduction in pain for over 2 months.
18/26 (66.7%) patients had sustained improvement in function and
1/26 (4%) complained of worsening of pain, with reduced mobility
secondary to pain.
No other complication was reported.
98% of survey responders prescribed strong opioids, but only 38%

were aware of the BPS guidelines. 56% of responders did not risk
stratify patients before commencing opioids, 40% did not document
the goals of opioid therapy, whilst 34% agreed that it would be easier
to do so if they had a standard opioid contract. 53% used sustained
release preparations, 40% prescribed immediate release preparations
and 7% were unsure. 35% were not clear regarding dose range at
which to refer to specialists and the rest varied between 60 to 180
mgs/ day of morphine equivalent doses.
70-90 % of GPs informed patients about short-term side effects,
toxicity, etc but only 13% mentioned long term effects. 87% followed up patients weekly to monthly initially and, once stable, patients were reviewed quarterly or biannually. At these visits 50% of
GPs recorded adverse effects. Free text comments further illustrate
GPs concerns regarding opioid prescribing.
Conclusion
PLEA is a safe, and cost-effective treatment for chronic pain, as a
part of multidisciplinary management, in patients nonresponsive to
other conservative treatment modalities.
We implement the one-day protocol as described by Manchikanti
etal, who compared hypertonic-saline(HS) with 0.9%-saline(NS)
(4). HS-neurolysis has slightly better and longer lasting effect on pain
reduction comparedNS-adhesiolysis(4). However, HS inadvertently
injected into the subarachnoid space could result in serious complications(3,7).
We recommend that PLEA should be performed using NS and
hyluronidase, along with local anaesthetic and triamcinolone.
Conclusion
Strong opioids are widely prescribed for persistent pain in primary
care but existing guidelines on their use are not well known or followed. Comparing GP and patient responses (see other poster)
there seems to be discrepancies both between GP and patient recall of drug information delivered and mutual understanding of
what exactly is being reviewed during later follow-up visits. Better dissemination of guidelines and printed patient information is
clearly required. Some GPs would also welcome the use of opioid
contracts to aid clearer long-term communication and goal setting
with patients.
30
049
Hamza Alshuft1,2, Jennifer Dixon1,2, Laura Condon1, Robert

Dineen1, Dorothee Auer1,2
Good practice in opioid prescribing for persistent

pain: a survey of patients based on bps guidelines
Usman Bashir, Prit Anand Singh, Margaret Cullen
Western General Hospital, Edinburgh, Midlothian, UK
Background
Chronic pain affects around five million people in the UK. This pain
can lead to functional impairment -physically, emotionally and vocationally and thus can be very frustrating and disabling.
Opioids have a well established role in the management of pain in
the short and medium term, in a variety of non-cancer pain conditions.
Their safety and efficacy in the long term is still under investigation.
In 2010, British Pain Society (BPS), published guidelines about
Good practice in opioid prescribing for persistent pain. This comprehensive document provides detailed guidance on prescription of
Opioids for all practitioners in UK. A statement based on the above
document (in simple language) was also published for patients.
The objective of the survey was to review adherence to the BPS
guidelines by the prescribers (GP/Hospital doctors).
Methods
All patients attending local chronic pain clinics were requested to
complete a questionnaire on arrival. Those who identified themselves as taking strong opioids were asked to complete information
on the frequency of review following initial prescribing and their recollection of advice and warnings given by the prescriber. The data
was collected over a span of 6 weeks.
Results
126 patients were taking strong opioids. 67 (53%) were prescribed
opioids by the General Practitioner, the rest 59 (47%) were by a
hospital doctor.
Common adverse events were discussed with 62% (n=78), of patients.
Long-term adverse events were discussed with a third of patients
(n=42).
About 53% (n=67) had a discussion regarding driving and work.
36% (n=46) had been told about features of overdose/toxicity
14% (n=18) of patients were followed up on a monthly basis specifically for review of opioid prescribing.
Conclusion
In our survey we found that, more than half the clinicians had
discussed short term side effects and effect on driving and work.
However, only about one third of the patients had any communication regarding long-term effects and features related to opioid
toxicity/overdose. Although most patient were reviewed during
routine follow up appointments (3 to 4 months ) only a minority
of patients remembered being followed up specifically for opioid
medication review at regular intervals. In conclusion we found
that there appears to be very limited adherence to BPS guidelines
both in terms of initial discussion of possible adverse events and
regular follow up.
050
Brain cortical thickness correlates of chronic pain
duration in knee osteoarthritis
1University
of Nottingham, Nottingham, UK, 2The Arthritis Research

UK Pain Centre, Nottingham, UK
Background
Pain is the dominant complaint in OA but not all patients develop

pain1. Pain severity in OA is known to be often inconsistent with
the degree of joint pathology2 and conversely at least 12% of patients do not respond to TKR surgery in terms of pain relief3. Furthermore, placebo surgery can significantly reduce pain associated
with Knee OA4
Neuroimaging studies of chronic pain have reported morphological
changes in brain regions involved in pain processing. These include
but are not limited to the thalamus, anterior cingulate (ACC), insula,
brain stem, and dorsolateral prefrontal cortex5,6 (DLPFC), suggesting a central role in the process of pain chronification.
We hypothesised that pain-related changes in cortical thickness correlate with pain duration. To investigate that we undertook a research
ethic-committee approved MRI study in patients with chronic pain
in knee osteoarthritis (OA) and healthy controls.
Methods
Subjects: 26 adults aged 45-80y 64.7 8.5 (M SD), 14 males,
with knee OA chronic pain, and no other major medical or neuropsychiatric co-morbidities. Pain duration ranged 1-38y. 10 healthy
subjects aged 43-70y 56.9 9.5.
Data acquisition: High resolution structural MRI was performed
at 3T (GE Discovery 750) using a 32-channel head coil and FSPGR
scan(Voxel size= 1mm3, TE=3.3ms, TR=8.5ms TI=450)
Cortical Thickness measurements and statistical analysis:
For cortical thickness measurements we used FreeSurfer software
package Mac version 5.1 (www.surfer.nmr.mgh.harvard.edu).
QDEC (FreeSurfer-statistical tool) was used to perform whole-brain
surface based correlation analysis. Significance was set at p <0.001
(uncorrected) controlled for age. Independent t-test was used to
compare a selective ROI average cortical thickness between patients
and healthy controls
Results
Pain duration showed a significant negative correlation (thinner
cortex with longer pain) in a number of cortical areas namely for
clusters > 50mm for the left hemisphere; the inferior-parietal, cuneus,
precuneus, superior temporal, and the rostral middle frontal. And
for the right hemisphere significant negative correlation was found
in posterior insula, pericalcarine, inferior parietal, and caudal middle frontal. Cortical thickness was significantly reduced in patients
compared with healthy controls in the left inferior parietal average
thickness mm = (2.09 0.19 and 2.240.2.,p<0.05) and in the right
insula (2.2 0.18mm and 2.350.18, p<0.05)
Conclusion
Our preliminary results suggest that pain duration in knee OA is
accompanied by reduced cortical thickness. This is generally in line
with a previous volumetric study 5 which reported grey matter decrease in DLPF cortex with pain duration in back pain indicating
that prolonged pain experience may lead to regional brain atrophy.
Our study was limited by small sample size particularly for healthy
controls and the use of a liberal significance threshold of uncorrected
p<0.001. In the future we plan to expand the sample and allow for
multivariate analysis including the correction for potentially confounding gender and medication effects.
31
Abstracts
051
Hannah Wilson, Oras Alabas, Osama Tashani
Electrodermal responses to experimentally induced

pressure pain
Category: Experimental (Basic) Science

Osama Tashani, Kassra Scholl
Background

Background
Electrodermal response (EDR) is a measure of electrical skin conductivity and an indication of sweat gland activity which changes in response
to the sympathetic nervous system outflow. The measurement of EDR
is used to assess autonomic functional disorders such as lesions of the
peripheral nerves and nerve roots, central nervous system disorders and
other disorders of the sympathetic system (Kucera et al, 2004). However, there is a lack of research to investigate EDR changes during experimental pain sessions. The aim of this study was to determine whether
pressure pain has a significant impact on electrodermal responses.
Methods
Twenty healthy students (age ranges from 18 to 33 years, 10 females)
were recruited from Leeds Metropolitan University and pressure
pain was applied to the soft tissue between the metacarpals of the
thumb and index fingers of the dominant hand using an algometer
(SOMEDIC type II) while recording their electrodermal response
on a data acquisition system (PowerLab 16/35 with LabChart Pro,
ADInstruments) by measuring the electrical resistance between the
palmar middle phalanges of the middle and index fingers of the nondominant hand. After initial baseline EDR recording for 15 minutes
participants were informed of the imminent application of the algometer to determine whether there was a reaction to the anticipation of pain (T1) then pressure applied (T2) and pain threshold
was measured as participants indicated pain (T3). This cycle was
repeated after 10 minutes interval.
Results
EDR in (meanSD) micro-Siemens (S) showed no change from
7.26.5 at baseline to 7.66.5 at T1. However, the values at T2 (8.76.4)
and T3 (10.56.2) were statistically different (P<0.01, paired t-test) from
the baseline and T1. There were slight decrease in EDR during the interval but this was statistically insignificant (P=0.087).There were no significant gender differences in the pattern of changes in EDR.
Conclusion
Actual pain rather than anticipation of pain produced significant
changes in EDR activity. This study confirmed earlier reports which
suggested that sympathetic activity increases in response to pain.
However, further research is needed to investigate if EDR records
will benefit pain reporting in children and patients with impaired
communication skills.
Findings from previous studies demonstrated that pain sensitivity

level across menstrual cycle fluctuates in healthy volunteers suggesting that oestrogens and progesterone levels may affect pain
intensity ratings or thresholds. The aim of this study was to investigate the differences in pain sensitivity between women taking hormonal contraceptive pill and women menstruating naturally in cold
pressor task.
Methods
45 participants were recruited from Leeds Metropolitan University
(meanSD of age 22.24.2 years) and divided into three groups:
15 men, 15 women using hormonal contraceptive pills, 15 women
not using contraceptive pills. After initial familiarization session the
participants undertook an experiment involving two cycles of cold
pressor task with 5 minute interval between thecycles. Participants
held their least dominant hand in a water bath set at 32C for 3
minutes to standardise the skin temperature, then plunged this
hand into the ice water bath maintained at 0-1C. Time taken to
reach pain threshold, when participant reported pain, and pain
tolerance, when participant no longer could tolerate any more pain,
were measured in seconds. Participants were also asked to record
their pain intensity and unpleasantness levels on a 100mm VAS
(visual analogue scale).
Results
While there were no statistical differences between groups in pain
threshold (p=0.63, one way ANOVA), pain intensity (p=0.81) and
pain unpleasantness (p=0.08) average of pain tolerance of the two
cold pressor tests of men at (7270s) was significantly higher than
that of two women groups (with contraceptive= 24.543.6s, without contraceptive 15.816.1s, p< 0.01). The only difference between the two women groups were in cycle 2 of the cold pressor
task in which women on contraceptives rated pain unpleasantness
(66.117.9mm). This was more than unpleasantness ratings by
women off contraceptives (47.521.6mm) (P=0.02).
Conclusion
Results suggested, albeit reservedly, that women on hormonal contraceptive pills may respond differently than women not using contraceptive pills in some pain sensitivity measures. However, men still
have greater pain tolerance than women regardless of their use of
hormonal contraceptive pills. This indicates that differences between
men and women are more likely to be due to gender role and other
psychosocial factors rather than due to the effect of hormones.More
research in experimental settings to compare the pain sensitivity response between women on contraceptive pill and women menstruating naturally is needed.
References:
1. Kucera P, Goldenberg Z, Kurca E. Sympathetic skin response:
review of the method and its clinical use. Bratisl Lek Listy.
2004;105(3):108-16.
052
Hormonal contraceptive pill effect on pain sensitivity
of healthy volunteers
053
Is there a correlation between pressure pain thresholds and the level of endocannabinoids in cerebrospinal fluid or serum?
Danielle Reddi1, Katherine Chatten1, Emma-Louise Page2, Celia
Morgan2, Amod Manocha1, Sumit Gulati3, Brigitta Brandner1
1University College London Hospital, London, UK, 2University College
London, London, UK, 3Leeds Teaching Hospitals, Leeds, UK
32
Background
References:
Exogenous cannabinoids activate neuromodulatory receptors including the specific cannabinoid receptors CB1 and CB2. CB1 receptors
are predominantly found in the brain and spinal cord. The two most
studied endogenous ligands are arachidonoylethanolamine (anandamide or AEA) and 2-arachidonoylglycerol (2-AG). It is well established that exogenous cannabinoids have analgesic effects 1, and there
is growing evidence that increasing endocannabinoid levels in animals
can attenuate pain and reduce the development of hyperalgesia and
allodynia. Painful stimuli have been shown to result in increased levels
of anandamide in the brain in mice 2. Cerebrospinal fluid (CSF) anandamide levels have been studied in humans in relation to a number of
conditions 3,4, but the role of endocannabinoids in pain is less well established. Neither blood nor CSF levels have been previously reported
in relation to pressure pain thresholds (PPT). It was hypothesised that
lower CSF anandamide levels might be associated with lower PPT.
1. Guindon J et al. CNS and Neurological Disorders-Drug Targets

2009;8:403-421
2. Walker et al. PNAS 1999;96(21):12198-12203
3. Di Filippo M et al. J Neurol Neurosurg Psychiatry 2008;79: 1224-1229
4. Romigi et al. Epilepsia 2010;51(5):768-772
Methods
Ethical approval was obtained. Cannabis users and non-cannabis users were included to examine the effects of exogenous cannabinoids.
Subjects were screened for relevant exclusion criteria. Contraindications to PPT testing included peripheral neuropathy, rheumatological disease, pain symptoms, history of trauma or surgery to the
dominant hand and medication which might affect pain thresholds.
Informed consent was obtained.
Pressure pain threshold testing was performed using electronic pressure algometry by a single study investigator. A test measurement
was performed on the non-dominant hand followed by three PPT
readings from the dominant hand, approximately 15 seconds apart.
Following PPT testing participants underwent lumbar puncture
with collection of CSF. A blood sample was then taken. Blood and
CSF samples were chilled immediately. Endocannabinoid levels
were quantified using high-performance liquid chromatography /
mass spectrometry.
Data was analysed using the Spearman correlation coefficient and
Mann Whitney U test. A P value < 0.05 was considered statistically
significant.
Results
33 young, healthy subjects participated in the study. 20 were regular
cannabis users, with 10 categorised as heavy users and 10 light users, 13 were non-users. The mean age of participants was 21.9 years
(range 19 - 28 years). Male to female ratio 15:18.
Pressure pain thresholds varied from 149 to 1420 (median 390).
There was no significant difference between PPT in cannabis users
and non-cannabis users (P=0.439). No significant correlation was
found between CSF anandamide or 2-AG levels and PPT in any
group. There was a trend towards higher PPT in the light in the users, followed by heavy users and then the control group.
CSF anandamide levels varied from 0.0323 pmol/ml to 0.338 pmol/
ml. There was a trend towards higher CSF anandamide levels in the
light users compared to heavy users.
There was a significant correlation between PPT and serum anandamide level in the control group (P=0.006).
Conclusion
There was a significant positive correlation between PPT and serum
anandamide levels in the control group and a trend towards higher
CSF anandamide levels and higher PPT in the light cannabis users. This may suggest an analgesic effect of anandamide. The lowest
CSF anandamide level was in the heavy cannabis users which may
indicate down regulation of endocannabinoid production. Further
studies on a larger sample would help to clarify these findings.
054
Preliminary investigation of the relationship between
heat pain and electrodermal response of healthy
human participants
Tobias Stark1,2, Liam Hodge0 ,2, Osama Tashani0 ,2
1Offenburg University of Applied Sciences, Offenburg, Germany, 2Leeds
Metropolitan University, Leeds, UK
Background
Skin electrical conductance is affected by the secretion of accrine
glands in the palmer surface of fingers (sweating) and could potentially change in response to various noxious stimuli. This is an indirect measurement of sympathetic activity and usually called Electrodermal response (EDR). This study has been designed to investigate
how EDR could change in response to a heat stimulus.
Methods
The skin covering the thenar eminence on the palm of the hands of
20 healthy Leeds Metropolitan students (age range= 18-25 years, 10
women) was subjected to heat from a thermode of ThermoSensory
analyzer II (Medoc) and pain threshold (the minimum temperature
that induce pain) was measured. After a 10 minutes interval EDR of
participants was recorded for 2 minutes, using two electrodes connected to a PowerLab system powered by the a LabChart 6 software
(ADInstruments), and then suprathreshold temperature (2 degrees
Celsius over the pain threshold) was applied to the participants
same area for 30s. The EDR signals were obtained before, during
and after the suprathreshold heat pain stimulus.
Results
The EDR signals were put through a 1st derivation function to
show the changes from the baseline (before the heat stimulation).
All changes then have been statistically analysed as repeated measures and multivariate ANOVA detected an effect change in EDR
in response to heat stimulation and after the stimulation stopped
(F=5.36, p=0.014). The meanSD values of EDR in micro-Siemens
were (0.210.06) before, (0.120.04) during and (0.28+0.05) after
heat stimulation.
Conclusion
Interestingly, a large positive increase of EDR was found after 30
seconds of heat stimulus which was above pain threshold and not
during the heat pain stimulation. This suggests that a sympathetic
response to pain is not a direct response and could be delayed. However, data suggest that EDR could be easily used in conjunction with
other pain measurement in basic research.
055
Quality of life improvements after spinal cord
stimulator insertion for chronic pain
Category: Interventional Pain Management
33
Abstracts
Ruth Cowen, Amy Pennefather, Ben Thomas, Ian Goodall, Glyn
Towlerton
Chelsea & Westminster Hospital, London, UK
Background
NICE recommends Spinal Cord Stimulators (SCS) as a form of therapy for certain types of chronic pain. The benefits of this technique are
difficult to measure due to the heterogeneity of symptoms and subjective nature of pain. Patient reported outcome measures are becoming
increasingly important when evaluating the effectiveness of therapies.
We recognise the importance of long term follow up and therefore
looked to assess the clinical effectiveness of our SCS service by undertaking telephone follow up of our patient population. We used a combination of questions to review the effectiveness of treatment focussing
on on-going pain relief, ability to self-manage pain, changes in quality
of life, expectations and achievement of personal goals, and global perception of change. Our intention was to assess the long term effects
of the service we are providing in order to better inform ourselves and
our patients, and to guide future quality improvement measures.
Methods
We performed a telephone questionnaire on all patients who have
had a SCS inserted in our department for the treatment of neuropathic pain. The questionnaire was designed to evaluate most of the
core outcome measures suggested in the IMMPACT recommendations. It included questions on pain management, physical and emotional functioning, effectiveness of SCS, complications, specific and
global quality of life improvements, expectations and achievement of
goals. Contact details were obtained from the hospital records and
verbal consent was obtained from each patient. If no response to the
initial telephone call, patients were called on up to five different occasions. If no response or consent was obtained then these patients
were classed as non-responders. The information obtained from the
responders was analysed. A notes review was performed on responders to obtain additional information.
Results
Twenty seven (64%) of the 42 patients responded. SCS were inserted for non-ischaemic neuropathic pain in the back/lower limbs
(70%), upper limbs (19%) and ischaemic refractory angina (11%).
The mean follow up time was 25 months (SD 20). Stimulation
coverage of pain areas were 100% (mode, IQR 25) and pain relief
80% (mode, IQR 40). Improved pain management occurred in 85%
(26% some of the time, 48% most of the time and 11% all of the
time); 81% felt better since SCS insertion; 78% now have a better
quality of life; 56% have reduced medications; 63% better mood;
26% improved sleep; 56% better mobility; 26% improved ability to
wash/dress; and 63% are now more able to perform daily activities. The benefits met expectations in 74% and 48% were able to
meet pre-implantation goals. Complications occurred in 26% (IPG
site infection (3), catheter migration (2), catheter fracture (1), and
thromboembolism (1)).
Conclusion
SCS, inserted in our department, are effective long term treatment
for chronic pain. The majority continue to be effective resulting in
improvement in pain management (85%), mood (63%) and quality
of life (78%) years after insertion. Almost half of our patients (48%)
had managed to accomplish personal goals, including returning to
work and going abroad on holidays. All those patients (8) who have
had their SCS over 3 years continued to manage their pain better
and 87.5% felt their mood and quality of life was improved. There
was a low complication rate and none had a long term impact.
056
Patient experience survey following insertion of spinal cord stimulation. Evaluation of equipment issues
and patients reported outcome measures.
Juan Graterol, Nik Patel, Rose Marriott, Sarah Love-Jones
Frenchay Hosptial, North Birstol NHS Trust, Bristol, UK
Background
North Bristol NHS Trust has been a referral centre inserting
spinal cord stimulators since 1998. Patients come from a wide
geographical area and are assessed in a combined clinic with the
Chronic Pain services and the Neurosurgical department. These
clinics take place once a month and suitable candidates are offered a 5 day trial of percutaneous Boston Scientific Artisan leads
with a Boston Scientific Precision generator. Those who report
relief in symptoms greater than 50% will be offered surgical implantation within 3 months of the trial. Percutaneous devices
are inserted by the Chronic Pain team; the implantation is done
by the neurosurgical team. On occasions, it may be a combined
approach of leads inserted percutaneously with a surgically implanted generator.
Methods
A postal questionnaire was sent to patients following insertion of
trial leads to assess the patients experience. Information collected
aimed to assess the impact on symptoms and any side effects or
problems the patients may have encountered. It was a paper survey
of a single A4 sheet with 8 questions in a pre-paid return envelope.
The first 5 questions were Yes/No answers with space for free comments and inquired about any problems with the equipment: charging the battery, problems with the leads or need for further surgery.
It also asked patients if they had reduced their pain medication and
if they had been able to return to work. The last 3 questions used a
10 points numerical rating scale assessing pain reduction, improvement in quality of life and overall satisfaction. Brief Pain Inventory
and Neuropathic Pain Scales were done prior to insertion of the trial
leads and post operatively.
Results
The study analysed patients seen between February 2009 and June
2011 at Frenchay Hospital, North Bristol NHS Trust. A total of
72 patients were offered a trial of percutaneous SCS. Of these, 52
proceeded to a surgically implanted device and 35 responded the
survey. 54% were Females and the group had a median age of 52
years. Most common problems with the equipment were related
to the charging of the battery, around a 1/3 of patients complain
that it was difficult to find it, were faulty or would not hold the
charge. 5 patients needed further surgery to reposition the battery and 9 others needed surgery to revise the leads. 57% of the
patients reported they had been able to reduce the amount of pain
killer medication and 37% of patients were able to either return
to work or continue in employment. No statistical difference in
BPI or NPS.
Conclusion
Spinal cord stimulation seems to be a positive therapeutic option for
a well selected group of patients, having been assessed in a combined
clinic of Chronic Pain specialists and Neurosurgical department. Of
the 72 trial offered 72% proceeded to have a surgically implanted device. Problems with the equipment are not uncommon but outcome
measures such as reduction in medication and return to work seem
34
positive. Pain reduction, improvement in quality of life and overall
satisfaction were on average satisfactory. Sample size too small to
detect statistically significant difference in BPI or NPS.
057

058
Modified pathway for spinal stenosis management.
david spackman, mark sanders, lorraine tweedy
Physiotherapy after spinal interventions: are patients

getting physical?
Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK

Alan Fayaz, Kristin Ullrich
Background
Barts Health, London, UK

Background
There is on-going debate surrounding the use of interventional therapy
for spinal pain. Recent evidence based guidelines have suggested that
repeat interventions should only be considered if the benefit has been
maintained for six months or longer (Ref 1). There is evidence that
post-treatment exercise programmes can prevent recurrences of back
pain (Ref 2) and physiotherapy is at the forefront of the NICE care
pathway for patients with back pain (Ref 3). Interventional treatments
may be used as facilitators to involvement with exercise programs in
patients with chronic back pain. We reviewed a cohort of such patients
attending follow-up clinics after spinal interventions to see if they had
actually accessed physiotherapy services after their interventions.
Methods
Patients presenting for follow-up after spinal interventions initiated
locally were asked about access to physiotherapy following their
respective treatments. Where physiotherapy had been provided the
timing with relation to the intervention as well as the source of referral were noted. In cases where physiotherapy was not accessed
the original clinic letter suggesting the intervention as well as the
discharge letter following the intervention were addressed for reference to physiotherapy services. Data was collected across two sites
comparing access to physiotherapy between a physician-only pain
clinic and a multidisciplinary pain clinic, where physiotherapists are
present from the initial assessment.
Results
Data was collected on 44 patients across the two sites; patients had
received, on average, 2-3 interventions (range 1-10). Overall less
than 37% (16/44) patients received physiotherapy following their
interventions. Subgroup analysis identified that the proportion of
patients receiving physiotherapy in physician-only clinics was lower
than in multidisciplinary clinics (29% vs. 50%). The average time
delay between the patients most recent intervention and physiotherapy was 2.4 months. At our physician-only clinics a request for
referral to physiotherapy was only mentioned in 21% (6/28) clinic
letters to the GP, subsequently physiotherapy was only delivered in
33% (2/6) of these cases.
Conclusion
The majority of our patients are not being referred to physiotherapy
after their interventional procedures, despite re-attending for further interventions. Patients are more likely to access the service if
seen initially in a multidisciplinary pain clinic. Poor communication
with community physicians may be a determinant of the low referral
rates, but even where a request for physiotherapy had been made the
patient did not always benefit from the service. It is important that
we either consistently integrate physiotherapists into our pain clinics
or improve our communication with general practitioners in order to
maximise patients benefit from interventional procedures.
Epidural injection of steroids (ESI) can provide long lasting pain

relief and improvements in function in patients with lumbar spinal
stenosis (LSS) and can offer a low risk alternative to surgery. The
clinical response to epidural injection of steroids is unpredictable
but early assessment of clinical results may allow responders and
non-responders to be managed more effectively.
Methods
20 patients with radicular pain and MRI evidence of spinal stenosis
who had failed to respond to systemic analgesia and physical therapy
were allocated to the theatre list of a single pain specialist. Each had
trans-foraminal injection of local anaesthetic and steroid under Xray guidance (2mls 0.25% Chirocaine) and Depomedrone (80mgs).
This was targeted at the root level of greatest symptoms.
Patients were asked to complete an Oswestry score and a short-form
BPI intensity and function score pre-injection and at 8 weeks
post-injection. They completed a pain diary and EuroQol EQ-5D5L assessment tool to assess overall health status, pain and medication changes over the same period.
Patients were followed up via a telephone consultation at 8 weeks.
Pre and post-ESI scores were then compared and depending on outcome patients were either re-listed for further ESI at 6 months or
offered an outpatient appointment at 90 days to discuss alternative
management.
Results
15/20 patients reported significant improvements in pain and function at 8 weeks after ESI. Mean improvements in Oswestry scores
of 11.2% (sd7.78) and improvements in BPI intensity and function
scores of 2.6 (sd 2.06) and 2.0 (sd 1.72) respectively were found in
this group of responders. Non-responders were referred for outpatient consultation with our multi-disciplinary pain team where alternative pain control strategies were discussed.
Conclusion
Although inadequately powered to detect statistically significant
changes in BPI or Oswestry scores this study appears to show good
results at 8 weeks after ESI in 75% of carefully selected patients with
LSS. It is felt to be reasonable clinical practice to offer responders,
as identified by positive Oswestry and BPI scores at an 8-week telephone follow-up consultation, a repeat appointment for ESI 6 months
thereafter. This system allows the responders to be relisted approximately 4 weeks earlier than with conventional 90 day outpatient
follow up and relieves pressure on our outpatient appointments diary.
059
Sphenopalatine ganglion pulsed radiofrequency for
chronic facial pain
Ravi Nagaraja1, Arif Ghazi2, Charles Gauci2
1St
Bartholomews Hospital, London, UK, 2Whipps Cross University Hospital, London, UK
Abstracts
35
Background
backgrounds and experience (pain consultants and pain physicians

on Google groups). Questions were aimed to obtain relevant information regarding their current practice in the use of Epidural steroid
in patients with low back pain.
Completed responses were received from 74 members. Eighty two
percent of the respondents were Pain Medicine consultants, 14%
were Advanced Pain trainees and 4% were others. Over 46 % of
respondents had more than 10 years of pain experience.
The physicians had several ways of gauging the efficacy of a steroid injection ranging from- pain reduction 30-50%, benefit from 3
to 6 months, feedback questionnaire, functional improvement, VAS
score, patient self report, BPI scoring, ability to perform directed
regular exercise, Quality of life improvement etc.
Sphenopalatine ganglion(SPG) block has been done the early 1900s

when cocaine was used to block the ganglion for various pain syndromes. Sphenopalatine ganglion block is most commonly used for
sphenopalatine ganglion neuralgia, trigeminal neuralgia and atypical
facial pain. Slutjer first described the pulsed radiofrequency technique, where the generator output is interrupted to allow for the
elimination of heat between pulses. This novel approach is recommended for treatment applied to peripheral nerves where the application of heat carries significant risk.
Methods
A total of 9 patients between January 2010 and May 2012 were included in our audit to assess the efficacy of sphenopalatine ganglion
block. A review of case notes was done and also a telephone review
to assess the efficacy of the procedure.
Phone Questionnaire:
1) Has the procedure been effective?
2) Duration of pain relief
3) Any reduction of pain medications
4) Presence of autonomic symptoms
Results
A total of 9 patients had this procedure for chronic facial pain, atypical trigeminal neuralgia and atypical facial pain.
60% of patients reported good pain relief and it lasted from 4 to 6
months. In one of the patients the procedure was repeated for recurrence of symptoms. There was reduction in the use of medication in
one patient and the others were too scared to reduce the medications
because of fear of recurrence of symptoms.
Results
Almost 70% of the pain physicians regularly use epidural steroids for
LBP. 61% would perform their epidurals in prone position, while 31
% would perform in sitting position. 47% percent would use an 18 G
Touhy needle and 11% would use a 22G spinal needle for performing the procedure, with almost 44 % using a combination of techniques e.g. loss of resistance, fluoroscopic guidance with or without
contrast. There seemed to be almost an equal divide for preference of
steroid, with 48% using Triamcinolone and 44% using Methylprednisolone. 21% would either use (0.25%) Bupivacaine and another
20% (0.25%) Levobupivacaine. Almost 14% of pain physicians are
still using either 1 or 2% Lignocaine for their epidurals. Nearly 70%
would repeat epidural 1-2 times in a year and 14% would perform
3-4 times.
Conclusion
Sphenopalatine ganglion pulsed radiofrequency can give a variable

period of pain relief in select group of patients. The procedure was
repeated which means the pain relief was not expected to last permanently. The mechanism of action by which Pulsed radiofrequency
controls pain is unclear, but it may be due to a rapidly changing
electrical field. This group of patients come to us after having tried
various other treatments, it would be worthwhile to consider this
technique as one of the options available to provide pain relief
Although epidural steroid instillation is recommended in the presence of LBP along with lumbosacral radiculopathy, it is a commonly used intervention for LBP in the UK. Although numerous
systematic reviews have been undertaken on the efficacy of epidural
steroids in chronic back pain, none have revealed the superiority of
epidural instillation of steroids as an effective long-term treatment
for LBP.
Although the methodology of drug manufacture is different in the
UK when compared to the US, clinicians need to be aware of the potential danger of instillation of any drug into the epidural, or indeed,
the intrathecal space.
060
061
Use of epidural steroids by pain physicians in chronic

back pain - a survey of current practice in the uk
Bps-interventional pain sig (2012) annual scientific

meeting spinal cord stimulation uk practice survey

Deepak Malik1, Praveen Ganty2

Manish Gupta, Rajiv Chawla, Manohar Lal Sharma
Conclusion
1Leicester
Royal Infirmary, Leicester, UK, 2The Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
Background
Recently, there has been a series of patients in the US who have had
meningitis attributed to epidural steroids. This has led to a debate
on the rational use of epidural steroids in patients with low back
pain (LBP).
Our survey was aimed at the current usage and rationale of performing
epidural steroid instillations in patients with chronic low back pain in the
UK, and to look at the evidence base behind current practice.
Methods
An anonymised 10-point questionnaire was sent in October 2012
via an e-link on SurveyMonkey to pain physicians from varied
Walton Centre NHS Foundation Trust, Liverpool, UK

Background
Spinal Cord Stimulation (SCS) treatment has substantial evidence
base. SCS should be delivered within facilities that can offer multidisciplinary team (MDT) assessments, other pain management
options, management of complications or tolerance of neuromodulation and should be used as part of comprehensive rehabilitation
process. Not all patients are suitable for SCS. Referring clinicians
should be aware of indications for SCS. Techniques of SCS vary.
Electrodes may be inserted percutaneously via an epidural needle, or
surgically implanted via laminotomy by the neurosurgeon. It is considered good practice to allow patients to undergo a period of trial
stimulation. Patients should be screened for methicillin-resistant
Staphylococcus aureus (MRSA), and an antibiotic prophylaxis must
36
be administered. Appropriate infrastructure for ongoing surveillance, support and audit must be in place.
Methods
This short survey was distributed to 75 participants at the annual
scientific meeting of the Interventional pain special interest group
of the British Pain Society (BPS) in Manchester (September 2012).
This meeting was attended by pain clinicians (consultants and trainees) all across the country and provided a good forum to survey the
practice of SCS. However, not all participants were implanting SCS.
The aim of the survey was to get an overview of the current practice
of SCS amongst the members, aligned to recommendations by the
BPS and NICE (National Institute of Clinical Excellence). We enquired about: indications considered for referral or treatment; infrastructure, competency and audit; MDT approach; length of trial period; number of electrodes/contacts preferred; outcomes measured
for conversion to permanent implant; MRSA screening and antibiotic prophylaxis; and permanent implant technique (percutaneous
or surgical) and preferred site of battery implantation.
Results
Completed questionnaires were returned by 46 participants, yielding a response rate of 61.3%. The responders were a mix of SCS
and non-SCS providers in a ratio of 3:2. The results for indications
for this treatment were consistently reflective of the BPS guidelines
and NICE HTA / 2008 / 159. Most providers (>2/3) are able to
maintain their competency by doing >10 procedures in a year. Most
(>2/3) permanent implants are done by the pain specialist. Good
proportion (>2/3) are able to audit their outcomes. Almost all responders offer MDT assessment. A trial of 1 week is standard, unless
otherwise indicated. More than 80% respondents mentioned using
octopolar leads. MRSA screening is done by all; however timing of
antibiotic prophylaxis was inconsistent. Surgical method of lead implantation is not offered at most centres (<25%). As regards site of
battery implantation, they were no particular preference observed.
Conclusion
A multidisciplinary pain management team is the most appropriate
context in which to provide SCS. Teams must have and maintain the
competencies needed to offer the most appropriate techniques. Implanting centres should audit their activity and provide patients with
information on outcomes and complications. There is currently no national database of patients treated with SCS, but this is being currently
established. Antibiotics should be given as a single intravenous dose
30 minutes before the procedure. Collaboration with surgeons competent to deal with complications should be in place. These issues may
be relevant for future commissioning of neuromodulation in England.
062
Assessment of outcomes following interventional
procedures for pain management - the first year of
outcomes in glasgow
Clare Bridgestock1, Lars Williams2
1Stobhill
return appointments to be made. This also allows both procedure

specific and operator specific outcomes to be evaluated.
We have collated outcome data from 1/08/11 to 31/07/12 and our
primary objective is to report on the findings of the first year of outcomes including procedures performed, duration and degree of pain
relief, analgesic use, impact on sleep, mobility and quality of life following interventional procedures for pain management. We will also
quantify side effects suffered and examine whether data collection
can be further improved and if the interventional procedure process
can be modified to optimise service delivery.
Methods
The original outcomes questionnaire was developed by a multidisciplinary team, then validated and further modified after a pilot
study. Every patient attending for an interventional procedure for
pain management in Greater Glasgow and Clyde is given the questionnaire immediately after their procedure.
Data recorded on the questionnaire includes date and procedure
performed and operating physician. The patient is asked to complete
to complete the questionnaire at eight week after intervention, answering questions on duration and degree of pain relief, changes in
analgesic use, quality of life, sleep and mobility. There is also a specific field for detailing side effects. The patient is asked to return the
questionnaire by post to the pain department.
Data from completed questionnaires is inputted into a Microsoft Access database, primarily by the two authors.
Results
Outcome data from 1/08/11 to 31/07/12 was analysed, with a total
of 836 completed outcome forms for 1390 procedures, a return rate
of 60%. The most commonly performed procedures are sacro-iliac
joint injection, lumbar facet joint injection, high volume caudal, trigger point injections and lumbar nerve root block.
Overall, 57% of patients reported more than 30% pain relief and
47% of patients have a reduction in their pain for more than 5 weeks.
If a positive response is defined as >30% relief for >4 weeks, 42%
could be defined as responders.
53% of responders reduced their analgesic intake, 58% reported improved sleep, 53% reported improved mobility and 72% reported an
improvement in their quality of life.
25% of patients complained of side effects related to the procedures,
most commonly pain in the area of injection
Conclusion
In a proportion of patients, interventional procedures provide a
period of reduction in pain which may lead to improvement in
sleep, quality of life and mobility and a reduction in analgesic
medications.
We are investigating the possibility of an SMS reminder service to
improve return rates and also focussed patient education at the time
of the procedure, including information on pacing, graded activity
and reduction of medication.
With a growing database of operator and procedure-specific outcomes,
we will be able to provide accurate information to patients and audit
our own practice, as mandated by the new GMC revalidation process.
ACH, Glasgow, UK, 2New Victoria Hospital, Glasgow, UK
Background
A patient questionnaire to assess outcomes after interventional procedures for pain management was introduced into clinical care in
Spring 2011 after a successful pilot. Ongoing follow up for patients
should only be arranged after return of this questionnaire, requiring
engagement from patients with the service and allowing appropriate
063
Radiofrequency denervation (rfd) of peripheral
nerves in the management of trigeminal neuralgia
(tgn) in the elderly and patients with multiple sclerosis (ms).
37
Abstracts
Yee Cze Tang1, Margaret Bone1, Jonathan Hayter2
064
1Pain
Development of impedance guided nerve seeking needle
Management Department, University Hospitals of Leicester, Leicester, UK, 2Department of Maxillofacial Surgery, University Hospitals of
Leicester, Leicester, UK
Background
Trigeminal neuralgia causes recurrent, brief episodes of severe and
often incapacitating facial pain. The peak age of onset for classical
TGN is 60 years and many patients are elderly. Secondary TGN occurs in patients with multiple sclerosis, usually at a younger age. The
first line treatment is pharmacological management but when this
fails, interventional therapies may be considered. Current scientific
evidence supports microvascular decompression. Elderly patients
or those with MS may present significant anaesthetic and operative
risks, limiting such treatment.
The authors wished to assess their local practice within Leicestershire in this group of patients with regards to indications and
outcomes from the technique of RFD of the peripheral trigeminal
nerve.
Methods
This is a retrospective audit of patients undergoing peripheral nerve
RDF for TGN over a 10 year period from 2002 to 2012. A review of
the theatre records within the Pain Daycase Unit identified patients
undergoing Interventional Pain treatments for TGN. The medical
records of those undergoing RDF of peripheral TG nerves were assessed.
Demographic data, treatment details and outcomes were recorded.
Thirty three patients were identified. Twenty six patients had classical TGN for 19.8 years, with mean age of onset 67.9 years.
Seven patients had TGN associated with MS for 20.0 years, with
mean age of onset 37.3 years. All patients had significant co-morbidities.
Results
Prior to RFD treatment, those with classical TGN had been controlled on medication for a mean time of 7.9 (1 - 21) years and
patients with MS for a mean time of 13.4 (1 - 30) years.
The treated divisions were as follows: 1st division 4; 2nd division: 16;
3rd division: 9; 2nd and 3rd division: 4.
The average numbers of treatments for all patients was of 3.2
(range 1 - 8) and the mean time between treatments was 14.7
months.
Of the 33 patients, 27 reported benefit (pain relief >50% with reduction in medication) for a mean time of 9.6 months (2 - 48). 21 were
able to reduce their medication to a maintenance dose and 2 patient
stopped medication.
6 patients failed to gain benefit.
6 patients reported impaired sensation. No serious adverse events
were recorded with this treatment.
Conclusion
The scientific literature for percutaneous peripheral procedures is
sparse. Peters and Turo noted that series tended to be small with
shorter-term follow up and concluded that peripheral procedures
should be reserved for emergency use or in patients with significant medical problems restricting other procedures. Gronseth et al
reached similar conclusions.
The authors acknowledge the small series but consider the data demonstrates that the technique of RFD in the management of intractable TGN is an effective treatment in this selected group of patients
who may present a challenge for alternate interventional techniques.
Additionally, we recorded no serious adverse effects.

Arindam De1, John Taylor0 ,2, Kaddour Bouazza-Marouf0 ,2, Atul Gaur1
1University Hospitals of Leicester, Leicester, UK, 2Loughborough University,
Loughborough, UK
Background
We aim to develop a needle system, which will detect the tissue type
based on electrical impedance and offer unique guidance during regional and neuroaxial block. Currently the accuracy of nerve blocks
relies on performers experience and judgement, which result in increased risk of damage/harm to the patient/tissues. Presently, there
are Nerve stimulator, Fluroscopy (+/- Dye) guidance and recently
Ultrasound to locate and guide practitioners to nerve and nerve
plexuses, but with their own limitations. Our experiments at the
Electronics Laboratory of Loughborough University for developing
such needle system is described here.
Literature review: limited amount of impedance testing carried out
on animal tissues in the past, all of which have supported the theory
that impedance can be used to differentiate between various tissue
types.
Methods
The first set of tests done on individual tissues to understand specific
impedance characteristic. Muscle, fat and nerve tissues of chicken,
turkey, lamb, pork and beef samples, sourced from local butcher,
were tested.
The final set of tests done on composite samples submerged in artificial cerebrospinal fluid (CSF). Tests involved measuring impedance
as the needle travelled through different tissues. The key variables
were the temperature of testing, the signal frequency and the tissues
tested.
An oscilloscope was connected to a circuit board capable of generating frequencies up to 80 kHz and a constant current of 1mA. A step
motor driven, screw mounted, reproducible needle insertion was set
at 3mm/sec. The output value transmitted to a computer using a
Picolog 1216 Data Logger. The data logger took reading every 10
ms, which equates to every 0.03 mm travel of the needle.
Results
The results showed a significant difference between the tissues tested, particularly with CSF.
Higher frequencies display larger differences between impedances
of different tissue types. At 37C impedance are less than half the
magnitude of the 10C values, while the 20C are close to the 37C.
This suggests that impedance reduces as temperature increases and
is not linear.
The next stage of composite testing, simulating spinal injection,
aimed to identify tissue type based on impedance values as the needle
advances. At 5kHz there is no significant change to identify tissues.
But at both 10 kHz and 50 kHz significant drop in impedance by 5k
was demonstrated as the needle passed from muscle to CSF and into
nerve tissues. There was no identifiable difference between muscle
and fat tissues. But across majority of the frequency range - significant difference exists between nerve, muscle and CSF of all samples.
Conclusion
Significant leap towards development of impedance guided needle,
which can help practitioners who offer invasive nerve block techniques
for pain relief.
38
Tests show clear difference of impedance between tissue types in five
different animals. Composite test identified nerve, muscle and CSF.
There was a significant impedance drop in CSF. There was a definite
trend to suggest that higher temperature decreases impedance of tissues in a non-linear fashion. Differentiation between tissues is more
effective at higher frequencies.
Further tests are required for statistical significance. This experiment
will need to be taken to cadaver study for further development of
nerve seeking needle.

References:
1. Cooled radiofrequency system for the treatment of chronic pain
from sacroiliitis: the first case-series.
2. Kapural L, Nageeb F, Kapural M, Cata JP, Narouze S, Mekhail N.
3. Pain Pract. 2008 Sep-Oct;8(5):348-54.
4.
Reg
Anesth
Pain
Med.2001
Mar-Apr;26(2):137-42.
Radiofrequency sacroiliac joint denervation for sacroiliac
syndrome.
066
065
Retrospective audit on cooled radiofrequency denervation of sacroiliac joint
Satish Kumar Gopa Narasimhula, Saravana Kumar Kanakarajan
NHS Grampian Health Board, Aberdeen, UK
Background
SI Joint complex pain contributes 15-25% of low back pain. The
prevalence of SI joint pain is increasing. One of the treatment options for SIJ complex pain in cooled radiofrequency neurotomy. 2
RCTs have established the efficacy of cooled RF in SIJ complex
pain.
We recently started offering this type of treatment for our patient
population. We use Sacral Lateral Branch Blocks for selection of patients for cooled RF. We present our audited results.
Methods
We audited cooled RF SIJ neurotomy carried out in 18 month period from the beginning of January 2011 to June 2012. Our standard
practice is to undertake a third-party evaluation via a nurse-led telephone clinic. We collected information about the diagnostic blocks,
% of pain relief, Patient global impression of change scale, complications and duration of pain relief from the last available clinical
information.
Results
10 sacro-iliac cooled Radiofrequency neurotomy had been carried
out during this period in 9 patients. There were 4 males and 5 females. The average age was 60 with SD of 12.08. 8 patients had
the SI joint denervations for the first time while the other 2 had
repeated injection. All patients had at least one sacral lateral branch
blocks.
2 were failure as they lasted 4 weeks or less. Rest of them were success and reported a pain relief of 78% on average with SD of 14.3
The duration of pain relief 3 to 9 months. 4 patients are reporting
ongoing pain relief. 4 had stopped medications and 1 had reduced
medications. All of them rated their relief as very much improved
on PGIC.
Interestingly, the longest duration of pain relief was achieved when
patients had comparative of LBB rather than SI joint injection followed by LBB.
Conclusion
Audit has demonstrated that appropriate selection of patients for
denervation will get significant improvement in pain relief and improved PGIC scale.
It has also demonstrated that there will be decrease in Medication administration following denervation. Comparative lateral
branch blocks may be more predictive of duration of relief than SI
joint injections.
Radiofrequency denervation of medial branch of the

dorsal primary rami at lumbar level for low back pain
: use of diagnostic block and pain reduction/ relief
following procedure
Yuet Meng Andy Ng1, Nick Hacking3
1Royal
Manchester Childrens Hospital, Manchester, UK, 2North West

School of Anaesthesia, North West region, UK, 3Royal Preston Hospital,
Preston, Lancashire, UK
Background
Radiofrequency denervation techniques of articular nerves were first
described in 1975 . Since then, the use of radiofrequency (RF) denervation of facet joints for treating lumbar back pain has increased
significantly.Facet related chronic back pain ma account for up to
15% of all low back pain. At Royal Preston Hospital, Dr N Hacking is 1 of 5 Pain Management Consultants and associate specialists
who perform such procedures on a regular basis. The use of medial
branch blocks (MBB) as a diagnostic tool prior to proceeding to
RF denervation is a well established practice to minimise treatment
failure and achieve high quality pain relief. The Royal College of Anaesthetists publication of Audit Recipe (2006 and 2012) have made
recommendations regarding RBF denervation including the use of
diagnostic MB prior to RF. This audit was aimed to look at compliance of diagnostic blocks and pain relief at 3 months
Methods
A retrospective audit of RBF denervation of facet joints at lumbar
level by Dr N Hacking was conducted using electronic clinic letters
following outpatient clinic or telephone interviews. These patients
would have had their treatment in the first 9 months of 2011. All
follow-ups were performed in a 3-5 month window. A target of 50
patients would provide a good snapshot of the local service. Inclusion criterias were patients with low back pain of at least 6 months
duration, including those with radicular pain radiating to buttock or
lower limb. Patients report of pain reduction were obtained and divided into no relief, mild relief, good relief (< 3months), good relief
(>3 months) or excellent relief. Good pain relief was classified as
relief >50% and excellent as >80%. Any prior diagnostic MBB with
local anaesthetic performed were also recorded.
Results
50 patients were obtained from the corresponding 9 months where
there was sufficient useful details in the clinic or telephone follow-up
letters. 31 patients were female (62%) and 19 were male (38%). 46
patients had prior diagnostic MBB performed at least once before
proceeding to RF treatment. 3 patients had no MBB done while
there was no documentation in 1 patient.
36 patients (72%) reported good or excellent relief after 3 months.
Out of this 36, 12 of them reported excellent relief >80%. 3 patients (6
%) had good relief but lasted < 3 months. 5 (10%) reported only mild
pain relief. while 6 (12%) felt no benefit or change in pain severity.
39
Abstracts
In the small subgroup of patients where no prior MBB were performed, 2 had no benefit from RF treatment and 1 reported only
mild pain relief.
Conclusion
Successful treatment with RF requires careful patient selection and
diagnosis of facet-joint pain. Almost all patients received diagnostic
MBB prior to RF denervation. All of them had follow-up review
within a 3-5 month window.
It is encouraging that 72% of patients in the cohort reported good
or excellent relief. This compares well with the Gofield trial in Canada (68%) however they were reporting 6 month follow-up. The
retrospective nature of this audit would mean reliance complete
documentation in the letters which exclude poor documentation. A
prospective audit with 6 month follow-up would be beneficial in assessing longer term treatment efficacy.
23%(34) had 2 infusions and 12%(17) had 3 infusions. The most

common diagnoses were chronic widespread pain (fibromyalgia) and
refractory neuropathic pain. The most common dose used was 5mg/kg.
Safety
There were no reports of significant adverse effects or local anaesthetic toxicity and only 32 patients (21%) reported side effects. The
most common side effects reported were dizziness and temporary
paraesthesia. None of these side effects warranted the termination of
the infusion before its completion.
Efficacy
Decreased pain and/or improved quality of life was reported for 34%
of infusions. Subgroup analysis showed that 24 patients reported a
benefit after the first infusion and 9 of those patients had a positive
benefit after the second.
067
Conclusion
Safety and efficacy of lidocaine infusions in a district

general hospital : a case series report.
Intravenous lidocaine infusions can be delivered safely in the district

general hospital outpatients setting. The benefits noted in this case
series did not seem to be sustained on repeated infusions. Thorough
evaluation of efficacy was difficult due to the variety of patient diagnoses and variable dose regimes. Further studies need to focus
on identifying the patient population that will most benefit from lidocaine infusions and determining the appropriate dose regime. We
suggest that this could be achieved by starting a national database to
collect data which may yield more robust and useful information for
patients with chronic pain.

Sally-Anne Shiels, Deepak Ravindran
Royal Berkshire NHS Foundation Trust, Reading, Berkshire, UK
Background
Intravenous lidocaine is a local anaesthetic which is increasingly
being used as an infusion1 for the management of refractory neuropathic pain and in any chronic pain condition where central sensitisation is suspected to be a major contributing factor. Its use in this
form can now be applied to a variety of diagnoses2 such as complex
regional pain syndrome3, herpetic neuralgia4, and fibromyalgia5,6.
The drug is usually administered as a slow intravenous infusion
although there is no clear consensus on the optimal dose and duration of the infusion. The logistics of administering the infusion and
the care of the patient was initially confined to specialist inpatient
units but with increasing evidence on its safety and efficacy, lidocaine infusions are now performed in a variety of clinical settings.
This study sought to report the safety and efficacy of lidocaine infusions in a district general hospital outpatients setting from 2008
to 2012.
Methods
This report looked at the practice and use of lidocaine infusions in a
district general hospital administered over a 5 year period from 2008
to mid 2012. The primary outcome was the frequency of adverse
events in relation to lidocaine infusions. Secondary outcomes
included efficacy of the infusions in reducing pain, improvement in
quality of life and side effect profile.
This retrospective review of clinical notes was approved by the Local Clinical Audit committee. Notes of all patients who received lidocaine infusions from 2008 to 2012 were reviewed. Patients were
assessed by a consultant and consented for the infusion. A standard
data set included demographics, diagnosis at the time of referral
for infusion, dose, rate, side effects, adverse events including need
to abandon infusion. Concurrent analgesic medications were also
noted.
Results
150 lidocaine infusions were administered in this time period to 64
patients of which 70% were women (11 case notes were not available
for review). The majority of patients had only one infusion 44%(64),
068
A survey - dual antiplatelet therapy and interventional techniques for chronic spinal pain
Vinod Sanem Ramulu, Swaroop Sampu
Hull Royal Infirmary, Hull, UK
Background
Interventional techniques are performed very commonly on patients
with chronic spinal pain. It is not uncommon to come across patients
with spinal pain on dual antiplatelet therapy. Overall risk stratification
of interventional techniques in these patients is essential. Since there
are no clear established guidelines, management of these patients
most of the time is left to the attending pain physicians discretion.
Methods
We conducted an electronic survey by sending a questionnaire to all
the pain specialists registered with the British Pain Society. Questions included in the survey are about their own practice of managing patients on dual antiplatelet therapy coming for interventional
procedures for spinal pain. We also enquired if they had any departmental policy or guidelines in managing these patients.
Results
We received 63 responses in total. Consultants, advanced pain trainees and non-consultant career grade doctors took part in the survey.
The survey revealed some interesting findings about the management of patients on dual antiplatelet therapy coming for interventional techniques. The results showed
94.8% of the respondents consider stopping dual anti-platelet
therapy before intervention
40
Majority are concerned about continuing Clopidogrel than aspirin
Only 52.6% of the respondents consider speaking to primary
physician before stopping dual anti-platelet therapy
There is no consensus amongst pain physicians on when to stop
Clopidogrel before the procedure
There is no consensus amongst pain physicians on which pain
intervention is safe to perform while the patient is on dual antiplatelet therapy
Only 14% of the respondents had hospital policy in managing
this high risk group
88% of the respondents feel clear guidelines would help in managing these patients safely

recorded. Of the 50 patients that complained of pain, 62% had clear
descriptions of the type: 72% had elements of neuropathic pain. 39/50
(78%) were currently on treatment for pain (those with no documentation were presumed not to be on any), 36% of these 39 patients had
comments on efficacy: 6 had pain fully controlled, 5 had reduction of
pain and 3 had no benefit. Medications were similar to those used to
manage pain in MS. Documentation of the effect of pain in terms of
mood (18%), psychological tension (5%), sleep (18%), quality of life
(8%), disability (13%) were at the respective percentages.
Conclusion
There is no consensus amongst pain physicians in the UK in

managing patients on dual antiplatelet therapy
Risk stratification of each interventional technique for chronic
spinal pain is essential in managing this high-risk group
Clear guidelines are necessary for the safe management of these patients on dual antiplatelet therapy suffering with chronic spinal pain
This audit of pain documentation at WCNN showed that despite

the multidisciplinary approach, more frequent and specific enquiry
into patients experience of pain is needed. Whilst enquiry about pain
may have been more frequent in practice, documentation was not
complete. Improved identification and documentation of pain would
prompt further assessment and management if required. Improved
documentation of the descriptions and effects of pain can also help
monitor and manage it. The use of a validated questionnaire such as
the Brief Pain Inventory may be valuable.
069
070
Documentation of pain management in a specialist

multidisciplinary neurology clinic
Audit into ketamine use in chronic pain: does it reduce

opioid consumption?
Category: Management (Audit)

Sizheng Zhao, Turo Nurmikko

Emma Baird, Jillian Davis
Walton Centre for Neurology and Neurosurgery, Liverpool, UK
Lancashire Teaching Hospitals NHS Trust, Preston, UK
Background
Background
Pain is an integral but generally underreported symptom associated

with Neuromyelitis Optica (NMO). The Walton Centre for Neurology and Neurosurgery (WCNN) is a highly specialist NMO national
referral centre, and provides an advisory service through a multidisciplinary clinic including consultant neurologist, specialist nurse, physiotherapist, psychologist, occupational therapist etc. The aim of this
audit was to assess how thoroughly the characteristics of pain and its
treatment success was documented in the context of a highly advanced
unit, set up for the sole purpose of holistic management of a neurological condition. NMO was chosen because pain associated with it has
not been clearly highlighted in clinical practice and therefore serves as
a rare opportunity to see how it is registered and dealt with, in contrast
to conditions where pain is the main presenting complaint.
The main mechanism of action of ketamine is as a non-competitive antagonist at the NMDA receptor. It is used to treat complex
chronic pain when conventional treatments have failed. Ketamine
has a significant side effect profile; from the more common effects of
hypertension and psychological disturbance to irreversible chemical
cystitis and hepatic dysfunction. The long term use of opioids has
been linked to endocrine and immunological dysfunction and the
risk of tolerance and addiction. Royal Preston Hospital is a large
teaching hospital with six pain consultants seeing 2000 new patients
a year. It has a dedicated Ketamine Clinic run by a specialist nurse.
The rational for a trial of ketamine, in addition to the obvious improvements in pain control, is to reduce opioid consumption.
Methods
A retrospective case note review of all patients taking ketamine in

Royal Preston hospital. There is a data base in which all patients
started on ketamine are recorded. From this 64 patients were identified; 4 were excluded as they had declined the trial. The remaining
60 patients chronic pain notes were reviewed including data from
the nurse lead clinic.
Conclusion
A retrospective case note audit was performed for 71 NMO patients

at the WCNN, using a questionnaire based on the Department of
Health guidelines for assessment of pain in Essence of Care 2010.
The guidelines stipulate that enquiry about pain should occur at every encounter, where patients pain management needs should be
identified by staff who are competent to recognise and assess pain.
Pain should be then be thoughtfully managed and regularly observed.
We audited these guidelines by assessing the ability of WCNN staff
to document the presence, type and description of pain, the management of pain and its efficacy, and the effects of pain. Only pain that
the patient experiences between relapses was evaluated.
Results
50/71 (70%) of patients had unambiguous documentation of the
presence/absence of pain. 50/71 (70%)of patients suffered pain between relapses: documentation of the location of pain was 100%,
whilst duration (22%), quality (62%), severity (28%), temporality
(30%) and exacerbating/relieving factors (44%) were less frequently
Methods
Results
The mean age of the patients analysed was 49 years, 53 % were male.
31 % were being treated for lower back pain and 15 % for generalised
pain. 58 % of patients were classified as having mixed pain, 32 % as
neuropathic and 10 % CRPS. The majority had had their pain for more
than five years (86%). The average dose of ketamine in a 24 hour period was 98 mg (range 20 - 200mgs). 20 % of the patients who started
taking ketamine stopped after a trial period because of poor response
or adverse side effects. 66 % of the patients who persisted taking it
experienced side effects. The opiate consumption remained unchanged
in 56 %, increased in 25 %, and decreased in 17 % of the cohort. Only
2 % of patients stopped all opioids once started on ketamine.
41
Abstracts
Conclusion
It would appear from this audit that it is unrealistic to expect this
group of patients to reduce their opioid consumption; therefore
we must reassess our goals when starting ketamine. Previously
follow up was intensive but did not include a formal assessment
of global function. Our practice now is to include such an assessment in our ketamine protocol. We will not continue to prescribe
ketamine when there is neither a reduction in opioid consumption
nor an improvement in functional capacity over a sixth month
trial period.
071
Observations of patient controlled analgesia out
with high dependency care: how safe are our standards?
Jonathan Seeley, Karen Birnie, Blair Tweedie, Susan Rae, Deborah
Morley
Western General Hospital, Edinburgh, Lothian, UK
Background
Patient controlled analgesia (PCA) pumps for postoperative analgesia have been reported in meta-analysis to have significantly greater
analgesic efficacy compared to as required opiates1. The main side
effect of respiratory depression has a quoted incidence of 0.1-0.8%2.
Previous papers have advocated observation regimens of various
time intervals3 and indicated that nurses basic pain knowledge is
poor, which may be reflected in suboptimal pain management of
this population5. Observation protocols vary throughout the UK and
there is no current evidence based consensus other than the requirement for further research1,2,4.
Established practice in our unit is for 1 hourly observations to include respiratory rate, pain, and mental state score. However, observational evidence suggested that this standard was not being adhered
to resulting in concerns regarding patient safety. We therefore formulated an audit to analyse adherence to our observations standard,
establish if this standard was adequate, and aim to improve patient
safety.
Ward 24 2/12(16.7%) sets compliant. Mean of 9.6 checks per 12

hour period or 0.79 per hour.
Overall means were 9.3 checks per 12 hour period or 0.77 per hour.
Fewest checks was 5 in 12 hours; no significant episodes of respiratory depression.
Tutorials noted to be poorly attended by both wards.
Re-audit. 27 observation sets
Ward 23 5/16(31%) sets compliant. Mean of 8.9 checks per 12 hours
or 0.75 per hour.
Ward 24 1/11(9%) sets compliant. Mean of 9 checks per 12 hours
or 0.76 per hour.
Overall 8.9 checks per 12 hours or 0.76 per hour. Fewest checks
were 3 in 12 hours.
1 critical incident of respiratory depression requiring naloxone and
HDU on day 1 of repeat audit, ward 23
Conclusion
Audit 1 established inadequate standard adherence, whilst re-audit
demonstrated improved ward 23 results, alongside ward 24 stagnation and no overall positive educational programme impact.
Improved performance on ward 23 was likely secondary to the critical
incident as poor tutorial attendance undoubtedly limited educational
benefits. As adherence remained suboptimal, we cannot draw conclusions regarding our standard in comparison with other regimes.
Focus now shifts towards delivering improved education and attendance prior to re-audit; with evolving methodology including an expanded timeframe and continued inclusion of all patients. Only by
improving adherence can we draw meaningful conclusions regarding
observation regimens and PCA safety.
072
Waiting times for access to a uk multidisciplinary
chronic pain service: how do we comply with iasp recommendations?
Girish Rangaswamy, Quazi Siddiqui
University Hospital of North Durham, Durham, UK
Background
Methods
For a 2 week period, all patients with PCA pumps on non-high dependency colorectal wards (wards 23 and 24) were reviewed, looking at recording of hourly respiratory rate, pain score(1-10), AVPU
score; and respiratory depression requiring intervention; specifically
naloxone or high-dependency escalation.
Inclusion criteria were all patients on PCAs for longer than 12 hours,
with no exclusion criteria. Charge nurses had no prior knowledge of
the audit.
Scores recorded as observations per 12 hour period either since
return from recovery, or since last recording period. Scores always
taken between 1700-1800 daily, and not counted if more than 1 set
of observations taken in a 1 hour period.
Following initial audit, our Acute Pain Team undertook a nurse education programme consisting of discussion of audit findings with
charge nurses and tutorials regarding risks of respiratory depression.
3 months later, a repeat audit of the same wards with same criteria
was undertaken.
Results
Audit-1. 22 observation sets
Ward 23 0/10(0%) sets compliant with our standard of 1 hourly
checks. Mean was 7.6 checks every 12 hours or 0.63 per hour.
Timely access to the pain management is recognized as a fundamental human right by the Montreal Declaration (2010). Evidence
shows that while waiting for treatment, deterioration including escalation of pain, depression and decreased health-related quality of life
are likely (Lynch et al 2008). IASP has recently identified appropriate benchmarks for wait-times for treatment of chronic pain and endorsed a document (IASP 2010). In the United Kingdom, medically
accepted waiting times tailored to different pain conditions are almost non-existent and triaging is generally based on the information
provided by the referrer. The 18 weeks waiting for routine/regular
referral to treatment is generic and not specific to pain. We evaluated the current practice of waiting time in our multidisciplinary
pain unit, checked compliance with the IASP recommendations,
analyzed causes for non-compliance and recommended changes.
Methods
We audited consecutive new referrals to our multidisciplinary unit
over three-month period. We chronologically recorded the time
of 1st symptom, GP consultation, referral date, postal delay, triaging delay, specialist consultation and definitive treatment. Majority of the referrals were made through choose and book system
by GPs, advanced musculoskeletal practitioners and other hospital consultants. All referrals are initially triaged by chronic pain
42
consultants and marked as either routine or urgent. Occasionally, a
specific waiting time is marked for urgent cases as considered appropriate by the triaging consultant. Waiting time is defined as the time
from referral to initiation of condition specific treatment. In cases
where the treatment was initiated by the GP or other practitioners
before the pain clinic consultation, the appropriateness of the treatment for that particular condition is judged by the consensus of the
two consultants for the analysis of the audit result.
Results
We collected data of 162 consecutive referrals over three-month period. Among them, 113 were referred by GPs, 37 by consultants of
the same hospital, 3 by consultants from different hospitals and 9 by
the Advanced MSK practitioners. There were 2 most-urgent (IASP
recommended maximum delay - 1 week), 20 urgent (recommended
maximum delay - 1 month) and 140 routine cases (recommended
maximum delay - 8 weeks). Average delays from referral to treatment failed to meet the recommendations (8.2, 8.5 and 11.4 weeks
respectively for most-urgent, urgent and routine). While capacity was
a major issue, cause analysis revealed that average delay for triaging
of 2.1 weeks (2 days - 5.7 weeks) could be improved with better
referral and triaging system.
Conclusion
The result of this audit shows that the current trend of waiting times in
our unit for different pain conditions does not comply with the medically accepted waiting times recommended by the IASP. We recommended that the triaging delay should be addressed, referrers should
be encouraged to use C&B or fax to minimise postal delay, education
and guideline should be introduced for the primary care professionals
and provision for urgent appointment slots should be ensured.
073
Review of patient satisfaction for a fitness instructor
within a multidisciplinary pain management team
Linda Knott, John Clare
South Devon Healthcare NHS Foundation Trust, Torquay, UK
Background
A local pain management physiotherapy pain management service
was reconfigured in 2005 to include a 0.5 whole time equivalent fitness instructor (FI). Their job role has been refined over the years and
now includes a one-to-one caseload (hospital and community based);
input to the adult and adolescent/paediatric pain service; liaising with
and educating community exercise schemes; and input to three different pain management programmes. From February 2011-August
2012, 246 patients were seen by the instructor on referral from a pain
management physiotherapist. A patient satisfaction questionnaire was
developed in January 2012 to identify if this new provision meets the
needs of the client group. This poster represents a summary of quantitative and qualitative data from January 201-end of October 2012.
Methods
The current post-holder co-ordinated the development of an anonymised patient satisfaction questionnaire related to the goals of his
service, seeking advice from a clinical psychologist and physiotherapists within the service. Questionnaires were distributed by hand at
discharge, or sent by post if the patient failed to complete treatment.
Data was entered onto Excel spreadsheets and analysed using descriptive statistics and thematic analysis.

Results
Seventy-seven patients were referred to the FI, with six not optingin. 21(27.3%, n=71) failed to complete treatment, 36(50.7%) were
discharged to their GPs, 11(15.5%) were referred to community exercise schemes, 3(4.2%) back to pain physiotherapy or psychology.
50 satisfaction questionnaires were distributed to the patients who
completed treatment: 39 were returned. Age range 16-76 years; 22
females, 17 males. All respondents reported: increased benefit for
confidence in undertaking a regular exercise programme: range 3-5
on a 0-5 scale, average 4.7; improved motivation to exercise: range
2-5, average 4.6. The least endorsed benefit was help for weight loss
(n=25), range 0-5, average 3.7. Eight described exercising regularly
(eg brisk walk or cycling at least twice a week) prior to seeing the
FI, with 37 compliant on discharge. The poster describes the data
in more detail, including qualitative feedback with 47 positive statements, three negative, and three suggestions for improvement.
Conclusion
The fitness instructor post is an extremely valuable resource within this
service. Training in pain management theory and skills is extensive, and
clinical supervision is ongoing, but he has subsequently been able to reduce follow-up rates for the physiotherapists, create links and support
for fitness instructors and exercise schemes in the community and provide additional support to the pain management programmes. All of
the patient satisfaction feedback has been extremely positive - both anecdotally but also as shown in the ongoing service evaluation. The next
step will be to explore reasons for people failing to complete treatment.
074
Missed appointments in pain mdt clinics
kumar vasappa, alifia tameem, vish siddalingaiah
russells hall hospital, dudley, UK
Background
In 2011/12, 10% of Out Patient Appointments were not attended by
patients1.Missed appointments affect patient care significantly. They
lead to delayed care of other patients, financial loss for the Trust and
inefficient use of healthcare personnel`s time 2. Our objective was to
find the incidence of Missed Appointments in our Pain MDT Clinics, compare with National average and use these results to make
recommendations to improve.
Methods
Retrospective data for the Pain MDT Clinics were looked into for
period between Jan 2012 and Jul2012. The total number of Clinics,
Number of Patients booked and the actual completed Appointments
were calculated.
Results
Out of 690 Appointments made for 115 MDT Clinics, 601 patients had
attended leaving 89(12.9%) slots empty. These missed Appointments
were because of patients not attending or rescheduling the appointments
very late leaving not enough time to fill the slot with another patient.
Conclusion
Our Pain MDT Clinics have a missed appointment rate higher
than the national average. One of the main reasons for patients not
attending appointments is their forgetfulness 3. This could be addressed by implementing one or more methods of reminding them.
43
Abstracts
We recommend 1) Considering patient reminders like a letter week
before the appointment, SMS or telephonic voice message. 2)Larger
use of Choose and Book system. 3)To take up a bigger survey involving other specialty clinics to see the Trust`s Missed Appointment rate.
075
Glasgow pain management programme graduateswhat next in the pain service?
Clare Bridgestock1, Lars Williams2
1Stobhill
ACH, Glasgow, UK, 2New Victoria Hospital, Glasgow, UK
Background
The Glasgow Pain Management Programme (PMP) is a psychology-led outpatient rehabilitation programme for patients with chronic
pain, with referrals from local secondary care pain services. Based
on the principles of acceptance and commitment therapy, one of the
primary aims is to foster self-reliance and self-management of ongoing pain and painful flare-ups, without recourse to treatment-seeking
from primary and secondary care services.
We wanted to establish the number of patients who continued to receive treatment from local pain clinics following completion of PMP,
and the reasons for this. Ongoing attendance at pain clinics might be
led by pain service clinicians arranging a routine follow-up appointment, or by patients or GPs requesting re-referral into the pain service.
The former may be a necessity, but the latter might be seen as a failure
of the PMP to effect behaviour change in graduates of the programme.
Methods
All patients who completed (definition- attended 8 or more out of
12 sessions) the PMP in the time period Sept 2008 to October 2010
were tracked on the NHS Greater Glasgow and Clyde (GG&C) electronic patient records system. All pain service contacts subsequent
to completing the PMP were recorded. Referral and clinic letters
and notes were reviewed to establish reasons for ongoing attendance.
To establish clinicians opinion on the role of pain clinics following
PMP completion, an online survey was created which all clinicians
(33 people) working within the pain management service in NHS
GG&C were invited to complete. This questioned timing of referral
to the PMP in relation to ongoing pharmaceutical and interventional
pain management therapy, and also local policy for ongoing management of patients who have completed the PMP.
Results
During the audit period, 132 patients completed the Glasgow PMP.
After completion of PMP, 23% of patients attended 1 return appointment within the local pain service, a further 15% of patients
attended between 2 and 11 appointments and 8% remain within the
pain service.
By October 2012, 16% had been re-referred to local pain services
with a mean interval from completion of PMP to new appointment
of 20 months. 38% of those were seen once and discharged, the remainder had between 2 and 10 appointments. The most common
reason for re-referral was flare-up of pain and the majority of referrals were from primary care.
25 of 33 clinicians completed the survey. 64% refer once a patient is
suitable for PMP, and consensus is the PMP should be an exit route
from local pain services. Patients and primary care should be aware
of this plan.
Conclusion
A self-management programme, by definition, encourages patients
to consider alternatives to seeking medical help for ongoing pain and
flare-up management. Patients attending the Glasgow PMP have all

been assessed and treated first by local secondary care pain services,
and are referred to the PMP on the assumption that all investigations
are complete and all treatment options exhausted. Nevertheless, a
significant proportion of these patients continue to attend local pain
services. The reasons for this are complex, with both clinician and
patient factors playing a part. This audit represents a first step towards identifying the nature of this issue.
076
Use of ultrasound in chronic pain a survey of current
practice in uk
Deepak Malik1, Edward Lin2, Manohar Sharma3
1Leicester Royal Infirmary, University Hospitals of Leicester, Leicester,
UK, 2Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK, 3The Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, UK
Background
Ultrasound (USG) has been increasingly becoming popular as a
preferred imaging technique in interventional pain management. It
allows identification of various musculoskeletal and neuroanatomical structures avoiding radiation exposure where necessary to the
patient and staff.
Current use and possible future applications of ultrasound are
nerve blocks of the lumbar and cervical zygapophysial joints, stellate ganglion block, Suprascapular nerve block(SSNB), intercostal
nerve block (ICNB), paravertebral nerve blocks (PVB), inguinal
nerve blocks(INB), occipital nerve blocks(ONB), caudal epidural
injections(CEI), Sacroiliac joint block (SIJB) and injections of trigger points(TPI).
We conducted this survey to determine the current UK wide practise with the use of USG and potential for its use in the future for
various physician preferred techniques.
Methods
An anonymised 14 point questionnaire was sent in October 2012 via
an e-link on SurveyMonkey to pain physicians of various experience
backgrounds (via pain consultants and pain trainees googlegroups).
Questions were aimed to obtain relevant information regarding their
current practice in the use of ultrasound for various procedures.
Completed responses were received from 49 members. Sixty six percent of the respondents were Pain medicine consultants and 32 % were
Advanced Pain trainees. Over a quarter of respondents had more than
10 yrs of pain management experience. Almost 90% physicians were
unaware of any published guidelines for use of USG in chronic pain.
Results
Fifty-four percent wished to gain experience in the use of USG,25%
were novices and only 5% were experts.Forty percent confidently
use USG for nerve blocks, but wished to have more training, while
18% were under-confident. Seventy-two percent had easy access to
USG machines in theatres, 15% in theatres and clinic, while almost
5% did not have access in either. Eighty-three percent use USG during Ilio-inguinal, Ilio-hypogastric and genitofemoral blocks, 60%
during suprascapular block and 50% for trigger point injections.
Forty five percent perform facia iliaca, piriformis and ICNB using
USG. Eighty two percent would not perform USG guided Lumbar/
Cervical facet joint injections. One third respondents think that it
would be safe and anatomically correct to perform SIJB and CEI using USG, while 33% thought it may be possible to perform lumbar
facet injection using USG.
44
One-third of the respondents had attended a relevant USG training

course more than a year ago and 33% thought that departmental
training in USG was inadequate.
not well on that day and 1 patient left midway due to long waiting
times. There were communication problems in nearly 25% of the
patients
Conclusion
Conclusion
It is important for us to have a comprehensive view of the current practice of epidurals in UK, and guide our everyday practice
on current evidence base behind it. As nerves could be directly
visualised using ultrasound it has potential applications for variety of procedures like radiofrequency, chemical neurolysis or cryo
analgesia.
Limitations are the poor resolution of narrow-gauge needles, loss of
resolution with increasing working depth and possible interference of
echoes from overlying structures with the image of target area.
There still remains a steep learning curve to obtain expertise in its
use before it becomes an indispensable tool for every pain interventionalist.
To conclude, the average DNA incidence for the pain clinics is

10.1% which is higher than the national and trust DNA rates. Half
of the patients either forgot or did not receive the appointment. Interestingly 40% of the patients who DNA didnt register their mobile
numbers for a text reminder. We have now introduced a contactschecking service with our patients and register their mobile numbers
so that text reminders can be sent out. We are also looking into making a confirmation telephone call 1 week prior to the appointment
if possible.
077
Survey of patients who did not attend (dna) their outpatients appointment
Alifia Tameem2, Radhukar Pandrangi1, Abdul Nazal1
078
Are patients with temporomandibular disorders
(tmds) more likely to be distressed and have an
increased tendency to catastrophise if they have been
referred to more specialists?
Kate Parker1,2, Shahid Chaudhry3 ,4, Joanna Zakrzewska1,2
1Queen
Elizabeth Hospital, Birmingham, UK, 2Russell Hall Hospital,

Dudley, UK
College London Hospital, London, UK, 2Eastman Dental

Hospital, London, UK, 3Barts & The London, London, UK, 4Queen
Marys, University of London, London, UK
Background
Background
Every year the NHS loses 600 million pounds due to missed outpatient appointments and at least 6 million slots are wasted annually
depriving other patients of their appointments. It also leads to an
increased attendance in the emergency department adding to the
workload of the emergency department staff.A quarterly survey of
England between January 2012 to March 2012 revealed an average
DNA rate of 8.7%. With this in mind, we tried to capture the DNA
incidence at our hospital for new and follow up patients and also
tried to find out the reason why patients do not attend their designated appointments
TMDs involve the muscles of the face, neck and head and rarely the
temporomandibular joint itself. TMDs are the second commonest
chronic pain disorder after back pain and affect 10-15% of the US
population with an estimated annual cost of $4 million. Studies show
that dentists are confused about how to diagnose TMDs and lack confidence in their management. Dentists usually refer to other dental
specialties whereas GPs are most likely to refer to medical specialties, most commonly ENT. Patients are often then referred to an Oral
and Maxillofacial department (OMFS). Many patients will be seen by
busy OMFS who do not have the time for the management of these
patients using biopsychosocial methods. Some patient will have unnecessary surgical interventions. We hypothesise that distress and catastrophising increase as patients move from one provider to the next in
their quest to achieve pain relief and an improved quality of life.
Methods
We carried out a retrospective data collection from the pain clinics
at the Queen Elizabeth Hospital Birmingham. With the help of the
informatics department at the hospital and the intranet tool clinical portal, we noted the number of patients who failed to attend
their appointment, new as well as follow up appointment during a
6 week period between April and May 2012. A telephone interview
was made for the patients who DNA and they were asked why they
were unable to attend their appointment. We also asked them if they
received paper as well as text reminders or not prior to their appointment. We then compared the pain clinic DNA rates with the trust
DNA rates.
Results
During a 6 week period 39 out of 386 (10.1%)patients failed to
attend their appointment of which 15 were new patients and 24
DNA their follow up appointment. The follow up appointment
rate with the nurses was much better than with the doctors (8.1%
vs 13.4%) which may have been because some of the nurse led
follow ups were treatment based.We were able to interview nearly
half of these patients (20/39).Only 3 out of 20 confirmed that they
had received a reminder before the appointment.The most common reason for nonattendance (35%) was failure to receive an
appointment followed by forgetfulness (15%). 4/20 were actually
1University
Methods
The Eastman Dental Hospital runs a multidisciplinary Facial Pain
Unit with over 1500 attendances a year. A prospective database is kept
of all the patients seen. All patients at their initial consultation complete
a series of baseline questionnaires including the Chronic Graded Pain
Scale (CGPS, Von Korff) and the Pain Catastrophising Questionnaire
(PCS, Sullivan). A comprehensive structured history is taken which
includes past providers and treatments. The database was used to select
patients who had TMD as their primary diagnosis in the year 2011.
275 patients fulfilled these criteria of which 93 were excluded due to
incomplete baseline questionnaires. The data for the 182 patients who
had fully completed their questionnaires was analysed, including analysis of their referral pathway, PCS scores and CGPS scores to determine
if a correlation exists between the number of specialists a patient has
seen and their level of distress and catastrophising.
Results
77% of patients were female with an average age of 42.6 years. 72%
of patients had other associated chronic pain.
45
Abstracts
Most patients had been seen in primary care; 25% seeing their dentist, 17% their GP and 48% both. 51% had seen a specialist. 60%
had seen one specialist, 28% two, 9% three and 4% more than three.
The overall mean number of specialists seen was 1.6. For those with
low pain grades (1 and 2) it was 0.62 compared to 0.88 for those
with high pain grades (3 and 4). The difference in the number of
specialists seen between low and high pain grades was not statistically significant (t(182)=1.737, p>0,05).
56% of patients scored grade 3 or 4 on the CGPS indicating disability. The PCS showed 48% had no catastrophising, 33% moderate and
19% significant. The pattern of data suggests higher catastrophising
and pain scores associated with more visits.
overall morphine equivalent dose (in one patient this was by a factor
of 10). More than 75% continue of those on Tapentadol PR, even in
those not experiencing improved analgesia, as there is a significant
improvement in side effects which encourages them to continue. The
main advantages were: reduction in constipation and nausea, more
awake and less fatigue.
Discontinuations occurred because of opioid withdrawal, preference
for the previous opioid, dry mouth and headache, urinary retention,
hallucinations and because the GP was unable to continue the prescription and the patient was unable to attend the hospital for repeat
prescriptions. With the success of this initial trial of Tapentadol PR
the local GPs are now able to prescribe it, after an initial successful
trial supervised by the hospital.
Conclusion
Despite our research showing no significant relationship between
number of specialists seen and pain grade we maintain that early,
appropriate referral of patients with TMDs could reduce the chronicity and disability these patients experience. Many patients see
multiple specialists before achieving satisfactory management; showing many specialists are not equipped to manage TMDs successfully.
Patients should be referred to a facial pain unit in the first instance to
improve management and reduce distress and catastrophising.
A more biopsychosocial approach, with more dedicated patient services could significantly reduce costs, with OMFS only managing
the small proportion of patients requiring surgical interventions.
079
Tapentadol prolonged release - a year in the district
general hospital setting
Louise Jeynes, Christine Waters, Heather Riggs, Alison Morris,
Dawn Pretty
West Suffolk Hospital Foundation Trust, Bury St Edmunds, Suffolk, UK
Background
Chronic non-malignant pain affects a significant number of people,
having an impact on their quality of life as well as society as a whole (1).
Opioids have been used to assist in the management of chronic nonmalignant pain when other avenues have failed, but they are associated with significant side effects, particularly constipation, nausea and
drowsiness and are not particularly effective in neuropathic type pain.
Tapentadol is a new mixed action analgesic, acting at mu-opioid receptors and norepinephrine reuptake inhibition. Initial studies suggested similar analgesic efficacy of tapentadol to the equipotent dose
of oxycodone, with significantly less gastrointestinal side effects (1, 2).
Methods
Following the introduction of an Opioid Clinic, aimed at educating
patients and assisting the monitoring of the dose and effectiveness
of opioids, Tapentadol prolonged release (PR) was introduced as a
stage 3 strong opioid option. Due to restrictions in place, all patients had to be able to collect their monthly prescription from the
hospital. Following the introduction onto the formulary at the West
Suffolk Hospital Foundation Trust, the first forty patients prescribed
Tapentadol PR were monitored for changes in pain scores and quality of life (using Pain Assessment and Documentation Tool (PADT))
as well as recording the morphine equivalent dose before and after
starting Tapentadol PR. The results were then audited.
Results
More than 50% of the group experienced an improvement in their
pain and their function and quality of life. Many also reduced their
Conclusion
Tapentadol PR has proven an extremely useful addition to the analgesic armoury and is well tolerated. With its dual action the typical
opioid induced side effects are minimised. It has also been a very
useful carrot to encourage the patients down off large doses of opioid in order to try it, as we aimed to get the patients on to a dose of
opioid equivalent to a maximum of approximately 250mg Tapentadol PR twice daily prior to change over. The vast majority managed
the reduction, with only a few requiring an additional opioid.
080
Development of a questionnaire to facilitate appropriate referral of patients to a facial pain service
Supriya Ghurye, Roddy McMillan, Artemis Ghiai, Joanna Zakrzewska
Eastman Dental Hospital, London, UK
Background
Pain affecting the oral and facial region (orofacial pain) is a ubiquitous problem with prevalence in the United Kingdom estimated to be
around 7% of the population. Pain-related temporomandibular disorders (TMD) are one of the three most common chronic pain entities along with headache and backache. Other chronic orofacial pain
diagnoses include: trigeminal neuralgia, trigeminal neuropathic pain,
burning mouth syndrome and chronic idiopathic facial pain. Orofacial
pain conditions can provide dilemmas in both diagnosis and management; misdiagnosis is common and often results in inappropriate and
irreversible dental and surgical interventions. The authors present a
prospective clinical study involving patients referred to a secondary
care facial pain multi-disciplinary service. The study objectives were
to: determine the extent of pain-related comorbidity and chronic pain
disability within referred patients. Moreover, to investigate the utility
of a self-administered questionnaire to assist clinicians making more
appropriate and timely referrals to our facial pain service.
Methods
Consecutive attendees to a facial pain service completed several selfadministered questionnaires prior to their initial clinical assessment.
These included hospital anxiety and depression scale (HAD) and
the graded chronic pain scale (GCPS) which yields four grades with
grades 3 and 4 indicating high disability.A structured history and
examination was carried out which also determined whether there
were other non-orofacial chronic pain sites present, including headache. On the basis of all this a diagnosis and treatment care pathway
was determined. Outcomes included the following treatment groups:
1. Information and explanation, 2. Management with medications,
3. Physiotherapy, 4. Physiotherapy with psychology. Patients could
be allocated to one or more treatment groups. The results were then
46
analysed to determine whether the screening questionnaires could
predict the care pathway used.
Results
A total of 50 participants were entered into the study: 11 male(22%)
mean age 58.44.7 years (range: 25-80), 39 female(78%) mean age
45.72.9 years (range: 22-78) with a male: female ratio of 1:3.5.
The clinical diagnoses provided after clinical assessment were:
TMD (66%), TMD with concomitant non-dental facial pain(10%)
, chronic idiopathic facial pain (10%), trigeminal neuropathic pain
(6%), trigeminal neuralgia (4%) and burning mouth syndrome
(4%). 58% of participants scored grade 1 and 2 on GCPS, of these
24% showed evidence of anxiety and 34% depression. In grades 3
and 4, anxiety and depression were 57% and 86% respectively. Furthermore, 43% of grades 3 and 4 demonstrated additional pain sites
3; compared to 31% in grades 1 and 2. Grade 1 and 2 comprised
66% of treatment group 1 and 71% of group 3. Conversely grade 3
and 4 patients predominated in treatment groups 2 and 4 at (60)%.
Conclusion
The results of this study suggest there are high levels of chronic pain
disability and pain-related comorbidity within facial pain patients
referred to our service. The authors suggest that screening measures
for anxiety, depression and chronic pain disability may be useful in
identifying suitable patients for referral. As a result, this may facilitate earlier and more accurate identification of facial pain patients
who are at risk of disability and chronicity; thus prompting earlier
referral for appropriate specialist management and possibly improving patient outcomes.
081
Demographics and psychological correlates of tmd:
use of questionnaire data to inform multi-disciplinary
management pathways
Aleksandra Herbec, Jenna Love, Joanna Zakrzewska
Eastman Dental Hospital, UCLH NHS Foundation Trust, London, UK
Background
Although no consensus exists on the management of Temporomandibular Disorders (TMD), biomedical treatments and splints
have been commonly used. However, there is increasing evidence
that TMD is associated with several co-morbidities, including catastrophising, anxiety and depression, which all need addressing in
order to improve long-term outcomes. A new interdisciplinary and
holistic TMD management programme was established at our specialised facial pain unit (FPU). A baseline referral pathway is used
where subsequent TMD management is informed by the presence
of co-morbidity. Four pathways are available 1. Information and
explanation only 2. Physiotherapy-led TMD education group 3.
Cognitive-behavioural pain management programme facilitated by
physiotherapy and psychology 4. Medications with or without any of
the above. The present study is a first step in evaluating the validity
of the referral pathway, and aims to assess the prevalence of comorbidities and catastrophising among patients who present with
TMD symptoms at the first specialist consultation in FPU.

(PCS), and on anxiety and depression, assessed with Hospital Anxiety
and Depression Scale (HADS) were selected. These measurements
were part of a routinely administered battery of questionnaires given
to all patients at the first specialist consultations with the facial pain
consultant. The proportion of patients presenting with elevated scores
(score above 8) on anxiety or depression scales were calculated. Mean
PCS scores, as well as proportions of low (scores =<19), moderate
(20-30), and high (=>31) catastrophisers were computed. Scores
of men and women were compared using t-test and chi-square. After completing a full structured history, examination and discussing
treatment options allocations were made to one of the four pathways.
Results
In the assessed time period, 181 patients were given a primary diagnosis of TMD , and data from HADS and PCS were available for
156 of them (25.6% men). Patients mean age was 43.3 (SD=15.6),
and 151 (96.8%) suffered also from other chronic pains including
headache. Eighty-two (52.6.%) patients were classified as having
elevated levels of anxiety and 54 (34.6 %) of depression, with no
significant differences between men and women (both chi-square
tests p> 0.05). Forty-four (28.2%) patients scored high on both
anxiety and depression, with a higher proportion of men showing
symptoms of both (c2(1, N =156)= 5.65, p < .05). Mean PCS score
was 23.5 (SD=14.8), with no differences between men and women
(t(154)=.246, p>0.5). Seventy-one (45.5%) patients had low, 30
(19.2%) moderate, and 55 (35.3%) high catastrophising scores.
Twenty-six (16.7%) of all patients (of which 30.1% were men)
scored high on catastrophising, anxiety and depression.
Conclusion
Symptoms of anxiety and depression, as well as catastrophising were
prevalent among both men and women with TMD. This may have
important implications for their management, as it indicates that
they may require a biopsychosocial management approach. It will
now be important to examine outcomes on these patients one year
on to evaluate if the baseline referral pathway is appropriate, whether the correct predictors are being used, and finally, if the baseline
questionnaires could play a greater role in determining the appropriate level of intervention in this stepped-care approach to TMD
management.
082
Explanation of the spinal cord stimulator devices to
facilitate mri scans
Vijay Bandikatla, Cherilyn Fenech, Stephany Harris, Tom Smith,
Adnan Al-Kaisy
Guys and St Thomass NHS Trust, London, UK
Background
Removal of Spinal Cord Stimulator (SCS) systems is sometimes necessary to facilitate MRI scans. We aimed to ascertain the incidence of
this scenario in our practice, and examine the indications for performing the MRI scans in SCS patients. We avoid implanting SCS systems in patients whom we think have a high likelihood of future MRI
follow-up e.g. history of cancer. We sought to identify further factors
that might predict future MRI requirement that we might be missing.
Methods
Participants were all the patients with primary pain diagnosis of
TMD at the FPU in the first 8 months of 2011 as identified from
prospective databases. Only patients for whom data were available
on both catastrophising, measured using Pain Catastrophising Scale
Methods
We analysed the SCS database of our hospital from January 2008 to
December 2011. We collected all the explanted cases and this data
was crosschecked with the hospital electronic patient records and/or
47
Abstracts
the medical records. We identified a total of 363 full implants over
the 4 year period (81 in 2008, 89 in 2009, 99 in 2010 and 94 in
2011). The following data were collected: sex, patient age, presenting
pain problem, date of implantation, procedure performed, and date
of explanation, and reason for performing the MRI scan.
work within the pain team, further medical advice and appointments, information given and signposting and referral on to services
outside of the pain team. The requirement for having both professionals present was also noted.
Results
Results
Explants for MRI scans numbered 9 over the 4 year period: 3 in
2008, 2 in 2009, 1 in 2010 and 3 in 2011. There were 6 male and
3 female patients with ages ranging from 4279 years. The average
duration of using the SCS was 6.47 years. In 3 patients the SCS was
in situ for over 10 years (range 6 months16 years).
In 8 out of 9 cases the primary reason for implantation was low back
pain +/- radiculopathy and in another case it was secondary to upper
limb CRPS. 7 of these cases were failed back surgeries.
The reasons for explanation for MRI scan were: new onset radiculopathy in 5 cases, severe progressive spinal canal stenosis in one
case. New unrelated intractable headache, arm pain and abdominal
pain occurred in the remaining 3 cases.
Conclusion
The incidence of SCS explanation for an MRI in our centre is reassuringly low. New onset radiculopathy/severe spinal stenosis accounted for 67% of cases. This is not unexpected in a population
with progressive spinal degeneration. Unrelated new symptoms account for the other 33.3% scans.
With current technology, explanation of SCS systems to enable MRI
scanning is unavoidable. This problem will only be resolved with
MRI compatible systems. These are in development and their approval for clinical use will be welcome.
083
An evaluation of the outcomes from a combined therapies assessment clinic for people with fibromyalgia
syndrome (fms).
Richard Walters, Rebecca Chasey, Phillipa Newton-Cross, Andrew
Gunatilleke
South Devon Healthcare NHS Foundation Trust, Torquay, Devon, UK
Background
During a clinical commissioning group review it was identified
that the service for people with FMS was fragmented in South
Devon. A local QUIP target had also been set to reduce secondary care referrals. Therefore a new and localised Map of Medicine
pathway was developed. This had an emphasis on primary care diagnosis and management, including advice on medication, physiotherapy, exercise and mental health services. A website with
information on pain management skills, FMS and medications
was also published to complement the Map of Medicine pathway.
Secondary care services were accessed by a specialist combined
physiotherapy and clinical psychology assessment clinic. This was
run with the support of a pain consultant. A review of the literature
indicates the importance of considering both physical and psychological factors in an integrated manner.
The outcomes of this clinic in its first year of running are described
alongside the implications for future changes.
Methods
After each assessment the outcomes for the patients were recorded
by the therapists involved. These included one to one and group
Over the time period 50 assessments were undertaken and the clinic
had three DNAs.
Of the 50 people who attend it was felt that a joint assessment was
helpful for 90% of these with the 4% needing only a pain physiotherapist and 6% needing only a clinical psychologist.
32% were referred on to one of the three team run programmes,
32% to pain management physiotherapy and 50% to pain management psychology (a number of one to one referrals were to both
services). 12% were directed to the FMS website.
14% of attendees required a consultant review and 54% required
further medical advice communicated via the clinic letter. A single
follow up appointment was required for 22% of people.
20% required referral to other clinicians including musculoskeletal
physiotherapy, dietetics and mental health services. Extensive liaison with other services was requires in 10% of cases including child
protection.
Conclusion
One year of running this clinic shows that a combined FMS therapies clinic with medical advice can aid access to a pain team. The
combination of the clinic, primary care advice and medical support
minimised the number of patients requiring subsequent consultant
clinics and therefore positively affecting waiting times.
Most patients that came through this clinic had complex needs requiring a joint approach. This may suggest other patients were managed effectively in primary care.
The pathway has been reviewed by the commissioning group and is
being extended to all widespread pain as well as enabling easier access from rheumatology services.
084
Clinical evaluation of the efficacy of oxycodone/
naloxone (targinact ) in the management of moderate
to severe pain associated with opiod-induced bowel
dysfunction
Lorraine Stevens, Margaret Bone
University Hospitals of Leicester NHS Trust, Leicester, UK
Background
Chronic pain affects around 5 million people in the UK. Patients
with moderate to severe pain may require strong opioids as part of
their management.80% patients treated with opioids experience at
least one adverse effect, commonly opioid-induced bowel dysfunction (OIBD) due to binding of opioid receptors in the GI tract
reducing peristaltic activity, GI secretions and increasing fluid absorption. OIBD is often debilitating with constipation, abdominal
pain and incomplete faecal evacuation despite, despite the use of
stool softeners and laxatives. Some patients avoid taking their analgesia because of the adverse effects, resulting in poor pain control.
Targinact (oxycodone/naloxone) was introduced for patients requiring opioids (dihydrocodeine, morphine, oxycodone or transdermal
fentanyl) with attendant OIBD. Many patients take a laxative regime
of fybogel, senna, lactulose, movical or enemas.
The aim of this audit was to assess the efficacy of targinact on selected
patients within a Pain Clinic setting.
48
Methods
The UHL Therapeutic Advisory Board approved the trial of targinact in 50 patients. All patients had been fully assessed in the Pain
Clinic. All were taking regular strong opioids for stable, nonmalignant chronic pain and reported significant OIBD requiring the
use of laxatives and bowel softeners.
Following informed consent, each prescription of opioid was
changed to an equipotent dose of oxycodone/naloxone. The first
and subsequent prescriptions were dispensed from UHL pharmacy.
Baseline and outcome data was recorded including previous analgesia and laxatives; pain severity; ability to undertake day to day
activities; mood; sleep and modified Bowel Function Index (BFI),
noting difficulty of defaecation, presence of incomplete evacuation
and judgment of constipation. Patients were reviewed by the clinical
nurse specialist at 1,4 and 12 weeks.
Results
22 patients were treated and complete data is available on 19. All 19
patients were taking a range of strong opioids and reported significant OIBD.
Mean pain severity: pre-treatment: 8.9 (5 - 10); 1 week: 5.1 (0 - 9);
4 weeks: 4.1 (0 - 7) and 12 weeks: 3.7 (0 - 6)
Day to day activities: pre-treatment: 15 restricted; 1 week: 1 improved; 4 weeks: 3 improved and 12 weeks: 3 improved.
Mood: pre-treatment: 12 anxiety /depression; 1 week:0 improved; 4
weeks:2 improved and 12 weeks:5 improved.
Sleep: pre-treatment: 18 restricted; 1 week: 0 improved; 4 weeks: 6
improved and 12 weeks: 6 improved.
Bowel Function index: pre-treatment: 19 poor; 1 week: 2 improved;
4 weeks: 8 improved and 12 weeks: 16 improved.
2 patients stopped all laxatives/stool softeners and 17 patients reduced their intake.
No adverse effects were recorded.
Conclusion
This audit in a small number of patients on strong opioids with
OIBD has shown a trend of improved pain relief and bowel function
in 15 out of 19 patients.
Patients with moderate to severe pain requiring opioid medication
often suffer from significant drug-induced side effects. In the elderly,
these may cause distressing consequences with patients reducing
their analgesic medication.
We consider that oxycodone/naloxone may have a place in the pharmacological management of patients with moderate to severe pain.
085
Pain recurrence and complications affect quality
of life in patients with trigeminal neuralgia treated
with posterior fossa surgery
Category: Management (Research)
Joanna Zakrzewska

practise but have not assessed patients quality of life and the fate of
those who had a recurrence of pain. It is postulated that patients who
are pain free, with no complications and not requiring drug therapy
are likely to have a high quality of life whereas recurrence of pain,
complications either due to surgery or drug use results in reduced
quality of life.
Methods
The data were drawn from one neurosurgeons entire posterior fossa
surgery practice from 1982 - 2002 with a mean follow up of five
years. A MVD was performed in 284 patients whereas 72 had had
a partial sensory rhizotomy (PSR). A questionnaire which included
the SF12, HAD scale and Brief Pain Inventory was sent out and
analysed by an independent research group to all the patients who
had been prospectively followed up. The response rate was over 90%.
The data on quality of life, recurrence and subsequent management
was evaluated. A failure was classified as no pain relief, partial pain
relief or return of pain within three months. Recurrences were defined as major if they required further treatment , minor if transient
and controlled by drugs. Those patients with recurrent pain at the
time of the questionnaire were then compared to a comparable medically managed cohort.
Results
In the MVD group 8% had no pain relief, 16 % had a recurrence,
30% had complications. Of those who had pain 54% opted to have
repeat surgery of which 29% had posterior fossa surgery whereas
the others had ablative surgery at the Gasserian ganglion. Reoperation was more likely to fail if patients have previously had
an ablative procedure. The PSR group had similar pain relief data
but 80% had complications and 15 had developed deafferentation
pain and it had a marked effect on quality of life. When comparing the BPIs of medically managed patients, MVD and PSR patients the highest disability was in the PSR group. The SF12 also
showed that complications had a larger impact on quality of life
than pain intensity. Depression was present in 24% of those who
had a recurrence whereas it was 9% in those who had a successful
outcome.
Conclusion
Outcomes after posterior fossa surgery are excellent but recurrences
and complications will have a significant impact on patients quality
of life and this needs to be discussed with patients when making decisions about treatment. Patients who undergo several surgical procedures without pain relief may not have classical TN. Given the higher
rate of complications after PSR patients should be consented separately for this procedure. Significant sensory loss impacts on quality
of life even if patients are pain free. Patients treated medically have
poorer quality of life than patients who undergo successful MVD.
086
Eastman Dental Hospital UCLH NHS Foundation Trust, London, UK
The impact of constipation - a survey of 2,000 patients

taking opioid medication for pain relief.
Background

Fiona Millard, Rupert Roe
Recent systematic reviews have shown that patients with trigeminal neuralgia have the best outcomes in terms of long term pain
relief if they undergo microvascular decompression MVD. However
a recent review of the neurosurgical literature shows that there have
only two reports measuring quality of life in patients post surgically
after undergoing Gamma knife surgery using the SF36. There is
also scant data on how patients with recurrences are managed. We
have reported on patient satisfaction with MVD from one large UK
Napp Pharmaceuticals Limited, Cambridge, UK

Background
Eight million people in the UK are currently prescribed an opioid
analgesic. Opioids are an effective treatment option for severe pain
where non-opioid analgesics have failed. However, 80% of patients
taking opioids experience at least one side-effect, many of which impact
49
Abstracts
the gastrointestinal tract. Although this can make GPs reluctant to
prescribe opioids, use of opioids is greater than ever due to the health
demands of an ageing population, combined with increasing concern regarding chronic use of NSAID medications. We interviewed
patients taking opioids for pain relief to determine how many experience symptoms of constipation, and how it affects their lives.
Methods
The survey was carried out by OnePoll as an internet-based questionnaire. Patients were screened and only those who were currently
taking opioids for pain relief were surveyed. The resulting data were
analysed by Just Health.
Results
2,000 opioid-treated patients took part in the survey; 58% (n=1165)
had experienced some degree of constipation, and 29% (n=561) experienced moderate-severe symptoms. Of the 561 patients experiencing moderate-severe constipation, over half (56%, n=313) had constipation for over 6 months, with 9% (n=49) of patients suffering from
constipation for over 5 years. 60% (n=334) of the same subgroup had
stopped, skipped or reduced their pain medication as a result of constipation, with a further 12% (n=65) having considered it. For half of
those with moderate-severe constipation (50%, n=278), the discomfort of constipation is as uncomfortable as the pain they were taking
medication for, and for 13% (n=71) the discomfort of constipation is
worse than their pain. Constipation was found to have an impact on
49% (n=273) of patients overall quality of life, eating habits, ability to
work and relationships with family, friends and partners.
Conclusion
The impact that constipation can have on a patient taking opioids
is often overlooked, and isnt seen to be a major problem. However,
many patients are reducing or stopping their dose of pain medication
as a result of their constipation, and find that many areas of their
lives are affected by it. This shows there is a need for health care professionals to assess the level of constipation in their opioid-treated
patients, and take steps to help them manage it.
087
Pain management, intimacy and parenthood amongst
couples living with endometriosis
Lorraine Culley1, Nicky Hudson1, Caroline Law1, Elaine Denny2,
Helene Mitchell1, Miriam Baumgarten3, Nick Raine-Fenning3
1De
2Birmingham
Montfort University, Leicester, UK,

City University,
Birmingham, UK, 3University of Nottingham, Nottingham, UK
Background
Endometriosis is an enigmatic, chronic gynaecological condition of
unknown aetiology affecting women of reproductive age. Incidence
is difficult to assess but has been estimated at between 5 and 15%
of the female population. Common symptoms are severe dysmenorrhoea, chronic pelvic pain, fatigue, menorrhagia, and dyspareunia.
It is also associated with 40% of attendances at infertility clinics.
As there is no cure for endometriosis the management focuses on
removal of ectopic endometrial tissue and symptom relief which
can involve a range of interventions including analgesics, hormonal
therapy and surgical interventions, with varying and unpredictable
rates of success. The aims of the UK-based Endopart study (funded
by the UK Economic and Social Research Council: ES/J003662/1)
are to explore the impact of endometriosis on heterosexual couples
and to contribute to enhancing the well-being of people living with
endometriosis by providing an evidence base for improving couple

support.
Methods
Contextual interviews with key informants (n=11) were followed by
qualitative interviews with 22 heterosexual couples which were analysed within a critical realist framework. Separate, in-depth, face-toface interviews (n=44) were conducted with women and men. Inclusion criteria were a laparoscopic diagnosis of endometriosis and that
couples had been living together for at least one year. Principles of
systematic sampling were employed to ensure diversity amongst participants regarding age, ethnicity, illness trajectory, and recruitment
route. Data were analysed thematically, informed by an interpretivist
and gender relational approach. A participatory stakeholder workshop with couples, healthcare providers and support group representatives enabled a critical dialogue on emergent findings and the development of recommendations for couple support in endometriosis.
Results
Endometriosis pain can have a major and devastating impact on all
aspects of womens lives and those of their partners. Two key dilemmas relating to pain management are discussed. First, dyspareunia
requires women to make a difficult choice between abstaining from
sex, with resultant feelings of guilt and concerns about risks to relationships, and enduring painful sex to experience desired intimacy
and closeness. When male partners are aware of dyspareunia, they
become reluctant to instigate sex and experience associated feelings
of guilt. Second, treatments that alleviate pain often prohibit conception and findings demonstrate the difficult choice couples have
to make between pain reduction and achieving parenthood, while
simultaneously assessing risks that their treatment may be ineffective or that conception may not occur. The decision making process
is further complicated when partners have differing priorities.
Conclusion
Desires for motherhood and intimacy shape womens choices concerning endometriosis pain management, and are, for some, prioritised over pain reduction. This study also uniquely illuminates that
men also have to consider their own desires for fatherhood or intimacy in the context of their partners endometriosis. Healthcare
providers need to understand the impact of endometriosis pain on
couples and the complex factors that influence attitudes and actions
concerning endometriosis pain management.
088
The safety profile of 5% lidocaine medicated plaster in
localized neuropathic pain (lnp): a review of literature
Category: Neuropathic Pain
Oscar de Leon-Casasola1, Simone Koenig2, Daniela Bertarelli3,
Irmgard Boesl2
1School of Medicine and Biomedical Sciences, University at Buffalo;
Roswell Park Cancer Institute, Buffalo, New York, USA, Compound
Development & Branding, Grunenthal, Aachen, Germany, Global Drug
Safety, Grunenthal, Aachen, Germany
Background
LNP is defined as neuropathic pain characterized by consistent,
circumscribed area(s) of maximum pain. Examples of clinical conditions generally fulfilling these definitions are post-herpetic neuralgia (PHN) and post-surgical neuropathic pain syndromes. Lidocaine, since long in use, has a known and acceptable safety profile at
recommended doses, particularly for topical use. 5% lidocaine
50
medicated plasters effect is independent of systemic absorption and
exerts its action directly in the skin where the plaster is applied.
Several clinical guidelines propose 5% lidocaine medicated plaster
as first line treatment of LNP, based on its high therapeutic success
rate and favourable safety profile. We reviewed 23 trials using 5%
lidocaine medicated plaster to compare the safety profile per clinical
LNP condition with its well-established safety profile in PHN.8 To
our knowledge this is the first systematic review of the safety profile
of 5% lidocaine medicated plaster across various LNP conditions.
Methods
23 trials were analyzed to compare the reported adverse events
to the known safety profile of 5% lidocaine medicated plaster
in PHN. Of these, 7 trials were randomized controlled whereas
16 were open label trials. All trials conducted between 1991 and
2011 were relevant for efficacy and safety evaluation in localized pain with a neuropathic component. The evaluated clinical
painful conditions and baseline characteristics covered a broad
population representing the average population with LNP. They included subjects with moderate to severe pain caused by painful diabetic and idiopathic distal sensory polyneuropathy, carpal tunnel syndrome (CTS), neuropathic component of osteoarthritis (OA) of the
knee and LBP, surgical or chronic post-traumatic neuropathic pain,
myofascial pain with neuropathic component, localized symptoms of
neuropathic pain of various etiologies and refractory peripheral LNP.
As the reviewed data are only available from publications without direct access to source data the safety information may be incomplete.
Results
The safety profile of 5% lidocaine medicated plaster summarized
here covered an exposed population of approximately 2000 patients,
thereof about 1500 treated with 5% lidocaine medicated plaster.
Across all indications investigated excluding PHN an incidence of drug
related adverse reactions (DRAEs) in up to 12% of patients was reported. The events for which the information was available were mostly
of mild or moderate intensity and mainly linked to application site reactions. Discontinuations due to DRAEs occurred in less than 5% of
patients. In PHN patients the most commonly reported DRAEs were
administration site reactions (such as burning, dermatitis, erythema,
pruritus, rash, skin irritation, and vesicles). The vast majority of DRAEs
were not serious and of mild to moderate intensity. Compared to 16%
DRAEs reported for PHN the data do not suggest a departure from the
established safety profile of 5% lidocaine medicated plaster in PHN.4
Conclusion
5% lidocaine medicated plaster appears to be safe and well tolerated
also in LNP models other than PHN. The observed safety profile seems
further in line with the one observed from data from spontaneous
safety reports collected by consumers and healthcare professionals for
approximately 16.47 million patients between 1999 and mid of 2012.
References
1.
2.
3.
4.
Mick et al 2012. CMRO; 28: 937-951

Rowbotham et al 1995. Ann Neurol (37) 246-253
Attal et al 2010. E J Neurol
SmPC Versatis, version 13.0; Sep 2011
089
Should the treatment of neuropathic pain target more
than just pain? Data from an efficacy trial with 5% lidocaine medicated plaster in post-herpetic neuralgia (phn)

Ralf Baron1, Jean Bruxelle2, Simone Koenig3, Marielle Eerdekens3,
Irmgard Boesl3
1Division of Neurological Pain Research and Therapy, Universittsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany, 2Pain Center, Fondation Adolphe de Rothschild, Paris, France, 3Compound Development
and Branding, Grunenthal, Aachen, Germany
Background
Unidimensional pain scales (e.g. 11-point NRS) have been
extensively used in clinical trials in a variety of pain models including
neuropathic pain. These scales are also recommended by regulatory
authorities for use in primary endpoints in trials targeted to support
an approval of new compounds. In order to enable translation of
these results from clinical trials into clinically meaningful changes,
secondary endpoints become more important.
It is thus useful to explore more than just pain relief in patients with
neuropathic pain. The impact of a pain treatment on quality of life
or sleep might provide additional insights and can be captured via
validated rating scales.
Based on data from an 8 week run-in phase of an efficacy trial with
5% lidocaine medicated plaster in patients suffering from PHN, we
assessed if treatment effects other than on pain should be considered
when installing a new treatment for neuropathic pain.
Methods
In this study 265 patients were treated for up to 8 weeks with 5% lidocaine
medicated plaster. After 8 weeks the patients response was assessed. When
the patients achieved at least moderate pain relief (equal to 4 on a 6-point
verbal rating scale) they were classified as responders.
263 patients were included in this efficacy analysis of the initial 8 weeks
of treatment (efficacy analysis set). A sleep questionnaire (CPSI) was
completed at screening, enrollment and thereafter at 1, 4 and 8 weeks. A
quality of life questionnaire (SF-36) was completed at screening and
after 8 weeks. Medical history comprised disease status regarding PHN
duration and detailed assessment of distribution of PHN location.
Results
The mean PHN duration was 37 months. It was affecting torso
(38.8%), head/face (12.5%), extremities (4.2%) or neck (3.0%). The
responder rate after 8 weeks was 51.7%.
After one week of treatment, the proportion of patients usually or
always having trouble falling asleep decreased with > 50%. The proportion of patients requiring sleeping medication decreased.
Patients, who usually or always awoke during the night due to pain
(18.6% and 9.9% respectively), already improved after one week of
treatment (decrease to 7.5% and 4.0% respectively). Likewise patients
who usually or always awoke with pain in the morning (22.4% and
19.4% respectively) improved already after 1 week of treatment (8.3%
and 12.6% respectively).These effects persisted throughout the 8 weeks.
Improvement was also observed in all categories of the SF-36 and
was most pronounced for the sections body pain and role emotional.
Conclusion
Results of this efficacy trial demonstrated the beneficial effects of 5%
lidocaine medicated plaster in patients with PHN. The distribution
of PHN shows that it can affect any part of the body. In addition to
pain relief 5% lidocaine medicated plaster was associated with improvements in sleep pattern suggesting a better quality of life.
References:
1 EMA: Guideline on clinical medicinal products for the treatment
of neuropathic pain, CPMP/EWP/252/03 Rev. 1
51
Abstracts
2 Binder, Bruxelle, Rogers, Hans, Bsl, Baron. Clin Drug Invest
2009; 29 (6):393-408
090
The effect of capsaicin 8% patch in patients with
peripheral neuropathic pain. A case report study.
Maria Pedro, Jan Shepard, Pierluigi di Vadi
University Hospital Lewisham, London, UK
The UHL Therapeutic Advisory Board approved the trial of capsaicin 8% in 50 patients, with up to 3 treatments per annum. A
detailed analysis of tariffs and care pathways was conducted and
ratified through interviews with NHS associates including pain
consultants and commissioners. Based upon the most applicable OPCS-4.5 and ICD-10 codes, the treatment was mapped to
HRG4, code AB04Z.
Involved doctors and clinical nurse specialists completed the pharmaceutical companys recognised training before prescribing and
administering capsaicin 8%.
The aim of the audit was to assess the efficacy of capsaicin 8% on
selected patients, within a Pain Clinic setting.
Background
Chronic pain of moderate to severe intensity occurs in 19% of adult
Europeans, seriously affecting the quality of their social and working lives (1) and is a substantial health care problem. Persistent pain
following surgery has been extensively investigated to find out any
predictive risk factors and its possible prevention (2, 3). The incidence of persistent localized pain was found to be present in approximately 30 % of patients one year after knee arthroscopy (4). No
information is available in literature about the effectiveness of topical
treatment in persistent localized pain following surgery.
Methods
We treated 11 consecutive patients suffering from localized chronic
neuropathic pain (more than 6 months) following surgery by applying capsaicin patch 8% accordingly with the agreed methodology
over the painful area of the skin (6). They were 7 female and 4 male
patients. The average age was 49.6. The pain score was measured by
the VAS scale (0-10) at baseline and at the 3-month follow up.
Results
A total of 7 patients reported improvement and 4 did not. The mean
numeric rate score (0-10) of all 11 patients was 8.3 at baseline and
6.2 at the follow up in three months. The average degree of improvement was 2.1 (25%). Among the patients who did improve 3 reported >50% pain relief. No side effects or serious adverse reaction
were reported.
Conclusion
Our case report study shows that the application of capsaicin patch
8% as a treatment for localized neuropathic pain following surgery
has a beneficial effect. No side effects were reported. A prospective,
randomized control study should be organized in order to confirm
these preliminary data.
091
Clinical evaluation of the efficacy of capsaicin 8%
topical patch (qutenza) in the management of neuropathic pain.
Margaret Bone, Lorraine Stevens, Karina Kennett, Lyn Moore
University Hospitals of Leicester NHS Trust, Leicester, UK
Background
Patients with regional neuropathic pain reporting allodynia, hyperalgesia and/or dysesthesia refractory to conventional neuropathic
modifying medication, present a management challenge. The capsaicin 8% patch has recently been introduced for the treatment of
peripheral neuropathic pain in non-diabetic adults either alone or in
combination with other medication.
Methods
All patients had been fully assessed in the Pain Clinic and diagnosed
with chronic neuropathic pain. All patients had received previous
trials of therapies for neuropathic pain as clinically appropriate,
including medication of tricyclic antidepressants, anticonvulsants,
selective serotonin reuptake inhibitors and topical lidocaine or
0.125% capsaicin cream; complimentary therapy of acupuncture
and transcutaneous nerve stimulation and interventional nerve
blocks.
Following written informed consent, baseline data and outcome data
was recorded including pain severity, pain-related functional impairment and evaluation of quality of life. Patients were reviewed by the
clinical nurse specialists at 1, 4 and 12 weeks.
Treatments were undertaken in well ventilated clinical areas. The affected allodynic area was mapped out and standard procedure for
capsaicin 8% application was followed.
Statistical analysis for the non-parametric data was undertaken with
Wilcoxon Signed Rank test.
Results
Complete data was available for 50 patients: 18 male, 32 female.
The mean area covered was 247 sq cm, with 37 patients receiving
one patch and 13, two patches. 13 patients received two treatments.
3 patients received 3 treatments.
Mean Pain Severity: pre treatment: 6.3 (SD 1.8); 1 month: 4.7 (SD
2.4); 3 months: 5.1 (SD2.5) showed statically significant reduction
(-1.6 (SE 0.5) p<0.006) at 3 months.
Mean Pain Related Functional Impairment: pre treatment: 5.9
(SD 2.3); 1 month: 4.6 (SD 2.4); 3 months: 4.7 (SD 3.0) showed
statically significant improvement (-0.9 (SE 0.5) p<0.08) at 3
months.
EQ-VAS: pre treatment: 49.3 (SD 20.7); 1 month: 61.4 (SD 18.8);
3 months: 63.4 (SD17.5) showed statically significant improvement
(11.6 (SE 33.6) p<0.005) at 3 months.
Adverse effects were minor and transitory with most patients reporting mild burning and erythema.
A clinically relevant reduction in oral medication was recorded.
Conclusion
This audit has demonstrated statistically significant improvement in
mean pain severity, pain-related functional impairment and EQ-VAS
scores in a small number of patients with neuropathic pain, refractory to standard treatments. 35 patients were assessed as improved,
with many being able to reduce their consumption of other analgesia. Adverse effects were minor.
We consider that capsaicin 8% was well tolerated in this group of
patients who were informed of the recognised attendant effects of
treatment.
We consider Qutenza has a place in the management of carefully
selected patients whose neuropathic pain has failed to be controlled
by other pharmacological means.
52
092
and 83.4% (131/157) of investigators at final evaluation; very much

improved was reported by 2.0% (3/152) and 1.3% (2/157) of patients and 0 and 3.2% (5/157) of investigators at randomization and
18.4% (28/152) and 19.7% (31/157) of patients and 17.1% (26/152)
and 19.1% (30/157) of investigators at final evaluation. CNS effects
were more frequent with combination therapy.
Results of patient and clinician global impressions of

change with tapentadol prolonged release (pr) versus
tapentadol pr/pregabalin combination therapy in patients
with severe, chronic low back pain with a neuropathic
component
Ralf Baron1, Andreas Schwittay2, Dietmar Falke3, Daniel Samper4,
Ilona Steigerwald3
1Division of Neurological Pain Research and Therapy, Universittsklinikum Schleswig-Holstein, Campus Kiel, Germany, 2Practice
for General Medicine, Special Pain Therapy & Palliative Medicine,
Bhlen, Germany, 3Medical Affairs Europe & Australia, Grnenthal
GmbH, Aachen, Germany, 4Hospital Germans Trias I Pujol, Badalona, Barcelona, Spain
Background
The combination of strong opioids and co-analgesics (eg, anticonvulsants) often provides effective analgesia for patients with severe
neuropathic pain and is also frequently used in severe mixed low
back pain; however, compared with monotherapy, combination therapies may be associated with poorer tolerability and more frequent
discontinuations. The centrally acting -opioid receptor agonist and
noradrenaline reuptake inhibitor tapentadol prolonged release (PR)
is effective and well tolerated for managing severe, chronic low back
pain with or without a neuropathic component. The current doubleblind phase 3b study (NCT01352741) evaluated the effectiveness
and tolerability of tapentadol PR monotherapy versus tapentadol
PR/pregabalin combination therapy for managing severe, chronic
low back pain with a neuropathic component. Patient global impression of change (PGIC) and clinician global impression of change
(CGIC) were measured as secondary effectiveness endpoints.
Methods
At baseline, patients were required to have a painDETECT unclear or positive rating and an average pain intensity score 6
(11-point numerical rating scale [NRS]-3 [average 3-day pain intensity]). Eligible patients were titrated to tapentadol PR 300 mg/day
over 3 weeks. Those patients with 1-point decrease in NRS-3 from
baseline and an average NRS-3 score 4 were randomized (1:1) to
receive target doses of tapentadol PR (500 mg/day) or tapentadol
PR (300 mg/day) plus pregabalin (300 mg/day) combination therapy
during an 8-week, double-blind comparative period. Analgesic effectiveness was assessed based on changes in pain intensity scores using
the 11-point NRS-3. Patients and investigators rated their impression of change in the patients overall condition on the PGIC and
CGIC, respectively, on a scale from 1 = very much improved to 7
= very much worse. Treatment-emergent adverse events (TEAEs)
were documented.
Results
Mean (SD) pain intensity (observed-case) in tapentadol PR (n=150)
and tapentadol PR/pregabalin (n=157) arms, respectively, was
8.4(1.11) and 8.4(1.07) at baseline, 5.9(1.41) and 5.9(1.28) at
randomization, and 4.3(2.49) and 4.2(2.50) at final evaluation
(changes from baseline and randomization, P<0.0001). Improvements (very much improved, much improved, minimally improved) in patients overall condition (tapentadol PR and tapentadol PR/pregabalin arms, respectively) were reported by 87.5%
(133/152) and 86.0% (135/157) of patients and 90.1% (137/152)
and 91.7% (144/157) of investigators at randomization and 82.9%
(126/152) and 82.8% (130/157) of patients and 84.9% (129/152)
Conclusion
Tapentadol PR monotherapy (500 mg/day) and a combination
of tapentadol PR (300 mg/day) plus pregabalin (300 mg/day)
showed similar significant reductions in pain intensity, with lower
incidences of CNS-related TEAEs with monotherapy. In both
treatment groups, more than 88% of patients and investigators
reported improvements in patients overall condition, with comparable percentages of patients and investigators reporting a rating
of very much improved at final evaluation. Results of the current
study suggest that tapentadol PR monotherapy is a viable treatment option in patients with severe, chronic low back pain with a
neuropathic component.
093
Functional health and well-being outcomes with
tapentadol prolonged release (pr) versus tapentadol pr/pregabalin combination therapy in patients
with severe, chronic low back pain with a neuropathic component
Daniel Samper1, Andreas Schwittay2, Dietmar Falke3, Ralf Baron4,
Ilona Steigerwald3
1Hospital
Germans Trias I Pujol, Badalona, Barcelona, Spain, 2Practice for General Medicine, Special Pain Therapy & Palliative Medicine,
Bhlen, Germany, 3Medical Affairs Europe & Australia, Grnenthal
GmbH, Aachen, Germany, 4Division of Neurological Pain Research
and Therapy, Universittsklinikum Schleswig-Holstein, Campus Kiel,
Germany
Background
Recent studies have shown that tapentadol prolonged release (PR),
a centrally acting -opioid receptor agonist and noradrenaline reuptake inhibitor, is effective and well tolerated for managing severe,
chronic low back pain with or without a neuropathic component.
This double-blind phase 3b study (NCT01352741) evaluated the
effectiveness and tolerability of tapentadol PR versus tapentadol PR
plus pregabalin for the management of severe, chronic low back pain
with a neuropathic component. Functional health and overall wellbeing were measured as secondary outcomes using the Short Form12 (SF-12) Health Survey.
Methods
Patients were required to have a painDETECT unclear or positive rating at baseline and an average baseline pain intensity score 6
(11-point NRS-3 [average 3-day pain intensity]). Patients were titrated to tapentadol PR 300 mg/day over 3 weeks. Patients with 1-point
decrease in NRS-3 from baseline and an average NRS-3 score 4
were randomized (1:1) to receive target doses of tapentadol PR (500
mg/day; T) or tapentadol PR (300 mg/day) plus pregabalin (300
mg/day; T+P) combination therapy during an 8-week, double-blind
comparative period. Changes in pain intensity scores from baseline
to final evaluation were determined using the 11-point NRS-3. Patients self-reported functional health and well-being were measured
using the SF-12 Health Survey (measures 8 health domains [physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health], summarized as
53
Abstracts
physical and mental health composite scores). Treatment-emergent
adverse events (TEAEs) were documented.
Results
With comparable reductions in pain intensity, mean (SD) changes
(observed-case) from baseline to final evaluation and randomization to final evaluation (presented as baseline to final evaluation [T
and T+P], randomization to final evaluation [T and T+P]) in SF-12
scores were: physical functioning, 10.6 (10.70) and 9.8 (10.02), 5.0
(10.75) and 5.5 (10.32); role-physical, 9.4 (10.27) and 9.9 (9.87),
4.2 (10.01) and 5.0 (9.44); bodily pain, 13.8 (12.20) and 12.3
(11.14), 6.5 (12.56) and 6.7 (11.02); general health, 10.5 (12.02)
and 10.8 (11.92), 5.4 (10.77) and 4.6 (10.53); vitality, 5.3 (10.48)
and 8.3 (9.65), 2.4 (8.56) and 3.4 (9.09); social functioning, 8.8
(10.87) and 6.8 (11.89), 3.7 (10.59) and 3.6 (9.96); role-emotional,
5.6 (12.62) and 7.9 (13.49), 1.4 (10.07) and 3.4 (11.38); and mental health, 6.8 (9.77) and 7.5 (10.14), 1.1 (8.63) and 3.0 (8.42). Significant (P<0.0001) improvements from baseline to final evaluation
were observed on all domains in both groups.
non-opioid analgesics. In contrast in 2011 no patient was discharged on

morphine but were on either codeine or tramadol and were twice more
likely to be on pregabalin compared to 2006. There was little change in
antidepressant prescribing between the two years. In 2011 the co-analgesics were prescribed earlier 3-38 days compared to 20-120 days in 2006.
Conclusion
The neuropathic pain protocol has enabled the early identification and
a more appropriate management of post burn pain and stopped the
use of strong opioids on discharge following major burns. This protocol could also apply to appropriate patients with minor burns and to
other high-risk surgical patients such as in breast surgery and trauma.
095
Participant evaluation of pain management programme
annual follow-up conference using delphi method
Category: Non-Pharmacological Pain Management
Ruth Whiteman, Paul Wilkinson
Conclusion
Pain Management Unit, RoyalVictoria Infirmary, Newcastle Upon Tyne, UK
Tapentadol PR monotherapy (500 mg/day) and a combination of

tapentadol PR (300 mg/day) plus pregabalin (300 mg/day) showed
comparable reductions in pain intensity. Both treatment regimens
were associated with significant improvements in patient-reported
measures of functional health and well-being. These favourable effectiveness, tolerability (with less CNS related TEAEs in the monotherapy arm), and quality-of-life outcomes suggest that monotherapy with tapentadol PR is a viable treatment option for patients with
severe low back pain with a neuropathic component.
Background
094
Impact of a neuropathic pain protocol on analgesia
prescribing following major burns
Mehreen Ahmed, Jonathan Rajan, Winston de Mello
Pain Clinic, University Hospital of South Manchester, Manchester, UK
Background
In 2005, 34 patients from the community were referred for management of post burn pain. Despite being on strong opioids (mainly
MST and Oramorph) analgesia provision was inadequate principally
due to the failure to identify and treat the neuropathic pain element
of post burn pain. A neuropathic pain protocol was introduced
using the LANSS scale to help identify and facilitate the use of
co-analgesics (lidocaine 5% plaster, pregabalin and amitriptyline) to
treat neuropathic post burn pain. The aim was to assess the impact of
this neuropathic pain protocol on analgesia prescribing on discharge
following major burn injury at the Burns Centre at UHSM.
Methods
A retrospective audit of case notes of patients with major burns (defined
as those patients admitted to the ICU on initial admission) eventually
discharged from the Burns Centre comparing 2006 and 2011. Patients
who were transferred, self-discharged or died were excluded. Data collected included age, gender, %TBSA, analgesic and co-analgesic on
admission and discharge and time in days to starting co-analgesics.
Results
There were 16 eligible patients in both years with an age range of 16-89
and 9 males (56.3%) in 2006 and 18-76 years and 10 males (62.5%)
in 2011.On discharge patients in both years were more likely to be on
The Pain Management Team in Newcastle-Upon-Tyne has been

running 3 to 4 6-week outpatient Pain Management Programmes
per year since 2002.
Each year, all patients who have completed a programme at any time
over the last 10 years are invited to attend an Annual Follow-Up
Conference. The conference offers refresher sessions on Pain Management techniques, and also has a social element. Critically, the
question arises of whether this is a worthwhile follow-up model?
Attendees are self-selecting, so the group of attendees varies from
year to year. Test-retest approaches using standardised psychometric
tests undertaken longitudinally are therefore not feasible. Potential
assessable outcomes might include altered utilisation of primary care
resources, changes in technical aspects of self-management or wellbeing. In this study we explored participants perceptions of what
they took away from the conference using focus groups to determine criteria. We then employed Delphi techniques to assess their
relative value.
Methods
Following a thorough consent process, delegates attending the
Annual Follow-Up Conference for Newcastles Pain Management
Programme in April 2012 were invited to form small groups of 5 to
10 individuals. Thirty nine delegates were divided into 6 groups with
5 electing not to participate.
Groups were asked to generate responses to the following question.
What will you take away from the annual follow-up conference?
The responses generated by the groups were reviewed to identify
key themes. These themes were collated, and a questionnaire was
produced by the investigators based on the responses.
A total of 18 distinct themes were generated. Questionnaires were
distributed to each individual, including the 5 delegates who had
not participated in the group exercise but wanted to participate in
the Delphi. Participants were then asked to rate each statement on a
scale of 0-10 based on its perceived importance to them.
Results
Forty four questionnaires were returned. Three questionnaires were
incomplete, but the responses from these were included in analysis
for the questions answered. Data sets for all questions and all but
one participant were found to follow a non-parametric distribution
54
with significant left skew. Median scores per question ranged from
8 to 10 (Median 9), and median score per participant ranged from
3.5 to 10 (Median 9).
The most highly valued aspects of the conference were predominantly
social, including the opportunity for ongoing contact with the Pain
Management Team, and deriving inspiration from other participants.
Questions relating to learning and maintaining Pain Management
techniques also scored highly. The impact on other healthcare utilisation was less clear, with the broadest range of responses returned to the
question relating to a reduction in General Practitioner consultation.
Conclusion
A significant proportion of patients who have completed a Pain
Management Programme in Newcastle over the last 10 years continue to choose to attend a one day Annual Follow-up Programme,
which they consider to be valuable in maintaining the benefits of
the original Programme and in many other ways. While aspects of
the Conference were valued by patients, based on these data alone
this perceived value cannot be translated into improved health care
outcomes as a direct consequence of long term follow-up. However,
this study provides credible patient-centred evidence that patients
gain from the long term follow up conference.
096
Does intervention by specialist physiotherapists
facilitate uptake of exercise and participation in
exercise on referral (eor) schemes in patients with
chronic pain?
Christopher Carter, Lis Hammond, CRD Laird
County Durham and Darlington NHS Foundation Trust, County
Durham, UK

Results
In total thirty-three patients were recruited to the study, twenty-five
female and eight male. The age range was 24 to 73 years. Five patients were lost to follow-up giving a response rate of 85%. Overall
sixteen patients took up EoR giving an uptake rate of 57%. Another
25% of patients intended to participate in an EoR scheme in the
future. Only 18% of patients had no intention of participating in
the EoR scheme. The dropout rate from those who took up the EoR
scheme was 38%. A physiotherapy prescribed home exercise regime
was the most popular form of exercise followed by walking and participation in the EoR scheme. Only one patient was not exercising
at the time of interview due to experiencing a flare-up in their pain.
This patient reported they had been exercising and fully intended to
get back to the EoR scheme once their flare-up had resolved.
Conclusion
The results appear to indicate that following intervention by specialist physiotherapists most patients in chronic pain continue with
some form of exercise including EoR schemes. This concurs with
the current evidence. Due to the small sample size it is difficult to
draw any clear conclusions from this study. A study with a larger
sample size is needed to investigate the impact of specialist physiotherapy on the uptake of exercise and the participation in Exercise
on Referral (EoR) schemes in patients with chronic pain in the
long-term.
097
Do patients with neuropathic pain benefit less from
pain management programmes?
Mark Rockett, Reuben Crossley
Plymouth Pain Management Centre, Plymouth, UK
Background
Background
There is strong evidence for the impact of physical inactivity on an everbroadening variety of health problems including chronic pain. Management of chronic pain often includes increasing physical activity and recovering lost function. This must be done in a safe and graded manner
and help sufferers accept responsibility for increasing their functional
capacity by promoting a positive view on physical activity (Main, Sullivan & Watson 2008). Specialist physiotherapists working in integrated
multidisciplinary pain management teams are ideally situated to provide such support. Once patients have completed their intervention
they are often left to manage on their own and can regress to pre-intervention levels of activity. Exercises on Referral (EoR) schemes facilitate
physical activity in previously inactive people (Hillsdon et al 2005; Williams 2009). The objectives were to determine the uptake and drop-out
rate of EoR schemes and whether individuals in chronic pain continue
exercising following intervention by pain management physiotherapist.
Multidisciplinary pain management programmes (PMP) have a

good evidence base for improving some aspects of chronic pain.
Neuropathic pain occurs in 6.9% of the population and is common among patients attending programmes. Patients experiencing
pain with neuropathic characteristics are often treated alongside
those with chronic nociceptive pain. It is known that neuropathic
pain (NeP) results in greater disability and higher levels of distress
than nociceptive pain, but it is not known whether these patients
respond less well to a PMP approach. We applied the S-LANSS
questionnaire at the end of each programme to retrospectively
identify patients with predominantly neuropathic pain within a
group of PMP patients (the NeP group). We carried out this audit to investigate the possibility that patients with predominately
neuropathic pain benefit less than patients with nociceptive pain
from a standard PMP approach using multiple questionnaires as
outcome measures.
Methods
A cross sectional survey design was used. The participants were
adults who had completed pain management physiotherapy
intervention(s) and had been referred to EoR during the period
January 2011 to January 2012. Participants had previously given
their verbal consent to be added to a database of patients who
would be contacted in January 2012. These participants were telephoned and asked some questions concerning their current exercise levels. Firstly, whether or not they had taken up their EoR
referral or whether they had started but dropped out. The second
part of the telephone interview involved asking patients what, if
any, exercise they were currently participating in.
Methods
Participants were recruited from three consecutive PMPs between
October 2011 and February 2012 (N=28). We recruited 25 patients. Data recorded at the start and end of each programme included the Brief Pain Inventory (BPI), the Hospital Anxiety and
Depression Scale (HADs), the Pain Self Efficacy Questionnaire
(PSEQ), the Oswestry Disability Index (ODI) and the Pain Catastrophising Scale (PCS). In addition to these outcome measures,
the S-LANSS questionnaire was administered at the end of each
programme for all patients attending the Pain Management Programme. Patients were allocated to the neuropathic group if they
55
Abstracts
scored >=12 points on the S-LANSS questionnaire. The demographic characteristics of the two groups were compared. As the
groups were not matched on sex or age, further statistical tests were
not carried out. The groups were compared on the basis of percentage improvement from baseline scores for the outcome measures
under study.
Results
Sixty percent of the patients were female. Neuropathic pain was
more common among female patients. Age ranged from 26 years
to 68 years. The mean age of patients with chronic nociceptive pain
was 53.8 years, versus 46.9 years for the NeP group. The NeP group
scored higher initially on BPI pain and anxiety scores, lower on depression and lower on self-efficacy. Mean percentage improvement
in questionnaire scores was significantly smaller for the NeP group.
In terms of pain interference, catastrophising, anxiety and depression, areas where PMPs often achieve significant improvements, the
NeP group improved by 5.5%, 2%, 7% and 8.6% respectively, compared to 30.8%, 29%, 24% and 23% in the nociceptive group. However, self-efficacy scores improved by approximately 20% in both
groups. Disability worsened in both groups (15% in the nociceptive
group and 4% in the NeP group). Pain scores improved by 6.1% in
the nociceptive group and 3.5% in the NeP group.
Conclusion
The majority of the patients attending the PMPs were experiencing
NeP. Younger, female patients were more likely to have NeP. This
is the first study to demonstrate that patients with predominantly
NeP benefit less from a multidisciplinary PMP than patients with
nociceptive pain. Further study is required to determine whether patients with high S-LANSS scores had a diagnosis that was consistent
with a high likelihood of NeP. It may then be appropriate to develop
specialist PMPs based on these diagnostic criteria. It is also not yet
clear what aspects of NeP prevent patients from benefitting from a
PMP approach.
098
A service evaluation on referrer awareness and
knowledge of pain management programme in leicester
Deepak Malik1, Alisdair Radcliff2, Laura Ambrose3, Margaret Bone4,
Edward Lin5
1Leicester
Royal Infirmary, University Hospitals of Leicester, Leicester,

UK, 2Leicester University, Leicester, UK, 3Leicester General Hospital,
Leicester, UK, 4Leicester General Hospital, Leicester, UK, 5Leicester General Hospital, Leicester, UK
Background
An evaluation into the effectiveness of a local PMP found significant
improvements in psychological outcomes and physical functioning
outcomes for patients who complete the 9 session program. However, a brief audit of the service (324 referrals) highlighted extremely
poor conversions of referrals starting a program (30%), although
very good levels of adherence to the program once assessed and
started (84%). Inappropriate and inconsistent referrals were highlighted to be the main causes of attrition. A service evaluation was
devised to investigate the referrals procedure with the aim of improving referral consistency and decreasing in
appropriate referrals. The clinical impacts of this are predicted to be
a reduction of inappropriate assessments (wasted clinical contact),
an increase in the percentage of referrals starting the program (increased
efficiency), a reduction in waiting time for patients starting a PMP

and subsequent increase in patient satisfaction.
Methods
Using a mixed-methods, between participants design, a bespoke
password secure web-based 20-item survey was emailed to a list
of clinicians (N=28) who had referral rights to the PMP. The response rate varied between professions with an overall response rate
of 82%. The survey included questions regarding knowledge of and
confidence in the PMP, clinical perspectives and expectations of the
referral procedure, and improvement suggestions. Statistical analysis was carried out on the quantitative data and Template Analysis
was carried out on the qualitative responses for insights into barriers to referrals, potential improvements of referral pathways, referrer
knowledge and information sharing.
Results
Qualitative
Themes of consistent knowledge
Structure of PMP (MDT approach for chronic pain), expectations
of knowledge and skill development (improve understanding and
reducing impacts of pain, improve patient control through coping/
management strategies).
Themes of inconsistent knowledge
Eligibility criteria and specifics of program
Referral pathway improvements
Increased information about PMP - leaflets, feedback, and open
days. All could be met through revamping the existing PMP information pack and resending to departments.
Quantitative
Positively, 82% of referrers consider the ability of patient to engage
with a group when referring and 91% highlighted the presence of
chronic pain as an essential eligibility criterion.
Responses highlighted the need for further education regarding
eligibility for the program as only 26% gave consideration to physical demands and 61% to psychological readiness to attend the
program.
Additionally, 44% do not consider preferred language when referring, highlighting the importance of awareness of specific needs of
the local community.
Conclusion
Whilst referrers displayed confident knowledge regarding the structure and expectations of PMPs, there were recurrent themes of
inconsistent knowledge of eligibility, explaining high levels of inappropriate referrals. The findings suggest further advertising of PMP
literature accompanied by education sessions on the goals of the
program and eligibility criteria offered. Service user input in these
education sessions will give greater levels of insight for clinicians and
observing at least the introduction day of the PMP should be a requirement for referrers. Additionally, the creation of PMPs which
are conducted in languages reflecting local demographics would increase the scope of the service.
099
The effectiveness of specialised pain management programmes: benchmarking against published outcomes
for general pain management programmes
Sarah Edwards, Amanda Williams, Maria Brezitski, Katrine Petersen,
56
Rebecca McLoughlin, Melissa Cohen, Anna Mandeville, Natasha
Curran, Andrew Baranowski, Julia Cambitzi, Suzanne Brook
University College London Hospitals NHS Foundation Trust, London, UK
Background
Patients with pelvic pain usually attend general pain management
programmes (PMPs). Some of their difficulties - embarrassment and
social anxiety associated with the location of their pain, and related
symptoms - are specific; others are largely shared with people with
chronic pain at other sites. The Pain Management Centre established
a PMP specifically for pelvic pain patients (Link) in 2009 to which
patients are referred by the multidisciplinary urogenital pain team,
We have now run 13 programmes, in single-sex groups. This study
aims to evaluate this specialised PMP by benchmarking against
group cognitive behavioural therapy (CBT) for mixed chronic pain.
Methods
The Link programme is adapted for pelvic and urogenital pain from
the well-established CBT PMP at the same Centre. Patients assessed
as suitable by a clinical psychologist and a physiotherapist attend
a seven-day programme, one of which includes friends and family
members, over seven weeks. Patients then attend one-, five- and
12-month follow-ups. Outcome measures are completed at the beginning and end of the programme, and at each follow-up.
The present study examines data from 118 Link patients from 2009
- 2012., when 88 women attended 10 programmes and 30 men attended three programmes. Male and female data were analysed separately, comparing baseline with one-month and one-year follow-up.
Data were benchmarked against the evaluation of a PMP for general
pain of Morley, Williams & Hussain, 2008.
Results
The median duration of pain was six years, with the most common
diagnoses being chronic pelvic pain, endometriosis and pudendal
neuralgia. 50% of women and 28% of men reported having had surgery for pain. The mean age of participants was 45.
Repeated measures ANOVA showed statistically significant reductions from baseline to one-month follow-up in pain intensity (BPI),
disability (BPI), catastrophic thinking about pain (PCS) and sexual
anxiety (MSQ). Mood (DAPOS anxiety and depression subscales)
and pain-related self-efficacy (PSEQ) also improved significantly.
Effect sizes (d) were compared to Morley et al. (2008), and found
to be within or exceeding the 95% confidence interval for pain intensity, disability and mood for both men and women. There were
some gender differences, with pain-related self-efficacy in men, and
catastrophic thinking about pain in women, meeting or exceeding
the benchmark.
One year outcomes are being collected and will be analysed and reported.
Conclusion
A specialised pain management programme for pelvic pain is effective in reducing pain intensity, disability and unhelpful thinking
about pain, and in improving mood and pain-related self-efficacy.
Anxiety about sexual activity, a particular difficulty for this group of
patients, is also significantly reduced. These changes hold for both
men and women, and meet or exceed the treatment benchmark for
this type of intervention.
100
Stop! Chronic back pain: preventing pain from becoming problematic

Meherzin Das1,2, Barbara Oldale1
1Poole
Hospital NHS Foundation Trust, Dorset, UK, 2Bournemouth University, Dorset, UK, 3Dorset HealthCare University NHS Foundation
Trust, Dorset, UK
Background
Traditional pain services operate in a linear manner: the median
time period from onset to pain clinic attendance is 12 years (Schulte et al., 2009) and people in UK wait twice as long as patients in
Europe for diagnosis and treatment. (European Consensus Report,
2010). Every year, 3.3 million people do not recover from their first
episode of pain, descending into the downward spiral of chronicity
and disability. As uncertainty, failed treatment and learned helplessness become enduring, 49% of pain sufferers develop depression and the burden on the individual and their family is intense
while the economic burden related to healthcare costs, employment
and the benefits system approximates 12.3 billion pa.
The STOP! project offered Early Multi-Disciplinary Intervention to
prevent chronicity from developing by recruiting patients earlier in
their journey with pain to teach them about self-management. Peer
support helped sustain the process and progress.
Methods
The STOP! Chronic Back Pain Project:
recruited people significantly earlier in their pain journey
by engaging traditional as well as less conventional referral
sources, such as the private sector, chiropractors, osteopaths and
the local media;
located PMPs in community settings - leisure centre - as well as
traditional out-patient settings;
established a Multi-Disciplinary Group Programme to prevent chronicity from developing. Patients attended 1 day/week
for 7 weeks and received Psychology, Occupational Therapy,
Physiotherapy, Mindfulness and Medical input;
offered Peer Support to help sustain the process of selfmanagement. Our service users provided unique tiers of support
by setting up a Wiki, Website and Facebook page. The aim of
our Pain Chain - each one reach one - was served by offering a
trained peer coach to each participant to provide 1-1 support to
facilitate change and clarify the concepts of pain management;
Results
A pre/post intervention format was employed using the following
battery of tests, which will be repeated at 1 year interval. Results
obtained are mentioned next to each test with the difference in pre/
post scores represented as a p value:
Roland Morris Disability Questionnaire: <.001
Pain Catastrophising Scale: <.001
HADS - Depression: <.001
HADS - Anxiety: .058
Euroqol: .002
Physiotherapy - Sit-to-stand: <.001
Physiotherapy - Step-ups: <.001
Self-reported change %: <.001
Qualitative feedback from staff (group format) and service users (1-1
semi-structured interview) was uniformly excellent:
This project leads the way towards less intervention and better selfmanagement. Commissioner
The STOP! Project has put pain at the heart of patients lives in terms
of self management and will lead to cost savings and better practice. GP
I think about my pain and what I can do each day, but it doesnt
govern me - I can now live my life. Service User
57
Abstracts
Conclusion
The STOP! Chronic Back Pain Project proved that early multidisciplinary intervention is clinically effective and can be delivered
in half the time and at half the cost compared to traditional PMPs.
Peer support furthers individual empowerment and self-reliance and
builds a supportive pain fraternity.
Our model of collaborative empiricism helped change clinicians attitudes and influence commissioners agenda.
STOP! successfully proved that Early Multi-Disciplinary Intervention can significantly reduce pain-related disability and have a positive impact at multiple levels by improving fitness and mood, helping
people return to meaningful occupation, increasing independence
and effectively enhancing their over-all quality of life.
PMP, 24 patients (22%) attended 3 parts of the course so also successfully completed, 18 patients (17%) failed to complete the course.
Patient Health Questionnaire (PHQ-9)
There is a 0.2 point (1.5%) reduction by the end of the course which
extends to a 3.1 point (23%) reduction in patients depression at
3 months. Patients remained in the moderately depressed category.
Owestry Disability Questionnaire
There is a 1 point (2%) reduction in patients disability index at 3
months, although patients remain in the severe disability category.
Generalised Anxiety Disorder Scale (GAD-7)
There is a 1.9 point (19%) reduction in patients anxiety post course,
although patients remain in the moderate anxiety category.
101
Conclusion
Audit of a pain management programme held in a Primary care setting
The results from this audit would suggest that although there is
a very conservative reduction recorded of patients perception of
their disability,there is much more of a significant change in both
patients measures of their depression and anxiety. The significance of these results would support that this type of intervention
(Community PMP) has the potential to offer both positive and enduring improvements to the quality of life of those that participate
in them. The next logical step for this audit is to now determine
if this trend will continue, through further data collection at
twelve months.

Christina Hambrook1, Jamie Kirkham1, Heather Hawksley1,2
1Kent
Community Health NHS Trust, Kent, UK, 2University of Surrey,

Guildford, Surrey, UK
Background
As part of their chronic pain pathway patients may be offered a Pain
Management Programme (PMP). In 2011 the course format was
altered; this allowed for the content to be reviewed and standardised.
This formed the baseline audit following the redesign; and assessed
the benefit of patients attendance on the PMP. It also jointly analysed data from the point of referral onto the programme and patient
attendance or attrition throughout the PMP.
The PMP is a multidisciplinary programme delivered equally by
Psychology,Physiotherapy and Clinical Nurse Specialists.It consists of 4 half-days, run on consecutive weeks. Throughout attendance, patients are introduced to a range of pain management
techniques. The programme conforms to current guidelines from
NICE and the BPS Pain Management Programme SIG: The purpose of which is to assist patients in gaining a greater confidence
in their own self management as a measure of improving their
quality of life.
Methods
A retrospective audit of patients who were invited to and attended
PMPs over a four month period between March and July 2012; it
covered eight PMPs, held in 7 different areas across the locality:
Three separat equestionnaires were used in the evaluation of this
intervention
Patient Health Questionnaire (PHQ-9)
Owestry Disability Questionnaire
Generalised Anxiety Disorder Scale (GAD-7)
Data was collected at 3 separate intervals in order to capture the influence of both attendance and possible benefits that this attendance
yielded. The first measure was taken as a baseline and gathered at
patients first attendance on week 1 of the programme. A second
identical measure was taken at week 4 and a final measure taken
at three months after successful completion of the PMP.Successful
completion and therefore data of this last set was recorded only if the
patient had attended at least 75%of the PMP.
Results
Over the audit period 224 people were invited to a PMP, of these 108
people went onto attend (48%). 66 patients (61%) attended the full
102
Pain demands an explanation: service evaluation of 1
day pain management programme for people with persistent pain
Jill Chanter, Jane Royle, Miranda Lowe
Sheffield Teaching Hospitals, Sheffield, UK
Background
Patient experience of health services is an important part of evaluating any benefit patients gain from an intervention and whether that
benefit is meaningful and sustained; it is also a central reference
point for those who are planning and commissioning services.
Anecdotal feedback from participants attending the 1 Day Pain Management Programme (PMP) suggested that learning about chronic
pain mechanisms resulted in a greater openness to considering self
management strategies for living with pain. This suggested a shift was
taking place but the nature and consequence of the shift remained
hidden. The aim of this evaluation was to explore what it was about
the programme that led to anecdotal reports of increased confidence
in the intentions to self manage pain and increase physical activity.
Methods
The sample was prospective, recruiting the next 70 out-patients
who attended the PMP and agreed to complete the questionnaires.
The PMP runs one day a week and the mean attendance is 8. The
data was collected over a period of 3 months from consecutive
programmes.
The design of the questionnaire was qualitative , asking questions
intended to capture any change in attitudes and beliefs as a result of
attending the group. Telephone follow ups at mean 6 months using
questionnaires designed to elicit information about any reported
intended and actual changes and any associated benefit reported
The data from the questionnaires was analysed using Content
Analysis methodology. The responses were entered into Excel to
enable coding of answers into Categories and then Themes.
58
Demographic data and Confidence scores were presented using
descriptive statistics.
Results
a significant increase in reported confidence in exercise and
movement
a significant increase in reported awareness of and plans to use
self management strategies
a significant shift of focus away from medication (n=69)
Pre PMP 87% identified mechanical/diagnostic reasons for their pain
Pre PMP 1% identified chemical vicious circles and effective management as explanations for their pain
Post PMP 2% identified mechanical/diagnostic reasons for their pain
Post PMP 72% identified chemical vicious circles and effective management as explanations for their pain
At mean 6 months follow up (n=31)
84% had attempted to implement self management strategies
49% reported sustained positive improvement in self management of
pain
19% reported a reduction in medication
Conclusion
Attending the 1 day PMP results in a significant shift in thoughts
and beliefs about the reasons for persistent pain and intentions to
self manage pain.
At follow up participants report a sustained change in identifying
activity and self management strategies to live with persistent pain.
Change in pain cognitions is associated with change in reported
physical performance.
Reported reduction in pain medication is associated with sustained
implementation of self management strategies.
103
Assessing the therapeutic benefits of an introductory session prior to enrolment on a pain management
programme
Yvette Coldicott, Rosie Odhuba
Ashford and St Peters Hospitals NHS Foundation Trust, Chertsey,
Surrey, UK

1. Whether they had found the introductory session helpful
2. Whether it gave them a better understanding of their pain
3. Whether it had led them to make changes to how they cope with
their pain
4. Whether it had made them feel better about their problem
The questionnaire used a combination of tick-box style answers and
space for free-text comments.
Results
29 people returned the questionnaire.
1. 97% had found the introductory session either very helpful or of
some help
2. 97% had a better understanding of their pain as a result of attending the session
Areas with the biggest increase in understanding were:

Acute vs Chronic Pain 66%
Managing activities eg pacing 59%
Emotions and pain eg vicious cycle 59%
Importance of exercise and fitness 59%
3. 62% had made changes to how they manage their pain
Areas with the greatest changes were:

How you think about your pain 45%
Managing activities 38%
Managing exercise 38%
4. 58% felt a little or a lot better about their pain problem In general,
comments were positive. 27 patients opted-in to attend the full
PMP.
Conclusion
This survey shows that patients do receive some therapeutic benefit
from attending the Introduction to Pain Management Session.
Patients find it helpful and informative, and it helps them to
change the way they manage their pain prior to attending the PMP.
This is important in view of the waiting list to attend the PMP. Also,
some patients may find the information given at this short multidisciplinary session enough, and subsequently not need to come on
the PMP.
Demonstrating therapeutic benefits from the Introductory session
also means that it can be classed as a clock-stopping intervention.
Background
Patients attending the pain clinic at our hospital may be advised to
consider attending the Pain Management Programme (PMP). Referral to the programme is then made by the patients themselves.
Following self-referral, patients are invited to attend an introductory
session (90 minutes duration). This was introduced in order reduce
DNA rates for assessment and PMP.
At the end of the session patients are given the option to opt-in.
They are then invited to a multi-disciplinary assessment, where their
suitability for a PMP is considered, together with which specific
programme is most appropriate. If a different intervention from the
PMP is necessary, eg medical treatment or individual psychology,
this is arranged from here.
This study evaluated how useful patients found the introductory session, as well as whether they learnt anything or made any changes
to the way they manage their pain as a direct result of the session.
104
A meta-ethnography of patients experience of chronic
non-malignant musculoskeletal pain
Category: Other
Francine Toye1, Kate Seers2, Nick Allcock3, Michelle Briggs4, Eloise
Carr5, JoyAnn Andrews1, Karen Barker1
1Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust,
Oxford, UK, 2Royal College of Nursing Research Institute, School of
Health & Social Studies, University of Warwick, Coventry, UK, 3Faculty of Medicine & Health Sciences, School of Nursing, Midwifery and
Physiotherapy, University of Nottingham, Nottingham, UK, 4Institute of
Health and Wellbeing, Leeds Metropolitan University, Leeds, UK, 5Faculty
of Nursing, University of Calgary, Alberta, Canada
Methods
Background
Patients who had attended the Introduction to Pain Management

Session were asked to complete a questionnaire between September
2011 and January 2012. The questionnaire asked them:
Many people suffer from musculoskeletal (MSK) pain. This pain

often has no medical explanation and does not go away. Some people find it so devastating that at times they would rather die than go
59
Abstracts
on in pain. A greater understanding of patients experiences of pain
could have an impact on healthcare in this group. Qualitative research aims to understand experience, but the increasing number of
qualitative studies can make it difficult to use this knowledge to inform clinical practice. A synthesis of qualitative research would help
us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples experience of healthcare
with the aim of improving it. The aim of this study is to: increase our
understanding of patients experiences of chronic MSK pain; utilise
existing research knowledge to improve understanding; and contribute to the development of methods for qualitative research synthesis.
Methods
We used the methods of meta-ethnography developed by Noblit
and Hare, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings.
There are 7 stages to a meta-ethnography synthesis: (1) Getting
started, (2) deciding what is relevant, (3) reading the studies, (4)
determining how studies are related to each other, (5) synthesising
translations, (6) translating studies into each other (7) expressing
the synthesis. The aim of analysis is to identify, describe and compare the metaphors or concepts and organise them into conceptual categories with shared meanings. We searched six electronic
databases, and included studies up until February 2012. We also
hand searched particular journals known to report qualitative studies, and looked through reference lists. We appraised each study to
decide whether or not to include it.
Results
We included 77 qualitative studies that explored adults experience of chronic non-malignant musculoskeletal (MSK) pain.
Twenty eight of these studies explored the experience of Fibromyalgia. We developed a conceptual model to explain patients
experience of chronic musculoskeletal pain. Our model reveals
that fundamental to the patients experience of chronic musculoskeletal is a constant struggle: (1) struggle to affirm my-self;
(2) struggle to re-construct my-self in time; (3) struggle to construct an explanation for suffering; (4) struggle to negotiate the
healthcare system; (5) struggle to prove legitimacy. The overriding theme of these categories is adversarial, giving a sense of being
guilty until proven innocent. However, in spite of this constant
struggle there is also a sense of (6) moving forward alongside my
pain by: listening to their body; finding a new self; becoming part
of a community; telling others about pain; realising that pain is
here to stay; becoming the expert.
Conclusion
Chronic MSK pain is experienced as a constant adversarial struggle.
Our model calls on us to challenge cultural notions about illness, in
particular, the expectation of achieving a diagnosis/cure. People with
chronic MSK pain do not feel believed, and this can have an impact
on participation in life. Central to the relationship between patient
and practitioner is the recognition of a person whose life has been
deeply changed. Our model suggests that feeling valued is not simply
an adjunct to the therapy, but central to it. The implications for clinical practice will be presented..
105
Struggling to construct reality - a meta-ethnography
of patients experience of chronic pelvic
Category: Other
Francine Toye1, Kate Seers2, Nick Allcock3, Michelle Briggs4, Eloise
Carr5, JoyAnn Andrews1, Karen Barker1
1Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust,

Oxford, UK, 2Royal College of Nursing Research Institute, School of
Health & Social Studies, University of Warwick, Coventry, UK, 3Faculty of Medicine & Health Sciences, School of Nursing, Midwifery and
Physiotherapy, University of Nottingham, Nottingham, UK, 4Institute of
Health and Wellbeing, Leeds Metropolitan University, Leeds, UK, 5Faculty
of Nursing, University of Calgary, Alberta, Canada
Background
Chronic pelvic pain (CPP) is a prevalent chronic pain condition with
a high disease burden. Its multifactorial nature makes it extremely
challenging for both clinicians and patients. The absence of a clear
pathology can exacerbate the challenge of pain, and a greater understanding of patients experiences of CPPS could help to shape
future healthcare for this group. Excluding qualitative research from
evidence based practice may mean that we neglect vital information
from decisions related to policy and practice. The aim of qualitative synthesis is to systematically review and integrate the findings of
qualitative research in order to increase our understanding. They can
also identify gaps in knowledge. We aimed to use a conceptual approach to qualitative synthesis to increase understanding of what it is
like to have CPP and to identify areas for further qualitative research
to increase our understanding of CPP in men and women.
Methods
We used the methods of meta-ethnography developed by
Noblit and Hare, which aim to develop concepts that help us
to understand a particular experience, by synthesising research findings. There are 7 stages to a meta-ethnography synthesis: (1) Getting
started, (2) deciding what is relevant, (3) reading the studies, (4)
determining how studies are related to each other, (5) synthesising
translations, (6) translating studies into each other (7) expressing the
synthesis. The aim of analysis is to identify, describe and compare the
metaphors or concepts and organise them into conceptual categories with shared meanings. We searched five electronic bibliographic
databases, and included studies up until September 2012. We kept
endometriosis and CPP studies separate during analysis so that we
could explore differences in experience. As we only found two studies that explored CPP in men,we also kept these studies separate
from the final line of argument analysis.
Results
We included 31 qualitative studies; 9 exploring womens experience of CPP, 2 exploring mens experience and 20 exploring the
experience of endometriosis. Our study shows that, like MSK pain,
CPP is relentless and biographically disruptive, profoundly affecting a persons sense of self. Women with CPP struggle to determine
whether pain is normal (not pathological/not real) or not-normal
(pathological/real). This struggle is played out through womens experience in healthcare; the absence of diagnosis means that CPP is
experienced as not real and therefore illegitimate. Women do not
feel believed or valued by health care professionals. This is exacerbated by, and also exacerbates, the culture of secrecy surrounding
womens problems. Entry into a community of other people with
CPP plays an important role in constructing pain as real and allows women to feel valued and believed. Mens accounts do not
describe this same construction of pathology, or the elevation of
experiential knowledge.
Conclusion
The struggle to construct pathological or not pathological reflects
associated cultural polarities which make it very difficult for people
with conditions that remain undiagnosed. This meta-ethnography
60
supports findings that the medical model, and its inherent dichotomies, does not fit the experience of CPP. This finding is likely to be
transferable to other health conditions and calls for change in the
cultural models that are currently used in health care. More research
is needed to explore the experience of CPP in men and gender differences in this experience.
106
Clinical utility of novel clinical signs in complex
regional pain syndrome
Category: Other
Anoop Kuttikat, Nicholas Shenker
Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Background
Complex Regional Pain Syndrome (CRPS) is a chronic, debilitating condition that usually arises after trauma to a limb. It is characterised by disproportionate pain, swelling, vasomotor, sudomotor, trophic and motor
changes. CRPS (incidence of 26/100,000 life years) is almost as common
as rheumatoid arthritis and 6 times as common as multiple sclerosis.
UK CRPS guidelines recommend prompt diagnosis and early treatment
to avoid secondary physical problems due to disuse of affected limb and
the psychological consequences of living with undiagnosed chronic
pain. However, diagnosing CRPS early remains a challenge. There is a
reported mean delay of 13 months from symptom onset to diagnosis.
Novel clinical signs of finger misperception, astereognosis, abnormal
hand laterality and body scheme have been reported in CRPS and
are presumed correlates of cortical reorganisation. We investigated
the clinical utility (sensitivity, specificity, positive and negative predictive values) of these signs in CRPS.
Methods
36 CRPS patients and 30 fracture patients recruited. 4 standardised clinical tests-1.Finger perception 2.Astereognosis 3.
Hand laterality and 4.Body scheme reporting. The optimum cutoffs for positive tests defined from pilot data (CRPS patients and
healthy volunteers) by plotting sensitivity and specificity for every
possible cut-offs and analysing the ROC curves and by independent review of results.
Results
The clinical utilities of the four novel signs were calculated compared
to fracture group. The most sensitive test was abnormal body scheme
(91.67%) followed by finger perception (77.8%). The most specific
tests were abnormal body scheme and astereognosis (70%). Abnormal body scheme had the highest positive and negative predictive values (78.6% & 87.5%). By using a cut off of 3 signs, the specificity
improves to 83% and positive predictive value improves to 81.48%.
Conclusion
Novel clinical signs (finger perception, astereognosis, hand laterality and body scheme reporting) are positive in many CRPS patients
and have significant clinical utility. Body scheme reporting (highest
sensitivity) if normal was the most useful test in ruling out CRPS.
3 out of 4 signs (highest specificity) if positive was most useful in
ruling in CRPS.
107
Problem of pain - impact of complex regional pain syndrome on employment
Category: Other

Benjamin Phillips2, Anoop Kuttikat1, Nicholas Shenker1
1Cambridge University Hospitals NHS Foundation Trust, Cambridge,
UK, 2School of Clinical Medicine, University of Cambridge, Cambridge,
UK
Background
Complex Regional Pain Syndrome (CRPS) is a chronic, debilitating pain condition that usually arises after trauma to a limb. It is
characterised by dis-proportionate pain, swelling, vasomotor, sudomotor, trophic and motor changes. CRPS is almost as common as
rheumatoid arthritis and six times as common as multiple sclerosis
with an estimated the incidence of 26/100,000 life-years. The exact
pathophysiology remains unclear; aberrant inflammation, vasomotor dysfunction and mal-adaptive neuroplasticity are implicated. The
socio-economic costs of CRPS are still emerging and we investigated
the impact of CRPS on employment.
Methods
The study enrolled patients diagnosed with CRPS (Budapest criteria), under the care of Rheumatology at Addenbrookes Hospital.
Participants answered a telephonic questionnaire designed to capture
snapshots of their employment history at three different points in
time: before onset of symptoms; point of entering the CRPS service;
and the present day. Information such as educational attainment, comorbidities, and receipt of social security benefit, was also gathered.
Results
The majority of patients (70%) stopped full-time work after developing symptoms of CRPS, and did not return to work after entering
the rheumatology service. This was measurable as a fall in average income (by 89.1%) and as a decrease in average hours worked. Average
amount of social security benefit received increased at the same time.
Time between onset of symptoms and diagnosis was significant in
continuing in, or returning to work, but unfortunately the majority
of patients experienced a delay in diagnosis longer than 1 year. Past
educational attainment was not predictive of unemployment. Strikingly, the socio-economic job classification before the onset of symptoms was linked to maintaining employment, as CRPS patients with
jobs ranked 5 or lower in the International Standard Classification of
Occupations (2008) were more likely to be working.
Conclusion
The effect of CRPS on employment is severe, and has serious economic implications for the individuals directly affected. Patients
who work in jobs with higher socioeconomic classification have a
worse prognosis for retaining employment. This may be explained by
harsher financial constraints on patients in lower categories, by the
hypothesis that individuals in more manual occupations are more
resilient in working in adverse circumstances, or by the hypothesis
that physical activity improves function in CRPS. Delay in diagnosis
adversely affects employment outcomes. Raising awareness of CRPS
among medical professionals is crucial to improve early diagnosis
and appropriate management.
108
Benzodiazepines are worse than opioids: negative medication effects in severe chronic pain
Category: Other
Jeremy Gauntlett-Gilbert1,2, Peter Brook1, Ana Jovicic0
1Bath Centre for Pain Services, Bath, UK, 2Dept of Psychology, University
of Bath, Bath, UK
Abstracts
61
Background
quality improvement consider paediatric pain adverse event indicators to be. This study, therefore, set out to identify what experts in
paediatric pain management and quality improvement considered
paediatric pain adverse care indicators to be.
There is concern about high levels of opioid prescription to patients

with non-malignant chronic pain. Dependence, side effects (both
medical and psychological) and hyperalgesia can arise from long
term opioid use. Pain management treatments can be rendered ineffective by sedation and emotional blunting. However, benzodiazepines are also used in chronic pain; this has also attracted criticism.
We examined associations between opioid use, benzodiazepine use
and patient functioning and mood in a severely disabled, psychologically distressed sample.
Methods
We calculated total daily morphine equivalent doses, and total daily
diazepam equivalent doses for a consecutive sample of 214 patients
attending adult residential or inpatient pain management programmes. Z-drugs were included in the diazepam equivalent scores.
Patients also completed a battery of self-report measures. We examined the amounts prescribed, and looked at the associations between
daily dosage, mood, functioning and other psychological variables.
Results
Both distributions of drug dosage were positively skewed. Median
morphine equivalent dose was 49mg (mean 114mg, range 0 to
520mg); daily median diazepam equivalent was 0mg (mean 3.4 mg,
range 0 to 40mg). 20% of the sample were on >180mg of morphine
equivalent daily. Opioid consumption was significantly correlated
with a range variables indexing poorer mood or function. However,
the correlations were objectively small. The size of association did
not increase when only patients on higher doses were analysed. In
contrast, associations between benzodiazepine consumption and
poorer outcomes were more consistent.
Methods
The Delphi technique relies on the judgment of an expert panel and
aims to develop consensus about a given subject area (Graham et al.
2003). When undertaking a Delphi study experts in the field complete a series of questionnaires. The first round is used to generate
ideas, which are reconsidered in subsequent rounds (Reid 1988).
In line with the Delphi technique the questionnaire for Round 1
asked a broad question: In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?
An e-questionnaire was developed for Round 2 using responses generated from Round 1 and asked respondents to indicate the importance of each potential indicator.
Results
Sixty-three experts responded to the Round 1. The responses were
grouped together in semantically similar ideas. This allowed a list of
possible adverse event indicators to be produced relating to postoperative and procedural pain. Forty-three experts responded to
Round 2. All but one indicator achieved a level of consensus of 70%
and so a third round was not carried out. Indicators include:
There is no documentation in the childs notes about their pain
or pain management
PRN pain medication is given without a pain score being documented
No evidence that the child received teaching (preparation) about
what the procedure is and what strategies they could use to help
manage their pain.
Conclusion
Both opioid and benzodiazepine consumption were broadly associated with poorer mood and functioning. In both cases, most patients
were on moderate doses, or not taking these drugs at all; however, a
minority were on a very high dose. Given the concern about the impact of opioids, associations between morphine-equivalent intake and
functioning were not as large as anticipated. Of course, this does not
preclude the risk of medical side-effects from opioid use. Benzodiazepine consumption was more consistently associated with poor outcome; the negative effects of this class of drugs merit more attention.
109
Identifying indicators for paediatric pain adverse
events: a delphi study
Category: Paediatric
Alison Twycross1, Jill Chorney2 ,3, Patrick McGrath2 ,3, Allen Finley2 ,3,
Darlene Boliver3, Katherine Mifflin2
1Kingston
University and St Georges University of London, London, UK,

2Dalhousie University, Halifax, Nova Scotia, Canada, 3IWK Health
Centre, Halifax, Nova Scotia, Canada
Background
Healthcare literature in the past 10 years has increasingly focused on
adverse events. The evidence for pain management is readily available and so children experiencing moderate to severe pain could be
considered an adverse event. Indeed, Chorney et al. (2010) suggest
the quality of pain management should be examined in this context.
This paper will discuss the results of a two-round Delphi study carried out to identify what experts in paediatric pain management and
Conclusion
A set of retrospective and prospective adverse event indicators for
post-operative and procedural pain were developed.These need testing further but may provide a useful tool for improving childrens
pain management.
110
Surgeons aims when managing paediatric post-operative pain: a qualitative study
Alison Twycross1, Anna Williams1, Allen Finley2 ,3
1Kingston
University and St Georges University of London, London, UK,

University, Halifax, Nova Scotia, Canada, 3IWK Health
Centre, Halifax, Nova Scotia, Canada
2Dalhousie
Background
Pain management practices continue to fall short of the ideal with
children experiencing moderate to severe unrelieved pain postoperatively (Twycross and Collis 2012, Kozlowski et al. 2012). In
one study 62.5% of nurses stated they aimed to relieve as much pain
as possible (Gadish et al. 1988). In another study 24% of the nurses
indicated they aimed to keep pain to a tolerable level or (give) enough
pain relief that pain is noticed but is not distressing (Caty et al. 1995).
More recently, nurses (n=19) were asked about their aims when
managing paediatric post-operative pain; reported practices were
compared to observed practice (Twycross and Finley 2012). Around
half the participants aimed for patients to be comfortable. Surgeons
aims when managing post-operative pain have not previously been
62
explored. This could contribute to the continuing sub-optimal pain
care. This study, therefore, set out to explore paediatric surgeons
aims when managing post-operative pain
Methods
A qualitative study design was employed, using semi-structured interviews to explore participants views in depth. An interview topic
guide was developed through an extensive review of the literature
and drawing on the researchers clinical experience. Eight consultant
surgeons from different specialities at one tertiary paediatric hospital in Canada participated in the study [orthopaedic (n=4), urology
(n=2), plastics (n=1), ophthalmology (n=1)]. Data were subjected
to content analysis, which involves the identification of common
themes across the dataset (Woods et al. 2002). Transcripts were first
analysed to generate initial codes reflecting key emergent themes.
All data were then organised according to these codes, with constant
comparison within and between transcripts.
Results
Surgeons overarching aim is to keep the child comfortable, without
eliminating pain completely. Various definitions of comfortable were
described, relating to the childs experience of pain itself and their
ability to undertake activities of daily living. Childrens behavioural
pain cues seem to be a primary consideration when making treatment decisions. The need to maintain a realistic approach was
emphasised and pain management described as a balancing act between concern for the childs present experience and fulfilling the
perceived responsibilities and expectations of professional medical
care.
Conclusion
Surgeons do not aim to eliminate pain completely. This may help
explain, at least in part, why children continue to experience moderate to severe pain post-operatively. This suggests that some pain is to
be expected, and that the diagnostic value of pain may in some cases
supersede concerns for the childs pain experience. Future research
should focus on exploring how these findings impact on the childs
pain experience.
111
Diffuse widespread pain presenting to a paediatric
chronic pain clinic - a review of cases 2001-2011
Helen Neary1,2, Joelle Despartmet2
Hey Childrens Hospital, Liverpool, UK, 2Montreal Childrens
Hospital, Montreal, Canada

Methods
The chronic pain clinic at the Montreal Childrens Hospital comprises of a multidisciplinary team, including physiotherapist and
psychologist. Patients are assessed during a combined interview. A
database of all patients attending this clinic has been maintained at
since 2001. Inclusion criteria were patients recorded as presenting
with diffuse widespread pain (DWP) as their primary complaint or
in conjunction with other sources of pain, including both idiopathic
and non-idiopathic origins. DWP within the clinic was defined as
musculoskeletal pain in 3 or more areas and experienced at least
once per week. Additional information within the database included
the impact of the pain on the childs activities of daily living including school attendance, participation in sports, maintenance of social
activity and interference with sleep pattern. Data was extracted from
Microsoft Access it was analysed using Microsoft Excel.
Results
39 (9.8%) patients presented with DWP out of a total of 398 over
the 11 years.92.6% were female (p = 0.0002), age range 7.4- 17.7
years with a mean of 14.4years. Mean duration of time the child
had experienced pain was 2.4 years (0.17-8.4 years).64.1% (25/39)
identified no precipitating event; 7 (17.9%) following surgery; 7 due
to disease process. 1 in 5 complained of additional sources of pain,
the most common of these being headaches affecting 10.3% patients
overall. An adverse effect on schooling (67%), sports participation
(69%) and sleep (74%) was seen; with 3 in 10 of total having all 3
areas affected.Physiotherapy was provided for 84.6% of patients, and
medications and psychology provided for 75.8%. Medications included anticonvulsants 50.3% (eg gabapentin), amitriptyline 30.8%,
and NSAIDs 23.1%. Mean duration of treatment is 10.7 months
(range 0.2-71.1 months); and 63.6% patients were finally discharged
fully recovered or greatly improved.
Conclusion
Diffuse, idiopathic pains during childhood are common, however in
a small but significant number of children they can have serious deleterious consequences which impact on many aspects of their lives.
Our clinic model, of medical treatment with integrated input from
psychology and physiotherapy, produced successful outcomes with
almost 2/3 patients functioning normally at discharge. There are now
studies which question if widespread pain in childhood predisposes
towards chronic widespread pain in adults, hence greater efforts are
needed to provide effective treatment combinations early, and a multidisciplinary approach is therefore essential to combat the multifactorial nature of diffuse widespread pain.
1Alder
Background
Musculoskeletal pain in children is common, with prevalence reported as between 5-38% (Schanberg LE, 2003). Pain in childhood
can have a large number of consequences both on the child, with
limitations in socializing, schooling and sleeping most commonly
reported; and also the functioning of the family. Those adolescents
with pain at multiple sites have been shown to have more disabilities than those with a single site pain; these pains can persist for
many years during childhood (El-Metwally A et al, 2004, reports a
4 year recurrence rate as high as 65%). Our aim was to review the
patients who attended the paediatric chronic pain clinic with diffuse
widespread pain, in particular relating to reporting of function impairment and the outcome following a treatment program with the
multidisciplinary team.
112
More accepting or less catastrophic? Therapeutic
change in adolescent chronic pain treatment
Jeremy Gauntlett-Gilbert1,2, Hannah Connell1, Jacqui Clinch1,3,
Lance McCracken1,4
1Bath
Centre for Pain Services, Bath, UK, 2Dept of Psychology, University

of Bath, Bath, UK, 3Bristol Royal Hospital for Children, Bristol, UK,
4Kings College London, London, UK
Background
Psychological treatments for paediatric chronic pain are moderately effective. However, it is unclear which psychological processes
are associated with improved functioning and decreased distress.
Researchers interested in Acceptance and Commitment Therapy
63
Abstracts
(ACT) treatment have pursued treatment process analysis in adult
populations. There are no such data for children or adolescents.
Methods
Ninety-six adolescents, and their parents, underwent an uncontrolled three week trial of Acceptance and Commitment Therapy
treatment in a residential setting. Patients were tertiary referrals
with high levels of disability and distress. Treatment incorporated
daily physical conditioning, activity management and psychology
intervention in an ACT model. Self-reported distress and functioning were measured, as well as objective physical measures, at pretreatment, post-treatment and three month follow-up. The association between psychological variables and change was examined by
analysing the relationship between early changes in psychological
variables (pre- to post-treatment) and sustained changes in outcome variables (pre-treatment to follow up).
Results
Adolescents showed sustained improvement in most self-reported and
objective physical domains at three-month follow up. Mean uncontrolled effect size was 0.45. Most changes in outcomes (pre-treatment
to follow-up) were associated with early changes in acceptance (pretreatment to post-treatment). The same was not true of early changes
in catastrophising. To address the possibility that early changes in acceptance were caused by a non-specific boost in functioning, rather
than treatment, we examined whether overall changes in acceptance
(pre-treatment to follow up) were associated with early changes in functioning (pre- to post-treatment). With one exception, they were not.
Conclusion
Intensive, residential ACT therapy can be a broadly successful treatment for severely affected adolescents with chronic pain. Successful
treatment outcomes were achieved in a manner consistent with the
theoretical model, that is, early changes in acceptance were associated with long-term clinical improvements. All improvements were
achieved with no thought-challenging interventions or attempts to
change physical or emotional states. Early changes in catastrophising
were not associated with most long-term improvements, consistent
with this process not being targeted in therapy.
Studies in adults have demonstrated that lidocaine 5% patches can

reduce the intensity of neuropathic pains.
This service evaluation was initiated to document the usage and efficacy of the 5% lidocaine patch in paediatric patients being managed
by paediatric pain teams in the UK. No change to current clinical
practice was required.
Methods
A two year service evaluation was initiated by the British Pain Societys Pain in Children Special Interest Group supported by an unrestricted educational grant from Grunenthal. Co-ordination of the
project was at Sheffield Childrens Hospital, where the service evaluation was registered with the Trusts clinical audit and effectiveness
department. The database was registered with the Healthcare Quality Improvement Partnership.
Invitations to take part along with questionnaires to be used were
distributed to 13 paediatric pain teams across the UK.
Anonymous pre-treatment data included: Age, sex, weight,
location & type of pain, diagnosis, duration of pain, pain score 0-10,
current medication, previous medication, application site, duration
and time of application planned. Follow up data were collected approximately 3 to 6 months post treatment. They included current
pain score, length of time patch used, side effects, reduction in other
medication, satisfaction score and any improvements in sleep and
function.
Results
Interim data from the first year of the evaluation are presented for 46
patients; 31 females and 15 males. Not all centres invited to take part
have provided data to the evaluation. Ages range from 6 17 years
with a mean of 12 years 9 months. Diagnoses and causes for neuropathic pain were very varied as were the sites of application. Pain
descriptors were typical for neuropathic pain. Complex regional pain
syndrome was the most common diagnosis (8 patients); the back was
the most common site of application (10 patients). Duration of use
ranged from one to six months. Overall benefit was reported by 28
patients, no benefit by 7, with 11 unsure. Local side effects only were
reported by 4 patients. 28 patients reported improvement in their
physical function and 18 reported improved sleep.
113
Conclusion
Lidocaine 5% patch (versatis) for localised chronic

neuropathic pain: a national multicentre evaluation
of use in children and adolescents
Analysis of interim data suggests that Lidocaine 5% patch (Verstais)

is helpful in treating localised neuropathic pain in children and adolescents. Over 50% of children and adolescents reported benefit to
their pain symptoms with concomitant improvement in physical function and sleep. Only local side effects were reported in a few patients.
Given the risk / benefit ratio of this treatment, the only issues with this
treatment in children and adolescents with localised neuropathic pain
would seem to be cost and lack of marketing authorisation.
John Goddard1,2, Rebecca Reaney1,2
1Sheffield
Childrens Hospital, Sheffield, UK, 2BPS pain in children SIG,

London, UK
Background
Chronic neuropathic pain in children and young people results
from a variety of medical conditions, e.g. trauma, infection, surgery,
cancer. Neuropathic pain frequently causes great distress and compromises quality of life. Neuropathic pain often responds poorly to
standard analgesics. Adjuvant analgesics such as antidepressants and
anticonvulsants are often effective but tolerability is frequently a
problem due to unpleasant side effects.
The safety and tolerability of the 5% lidocaine patch in adults is
established.
In children, most drug treatments used to treat chronic pain are
extrapolated from adult trials without evidence of efficacy in
children.
114
Paediatric pain clinic - referral pattern, demographics,
pain symptoms, diagnosis and management at first appointment of 139 new patients over a 3 year period (2009 - 2012)
Julie Hui, Elaine Wilson-Smith
Sheffield Childrens Hospital Chronic Pain Unit, Sheffield, UK
Background
Paediatric chronic pain has been shown to be higher in females with
a prevalence of up to 88%, with abdominal pain and headache being
64
most prevalent. There has been no published data from individual

paediatric pain management clinics in Britain regarding referral patterns, patient demographics, pain conditions and management.
Established in 1994, we have evolved into a tertiary multidisciplinary
paediatric pain clinic composed of anaesthetists, neurologists, pain
nurses, physiotherapists, occupational therapists, psychologists and
psychiatrists specialised in paediatric chronic pain medicine. During
our 4 clinics each month, joint consultations encompassing these
professions are conducted to address the biopsychosocial impact and
management of chronic pain.
The purpose of this study was the precise description and management of children referred to our pain clinic at the first presentation,
over a 3 year period.
As well as high pain intensity scores, more than 50% reported adverse affects on physical activity, sleep and social activity, and 45%
reporting mood being affected.
With referrals increasing year on year and the almost absolute need
for managing the complex biopsychosocial dimensions of chronic
pain with PMP, there is discernible demand for specialised paediatric multidisciplinary chronic pain clinics.
However, it is important to appreciate that referral patterns and
patient cohorts maybe specific to individual pain clinics according to surrounding local paediatric services in order to improve
referral pathways, accessibility, and appropriate targeted resource
management, particularly with the advent of clinical commissioning groups.
Methods
115
Data from new patients presenting to Sheffield Childrens Hospital

(SCH) chronic pain clinic from April 2009 - April 2012 was collected
retrospectively from new patient letters at first appointment.
Paperless records were not obtainable due to accessibility. Therefore,
of 182 patients, data was collected from 140 patients. 1 patient had
incomplete records and was excluded.
We examined 4 different aspects of our pain clinic activity:
The prescribing practice of general practitioners in

scotland when managing patients with chronic non
malignant pain and the factors that influence that
practice
1. Referral patterns - trend in number of referrals over 3 years, the

referring specialty and their location
2. Patient demographics - age, gender
3. Pain symptoms and diagnosis - site of pain, pain intensity (11 point
VAS scale), pain mechanism, effects on physical activity, sleep,
mood, school absenteeism and social interactions
4. Management - alteration in analgesia, interventions, pain management programme (PMP)
Information was gathered manually and inputted into a database
(Numbers, Apple Inc) and analysed using database functions.
Results
Referrals increased over 3 successive years (49, 52, 81).
Of 139 referrals, 109 came from SCH, mostly from orthopaedics
(45%), 20 from other hospitals and 10 from General Practitioners.
Females presented more commonly (71%).
We saw children between 6-17 years old with 12-14 years (29%) and
14-16 years (33%) most prevalent.
Lower limb (22%), back (17%) and combined lower limb and back
pain (12%) were the commonest pain sites, with overall mean pain
intensity 8.48.
Pure somatic (48%) and neuropathic pain (36%) had the highest
incidence by mechanism.
73% reported pain limited physical activity. Self reported disturbances in sleep (53%), mood; anxiety, feeling low, anger, stress or
behavioural change (45%) and social interactions with friends or being bullied (50%) were documented.
School absenteeism >20% affected 56 (40%), 12 required home
schooling, 8 were not in education.
Prescriptions were given for simple analgesics (19), moderate (34)
and strong opioids (3), adjuvant analgesics (41) and lignocaine
patches (16). 10 interventional procedures were planned.
All but 2 were referred to PMP.
Category: Primary care

John Macleod, Catherine Plant
NHS Highland, Inverness, UK
Background
The perception of staff within NHS Highland Pain Management
Service was that a large percentage of new patients referred to the
service were already being prescribed strong opioids and adjuvants
prior to their referral to the Pain Management Service.
The purpose of this audit was to firstly identify whether our perceptions were accurate and to see if this differed from other parts of
Scotland and secondly to try and clarify why these differences existed identifying where further training might be required.
Methods
Data was collected from 200 patients across 3 differing services
between March and July 2012, a well established MDT clinic in
Lothian, a newly established clinic in the Highlands and a unidisciplinary clinic in Dumfries. The General Practitioners of those
patients involved were contacted requesting them to fill in an anonymous questionnaire via survey monkey.
This looked at 4 areas
External influences on prescribing such as requests from other Doctors,
Personal Influences such as following guidelines and access to
psychology
The prescribing of specific medication, opioids adjuvants etc
Other influences such as cost, drug seeking behaviour or
addiction
A 39% response rate was obtained from both the Highlands and
Dumfries but only one response was returned from Lothian therefore Lothian has not been included in the second set of results.
Results
Conclusion
Although the case load in each area did differ this was not reflected
in patients prescribed analgesia on referral which varied from none
to multiple medications.
Females and children between 12-16 years old are most likely to
present at our pain clinic.
Most referrals are made by SCH orthopaedic surgeons which
probably explains the higher incidence of back or lower limb
pain, compared with headache and abdominal pain in previous
studies.
The percentage of patients utilising strong opioids and NSAIDs

differed between different areas.
Not all patients with a neuropathic element to their pain were
prescribed adjuvant medication
43-50% failed to take their medication as prescribed but few admitted overmedicating.
65
Abstracts
The factors influencing prescribing though were similar across
areas
Most common being Consultant requests, continuation of prescriptions, patient pressure and cost.
High adherence was demonstrated to Trust Formularies and
Government Guidelines but prescribing was frequently utilised
due to lack of access to psychology
Confidence to utilise different analgesic groups varied. Especially
around combining medications, escalation of doses, prescribing
for those with co morbidities and unlicensed drugs
Conclusion
Differences were found across the areas in the analgesic
medication prescribed to patients by their GPs for chronic nonmalignant pain. A limitation of the audit was that medications
which had been utilised and discontinued for any reason had not
been recorded.
Education would be beneficial in both the Highlands and Dumfries
and Galloway on;
The use of adjuvant medication, l particularly their therapeutic
properties and dosing regimes
Unlicensed medications
Utilising analgesics with the patient with co morbidities
Taking patients off unhelpful medications

Discussions will be had as to how best this training can be supplied.
116
Sheffield health trainers community chronic pain
service pilot
Tim Williams1, Janet Harris2, Oliver Hart3, Chris Nield4, Gareth Johnstone5, Aziz Muthana5, Chris Hanson6
1Sothall Medical Centre, Sheffield, UK, 2School of Health and Related
Research (Sheffield University), Sheffield, UK, 3Sloan Medical Centre,
Sheffield, UK, 4Department Public Health, NHS Sheffield, Sheffield, UK,
5NHS Sheffield, Sheffield, UK, 6Shipshape, Sheffield, UK
Background
A recent health needs assessment demonstrated that Sheffield
health services are dealing with a high burden of chronic pain
with secondary care able to see just 7% of even the most severely
effected(1). Health Trainers, used to support behaviour change in
other long term conditions, have been incorporated as part of an
MDT, in a tier 2 chronic pain service in Kirklees. In 2011 a team,
including PCT commissioners, GPSIs, Health Trainers, Community
Nurses and a University Researcher, from Sheffield won a regional
50,000 award to pilot a Tier 1 community-based service. This
used Health Trainers, to support patients with chronic pain to selfmanage their condition, alongside their normal GP care. The aim of
the evaluation was to assess the feasibility and effectiveness of the
pilot service and to establish whether this approach would alter the
treatment pathway for a subset of patients with chronic pain pre- or
post-Pain Clinic attendance.
Methods
Training in chronic pain was delivered, to Health Trainers and
primary and secondary care pain teams over two days, by Francis Cole (GPSI, Kirklees) and Pete Moore (author of the Pain
Toolkit).It was assessed using before-after questionnaires for
satisfaction, surveys for self-rating knowledge and confidence, and

a knowledge test. 7 GP practices were recruited including 4 with
a GP with an interest in chronic pain and 3 practices with previous experience of the generic Health Trainer service. They were
presented with an overview of the referral process into the service
and also sent a monthly newsletter on how the 9 month pilot was
progressing. Implementation of the pilot was evaluated via interviews with Health Trainers and referral statistics. Patients ability
to self-manage chronic pain was evaluated quantitatively using the
Department of Health national Data Collection and Reporting
System (DCRS) for Health Trainers, and qualitatively through patient interviews.
Results
All health providers consistently rated themselves higher in terms of
knowledge, ability and understanding of chronic pain following their
training. Knowledge tests confirmed a consistent increase in knowledge of how to work with patients with chronic pain.
143 referrals were received, exceeding the projected number of
referrals by 50%. 45% of patients would have been referred to
a secondary care pain service if the community service had not
been available.
Patients reported increases in Self-efficacy (8%), General Health
(35%) and Wellbeing (53%) measures. Generic life goals fully or
partly achieved by 75% of participants provided the foundation for
achieving health outcomes such as increased physical activity. These
goals included, more accurate or less use of medication, greater
participation in family life and social activities, ability to negotiate
changes in work environment with their employers, and motivation
to collect information on alternative employment and training programmes.
Conclusion
This pilot demonstrates that such a community pain service can be
successfully implemented, allowing potentially more appropriate use
of NHS resources. Both quantitative and qualitative assessments
showed that Health Trainer support was instrumental in helping
patients to develop capability and motivation to self-manage pain.
This is consistent with the capability-opportunity-motivation model
proposed by Michie et al, 2011 (2). It was clear that, although patients found services offered by GPs and secondary care pain services useful, the Health Trainer programme is clearly filling a need
for help in terms of overall condition management in the context of
everyday life.
117
Psychological stress and widespread pain: the moderating effects of childhood abuse.
April Woodward1, Paul Campbell1, Francis Creed2, Barbara Tomenson2,
John McBeth1
1Keele University, Stoke on trent, UK, 2Manchester University, Manchester, UK
Background
The aetiology of widespread pain (WP) is complex. Psychological
stress, including anxiety, depression, somatisation and recent life
threatening events, predict symptom onset. Childhood abuse may
act to confer a susceptibility to developing WP on exposure to psychological stress in adulthood. The aim of the study was to test the
hypothesis that the relationship between psychological stress and
WP was moderated by childhood abuse.
66
Methods
In a population-based cross-sectional study, 2,490 adults aged 25-65
years were mailed a questionnaire that collected data on the number
of pain sites (range 0 - 29) and psychological stress (anxiety, depression, somatic symptoms, recent threatening events). A childhood
abuse questionnaire assessed physical (often hit, kicked or beaten
or any threat to life), emotional (often insulted, humiliated or made
to feel guilty), and sexual (touched or made to touch someone; attempted or completed intercourse) abuse before the participant was
17 years old. Structural equation modelling tested the association
between psychological stress and the number of pain sites, adjusted
for age and sex. Multiple-group analysis tested the moderating effects of childhood physical, emotional and sexual abuse individually
and combined, as childhood abuse. Results are presented as standardised regression weights () with 95% confidence intervals (CI)
and variance explained (R2). Model fit was assessed by root mean
square error of approximation (RMSEA).
Results
1430 (57%) individuals returned a questionnaire with complete
pain, stress and abuse data. Childhood abuse was reported by 255
(18%) participants; 57 (4%) reported physical abuse, 200 (14%)
sexual abuse and 70 (5%) emotional abuse. Overall, the hypothesised model adequately fit the data (RMSEA = 0.04). Higher levels
of psychological stress were associated with a higher number of pain
sites ( = 0.51, 95% CI 0.43, 0.58), explaining 26% of the variance in the number of pain sites reported. Multiple-group analysis
showed that reporting childhood abuse increased the strength of this
association ( = 0.58, 95% CI 0.41, 0.73, R2 35%) compared to
reporting no abuse ( = 0.47, 95% CI 0.38, 0.55; R2 23%). This
moderation effect was strongest for those reporting physical abuse
(physical abuse = 0.62, 95% CI 0.25, 0.86, R2 40%; no physical
abuse = 0.47, 95% CI 0.38, 0.55; R2 24%).
Conclusion
The association between psychological stress and number of pain
sites was stronger in those individuals reporting childhood abuse.
The amount of the variance explained in number of painful sites
increased by 12% for those reporting child abuse in general, and by
16% for those experiencing physical abuse specifically. These data
add further weight to the hypothesis that events in early childhood
confer a susceptibility to developing WP later in life.
118
Attentional bias to generalised threat in fibromyalgia: a visual probe study. Preliminary results for
discussion
Category: Psychology
Marianne Roberts2, Gary Lee1,2, Lucy Cowans1, Isobel Rice1, Matt
Garner2
1Chronic
Pain Team Isle of Wight NHS Trust, Isle of Wight, UK, 2University of Southampton, Southampton, UK

is conceptualised as the conscious output of the unconscious perception of somatic threat, then both this and environmental threat
may share a common adaptive neural architecture. Consequently,
central changes from exposure to sustained threat may prime pain
perception in response to decreasing levels of somatic (nociceptive)
stimulation .
From this model, we would predict a generalized elevation of threat
perception in FMS. This preliminary study presents data suggesting
that fibromyalgia could associated with a generalised threat processing bias, notably selective attention to threat.
Methods
17 FMS patients and 17 healthy controls completed a modified visual probe paradigm that measured selective attention to general
threat words. In this task participants viewed pairs of words (threat
and neutral words matched for length) that were presented for
500msec. Participants were instructed to classify a visual target (left
vs. right arrow) that immediately appeared either behind the threat
word or neutral word (with equal probability). Speeded reaction
times to classify targets that are presented in the location of threat
(relative to neutral) words is commensurate with selective attention
(vigilance) to threat.
Results
Mixed design analysis of variance (ANOVA) revealed a nearsignificant interaction between group (FMS vs. control), threat
word location, and target location (threat or neutral location),
F(1,32) = 3.06, p = .09. This interaction was characterized by selective attention to generalized threat in the FMS group (mean
= 15.2msec) but no bias in control group (mean = -2.6 msec).
Correlations confirmed that increased MPQ total pain score was
associated with greater attentional bias to threat. Consistent with
previous studies, vigilance to threat was associated with state anxiety and trait anxiety.
Partial correlations indicated that severity of pain and anxiety were
both associated with attention to threat, but not independent of oneanother.
Conclusion
Although the study was limited by low power, these findings offer
preliminary evidence of broader sensitivity to generalized threat in
fibromyalgia. Our data further suggest that elevated threat (AB) may
represent a unifying mechanism that covaries with pain severity, and
anxiety, and imply a complex relationship between anxiety, pain, and
threat processing that warrants further investigation.
119
The use of eye-tracking to assess attentional bias and
attentional control in chronic pain
Daniel Schoth, Hayward Godwin, Christina Liossi, Simon Liversedge
University of Southampton, Southampton, Hampshire, UK
Background
Background
Threat processing accounts of pain are significant when considering
conditions like fibromyalgia(FMS), and there is general agreement
that underpinning FMS are adaptive changes to the central nervous
system including central structures associated with general threat
processing.
We posit that exposure to sustained periods of environmental threat
(common to FMS) lead to augmented threat processing. If pain
Research using the visual-probe paradigm has shown patients with

chronic pain to demonstrate attentional biases for pain-related information compared to healthy individuals. Two important questions
remain to be addressed. First, the time-course of attentional bias has
not been sufficiently explored. The visual-probe task only captures
a snapshot of attention, and it is unknown how quickly biases arise.
Second, attentional bias may be moderated by attentional control.
Patients with poor attentional control may have difficulties inhibiting
67
Abstracts
attention from shifting automatically towards pain-related information. Eye-tracking is ideally suited to explore these questions, providing moment-to-moment information on attentional processes. This
technology was therefore used in the current investigations, with
different samples of chronic-pain participants completing a visualprobe task and an anti-saccade task to explore attentional bias timecourse and attentional control respectively.
Methods
Experiment 1: 44 participants (22 chronic headache, 22 healthy)
completed a pictorial version of the visual-probe task, which presented headache-related/neutral and pain-related/neutral images
simultaneously in different locations. After 500 or 1250ms, one of
these images was replaced with a dot, the location of which participants had to indicate as quickly as possible. Response times and
eye-movements provide an indication of whether participants bias
towards or away from pain-related information.
Experiment 2: 47 participants (23 chronic headache, 24 healthy)
completed an anti-saccade task. In this task, participants fixate their
gaze upon a central cross, which is then replaced by a peripheral cue
(i.e. dot, painful, angry, or neutral face) to either the left or right.
Participants must avoid looking at this, instead shifting their gaze
to the cues mirror location. Attentional control is needed to inhibit
fixations to cues, which is more difficult for information relevant to
the individuals emotional concerns.
Results
Experiment 1: chronic headache participants made significantly
fewer fixations during headache trials than pain-related trials, which
were of significantly longer duration. No significant between-group
differences were found for initial saccade onset latency (i.e. the time
taken to initiate the first eye-movement), or initial fixation direction (i.e. the first image fixated). For manual response times, the
healthy control group responded significantly faster to probes during
1250ms trials than the chronic headache group.
Experiment 2: The chronic headache group, compared to the healthy
control group, took significantly longer to i) initiate their first eyemovement, and ii) fixate their gaze in the correct location during anti-saccade trials. No evidence was found to suggest the chronic pain
group had specific difficulties inhibiting automatic eye-movements
towards painful faces.
Conclusion
The visual-probe task showed disorder-specific information influences attention differently than general pain-related information.
This confirms the results of former investigations which highlight
the attention-capturing quality of information specifically relevant
to the participant. The results of the anti-saccade task also support
those of former research, showing poorer levels of attentional control in individuals with chronic pain compared to healthy controls.
As eye-movement latencies were slower for the chronic headache
group, this may reflect greater effort needed to suppress the automatic tendency to shift attention towards stimuli presented in the
peripheral field.
Background
Reducing patients opiate medication use and/or dose is of interest given the significant problems associated with long term opiate use. The main objective of this prospective observational study
was to examine whether attending an inpatient multidisciplinary
pain management programme (INPUT-PMP) led to a reduction
in patients daily dose of opiate pain medication. This had been
noted as a secondary finding on a previous audit several years ago.
This previous audit had found that the mean morphine equivalent
dose reduced from 88.78mg/day pre-programme to 59.14mg/day
post-programme.
Methods
The study was done at the INPUT-PMP at St Thomas Hospital,
London. INPUT_PMP is a residential course that the patients attend for 4 days a week over 4 consecutive weeks. This provides over
128 hours of therapy. INPUT-PMP is multidisciplinary cognitive behavioural therapy programme for chronic pain patients delivered by
clinical psychologists, pain doctors, specialist nurses, occupational
therapists and physiotherapists.
A prospective analysis was performed of all patients attending
(INPUT-PMP) between January 2011 and January2012. A record
was kept of the drugs (type and daily dose) that the patients were
taking prior to starting INPUT-PMP. This data was also recorded at
the end of the programme and at the follow up sessions. 125 patients
completed the INPUT-PMP during the study period. All of these
were included in the study.
The data were analysed using mean and 95% confidence interval
calculations.
Results
125 patients took opiate medication prior to attending INPUT-PMP
at a morphine equivalent mean dose of 40.89mg/day (95%CI =
20.77 - 61.00mg)
At the end of the 4 week programme the mean morphine equivalent dose was 28mg/day and at 1 year follow up it was 25.41mg/day
(95%CI = 12.59 - 38.24mg)
Reductions were also observed in daily dose of non-steroidal anti-inflammatory drugs, total number of drugs and number of classes of drugs.
Conclusion
A 4 week inpatient multidisciplinary pain management programme
(PMP) incorporating pain management principles within a cognitive behavioural framework can lead to a reduction in opiate pain
medication use.
This reduction was sustained at 1 year follow up.
121
Maximising self-care through familiarity: the role of
practice effects in enhancing active and passive pain
management
Katherine Finlay, Joanna Rogers
120
University of Buckingham, Buckingham, UK
Opiate medication reduction following pain management programme
Background
Catherine Stack, David Pang, Estelle Barker, Sandesha Kothari,
Arni Woolfenden
St Thomas Hospital, London, UK
Distraction and relaxation are regularly recommended as part of

multimodal Pain Management Programmes (BPS, 2009). However
minimal research has assessed the role of practice effects or familiarity
with such cognitive pain management strategies when used consistently
over time. It is possible that their efficacy declines with repeated use,
68
and that their recommendation for self-care is time-limited and low
in clinical relevance. The perceived benefits may also be related to
the level of active engagement required of the user by the distractor,
in accordance with Multiple Resource Theory (Wickens, 2002). Active distraction approaches must be compared with passive strategies,
practiced consistently in a familial setting, in order to justify their continued inclusion in multidisciplinary Pain Management Programmes.
Methods
Passive distraction (participant-selected preferred music) and active
distraction (standardised, guided Progressive Muscle Relaxation;
PMR) were compared against a no distraction control on the coldpressor test (CPT) using a JeioTech circulating water bath at 0. In a
repeated measures, between-subjects design, seventy healthy participants were recruited from a community-based sample (31 males, 39
males; mean age = 37.5 years). Participants completed the CPT four
times, at baseline and with distraction or no distraction at week 1 and
again at week 2. Participants dominant arms were used for testing
and hand temperature was returned to baseline temperature between
trials. Participants in the music and PMR conditions practised their
distraction strategies daily between trials (7 days), with control participants keeping an activity log. Primary outcome measures were pain
tolerance and intensity. Secondary outcome measures included statetrait anxiety (STAI), pain threshold, heart rate, sensory/affective pain
(SF-MPQ), general self-efficacy and perceived efficacy of distraction.
Results
Manipulation checks demonstrated that mean familiarity with and
preference for distractors increased significantly from week 1 to week
2 (p<.001), demonstrating practice did enhance familiarity and preference in experimental participants. Repeated measures ANOVAs
showed that pain tolerance increased across Weeks of Testing, with
Tolerance during PMR/Music trials significantly enhanced over control (p<.01), therefore pain tolerance was enhanced with greater familiarity with distraction. Practice with PMR significantly increased
pain threshold at week 2 over music or control (p<.01), with PMR
delaying onset of pain. Pain intensity also showed reductions with
distractor familiarity, but only for the music group (p<.05). PMR
significantly reduced anxiety over music or control, but familiarity
provided no additional enhancement. Self-efficacy was significantly elevated after practice in both PMR (p<.05) and music groups
(p<.001). Finally, PMR reduced Heart Rate to a greater extent at
week 2 than music, demonstrating that physiological control is facilitated through PMR repetition.
Conclusion
These findings emphasise the role of practice in maximising the impact of cognitive distraction strategies, justifying their continued
recommendation on Pain Management Programmes for patient
self-care at home. Repeated exposure to distraction approaches enhanced optimal arousal and complexity, maximising pain management (Berlyne, 1971). Active and passive distractors were beneficial;
active distraction through PMR enhanced coping through improved
tolerance, threshold and anxiety management, but passive distraction
through music reduced pain intensity and improved self-efficacy to a
greater extent. It is suggested that both PMR, and music, are used together as part of a multidimensional toolkit for use in pain management.
122
Pain communication through body posture: the creation and validation of a new stimulus set of affective
body posture images including pain.

Joseph Walsh, Edmund Keogh, Christopher Eccleston
Background
Pain does not occur in isolation, but is influenced by social interactions and contextual cues. Being able to effectively communicate
pain facilitates helping behaviour from others. Emotions are communicated through the use of nonverbal behaviours, including facial
expression, vocalisation, and body posture. Pain has also been shown
to be communicated through these channels. However, whilst cues
associated with facial expressions (Simon et al, 2009, Craig, 1992)
and vocalisations (Belin et al, 2007) of pain have been identified, less
is known about specific body postures. This is surprising considering the importance given to postural-based pain behaviours such as
guarding. The present study therefore aimed to start a programme of
research that looks at pain postures. The first goal was to create and
validate a new stimulus set of affective body postures which included
pain, in order to investigate pain body postures and facilitate further
research in this area.
Methods
Part 1: 21 actors (11 male) were filmed performing a series of affective
body postures. Each actor produced 8 affective postures (happiness,
sadness, fear, anger, disgust, surprise, pain and no emotion), resulting
in 374 stimuli. Each of these was edited to 2 seconds in length (50
frames at 25 frames per second), sound removed, and faces blurred to
control for any communicative effect of facial expression.
Part 2: The stimuli were presented to 20 adults (10 male). They identified the emotion presented in each clip, and rated its valence and
arousal. A final stimulus set of 128 stimuli was selected based on recognition rates. This set was made up the 16 actors with the highest
overall recognition rates (8 male), all performing each emotion once.
These stimuli were then coded using the Body Action Posture Coding System (BAPS) to provide and objective description of postures
which communicate each emotion.
Results
ANOVA was used to examine whether emotion, participant sex and
actor sex had a significant influence on recognition accuracy, valence
and arousal. No significant effect, or interaction, involving either sex
variable was found. However, a significant main effect of emotion
was found (F(7,2612)= 479.81, p<0.001). Emotion recognition was
generally good, apart from disgust and surprise. Pain had a high
recognition accuracy rate (93.7%). Post-hoc Tukey tests showed that
pain accuracy was significantly higher than fear, surprise and disgust.
Pain was rated the most unpleasant emotion, and was rated significantly more unpleasant than any other emotion. Arousal ratings for
pain were significantly higher than for sadness or happiness, with no
significant difference with the other emotions.
BAPS results showed that specific actions were consistently present
throughout stimuli recognised as communicating pain. High muscle
tension, rigid movements, angular postures, and hand interaction
with specific pain/injury sites were all demonstrated.
Conclusion
We have created a new stimulus set of affective body posture that
seem to convey pain and other core emotions. Our results suggest
experimental stimuli can be developed that communicate pain
through body posture images. These stimuli reflect specific actions
and postural cues that observers perceived as reflecting pain, and
which seem to be differentiated from other emotions. This suggests
that pain might be communicated, much like other affective states,
through the body. We hope that this new stimulus set will facilitate
69
Abstracts
further research into both pain communication through body postures, and more generally into emotion communication.
department. We are also considering sending a copy of the GP letter

to the patients so that they can follow up on their management.
123
124
Impact of psychology assessment in our mdt clinics...

Are our patients getting benefits from our psychology
service provided?
Not everyone is a meditator: subgroups of patients

with severe chronic pain defined by mindfulness and
acceptance variables
Alifia Tameem1, Kumar Vasappa1, Karen Lemarchand2, Vish Siddalingaiah1
Jeremy Gauntlett-Gilbert1,2
1Russell
hall
hospital, dudley, UK, 2Cross
Street Health, dudley, UK
Background
Treatment of chronic pain should be multimodal and multidisciplinary (MDT)as it maximises pain reduction and reduces the negative impact of pain on work productivity. Psychological interventions teach patients pain coping strategies which help them reduce
their disability and emotional distress. All new patients at our hospital attend the MDT clinic where they are assessed by a psychologist, a physiotherapist and a doctor specialised in pain management.
Patients who are deemed to benefit from further psychology input
i.e. IAPT, counselling, 1 to 1 psychology are highlighted to the GP
services for a further referral to psychology department.With this
in mind, we carried out a retrospective survey of our MDT clinics
with an aim to find out the number of patients who were referred to
the GP services for further psychology input and how many of them
were eventually referred to the psychology dept for assessment/
management.
Methods
This was a retrospective data collection at our hospital for a period of 7
months from January 2012 to end July 2012. All the new MDT patient
clinic lists are available on the hospital intranet system. The patient letters typed by the secretaries are on the hospital hard drive with special
access to the pain management team. After we had a list of the patients
who attended the MDT clinics, we went through their letters to their
GP to decipher if the GP had been requested to either monitor the patients mood or refer for further psychological input.Subsequently, we
visited our local health centre - Cross Street Health centre and found
out the total number of patients where the psychology referral was
made by the GP and whether the patients attended the service or not
1Bath Centre for Pain Services, Bath, UK, 2Dept of Psychology, University
of Bath, Bath, UK
Background
Acceptance and mindfulness are strongly associated with distress and
functioning in patients with severe chronic pain. Improvements in
treatment seem to be associated with patients ability to accept pain
better, and to stay in the present moment without judgement. However, it is clear that patients arrive in treatment with different pre-existing
capacities for these behavioural qualities. We investigated possible subgroups of patients on acceptance and mindfulness variables.
Methods
We examined a consecutive sample of 169 patients attending for
residential or inpatient pain management treatment. Patients completed a range of self-report questionnaires at the pre-treatment
time point. We carried out a hierarchical cluster analysis, using the
following variables: (1) acceptance of pain, (2) general acceptance
of emotion and (3) mindfulness. We then examined the resultant
clusters, characterising them and examining their relationship to
patient functioning and distress.
Results
A four-cluster or six-cluster solution fitted the data. As the six-cluster
solution created some small groups (<10% of the whole data set), we
opted to use the four-cluster solution. Inspection of means and posthoc analysis led to characterisation of the four groups as follows: (1)
reference group (average acceptance and mindfulness scores), (2)
mindful but not accepting group (average self-reported mindfulness
but low pain and general acceptance), (3) highly accepting (highly
accepting and mindful), (4) pain but not emotions (average pain acceptance but low emotional acceptance). Post-hoc ANOVAs showed
that these clusters had distinct patterns of disability and distress.
Results
Out of the 601 new patients seen in our MDT clinics in a 7 month
period, 20% (120 pts) of them were highlighted to be in need of
further psychology input at the Cross street health centre. Of these,
31 patients who found to have a low mood needing monitoring by
the GP. 5 patients from them were referred to the health centre and
they all attended the services. 54/120 patients (45%) needed IAPT
services of which only 20 pts were referred to the health centre by the
GP and a further 6 pts had direct referral via the Pain management
consultant with an 84% attendance rate. 35/120 patients were in
need of counselling but only 6 patients had been offered the services.
Conclusion
Despite being aware of the benefits psychology can provide for our
chronic pain patients, retrospective data analysis highlights potential
pitfalls in the referral service.Following on from this survey,the information gathered is going to be highlighted to the GP surgeries which
are local to us and after consultation with them, we hope to establish a
direct referral system to the psychology dept from the pain management
Conclusion
It is possible to classify untreated patients with pain according to
their propensity to be mindful, and to accept pain and emotions. The
subgroups identified in this study clearly differed in their levels of
functioning and distress. In particular, the two subgroups with low
emotional acceptance - even where they report better mindfulness,
or pain acceptance - were distressed and struggled with psychosocial
functioning.
125
Locus of control- an association with catastrophising
in chronic pain?
Gauri Dashputre1, David Johnston0 ,2, John OHanlon0 ,3
1Speciality Trainee
Belfast City Hospital, Belfast , Northern Ireland, UK,

Ulster Hospital, Belfast, Northern Ireland, UK, 3Consultant Mater Infirmorum hospital, Belfast, Northern Ireland, UK
2Speciality Trainee
70
Background
Methods
Locus of control (LOC) refers to how people believe their own actions impact personal event occurrences. It has been shown to predict pain intensity. Furthermore , chronic pain in patients with an
external LOC is more likely to have negative consequences on their
quality of life. The pain catastrophising scale (PCS) is used to predict
subjective pain severity, physical and psychological disability. It also
projects the course of outcome in chronic pain.
New and follow up patients attending the pain clinic were asked to
complete The PHQ-9 form whilst waiting to be seen and then hand
the completed form to their pain doctor in the clinic. The Doctor
would then score the form to determine if the patient appeared depressed or not and the severity. The doctor recorded the pain diagnosis, whether or not the patient was on antidepressants (with details if
so), and if the GP had been informed of the score.
Aim:
e wanted to determine if there was a trend between a more external
W
LOC and a Higher PCS score in patients attending chronic pain clinic. The secondary objective was to assess patients employment status
and learn if there was a correlation with having an external LOC.
Methods
Patients waiting to attend the chronic pain clinic were asked to complete a multidimensional health control of locus questionnaire . This
produced overall scores for internal and external LOC (range 6-36).
Sources of external LOC (chance, powerful others and doctors)
were scored as well. A further questionnaire rating PCS (0-52) was
also completed. Patients undergoing intervention were excluded.
Results
Thirty patients completed both questionnaire (10 male, 20 female).
Results showed when patients average PCS scores increased, there
was a decrease in the internal LOC scores . In working patients
(n=9) average external LOC score was 14, while in the unemployed
group (n=21) the average external LOC was 23.
Conclusion
Patients with a greater PCS scores appear more likely to have a high
external LOC. This has a negatively prognostic influence for these
patients coping strategies , which in turn will affect morbidity of
chronic pain and impact on quality of life . Combining these scoring
systems could be used to help target rehabilitation strategies for each
individual according to their LOC.
126
The patient health questionnaire 9 (phq9) to assess
levels of depression in the pain clinic patient.
Ben Eden-Green, Sarah Muldoon, Carolyne Timberlake
Results
Over a 2 month period, 109 patients completed the PHQ-9 form and
these were collated and analysed. The age ranged from 19 - 91 years,
mean of 54, (median 52y), 57 were new referrals. The majority were
female (65%). Out of a total score of 27, 34 patients (30%) scored
4 or less indicating none or minimal depression. 24 patients (22%)
scored between 5 - 9 indicating mild depression. 16 patients (15%)
indicated moderate depression (score 10 - 14). 20 patients (18%)
scored at a level to indicate moderately severe depression. 15 patients
(14%) gave a score between 20-27 indicating severe depression.
Of the 35 patients with significant depression (score > 15), 25 were
female, with a mean age of 51y (range 23-91). 15 were new patient
referrals. Only 16 patients were currently on treatment for depression. In all these patients the GP was informed of the PHQ-9 score.
Conclusion
32% of the patients attending the pain clinic in this 2 month period
had evidence of major depression. Less than half the patients were
receiving any form of treatment for this. Informing the GP, having
assessed the patient with a tool that they already use, will hopefully
allow them to start treatment and assess the success by repeating the
PHQ-9 form. It is also a very helpful tool in the pain clinic to allow
you to approach the subject of the patients mood and explain to
them how depression impacts on pain and encourage them to seek
treatment.
127
An assessment of the impact of psychological variables on outcome following total knee replacement,
a single centre study
Mark Alexander-Williams1,2, Charlotte Smith2, John Lambie2
1Mid Essex Hospital NHS Trust, Chelmsford, UK, 2Anglia Ruskin University, Cambridge, UK
Princess Royal University Hospital, Farnborough, Kent, UK
Background
Background
The main purpose of a total knee arthroplasty (TKA) is to reduce

knee pain and improve mobility. In 20% of patients however knee
replacement surgery is ineffective in significantly alleviating these
symptoms1. There appears to be no common organic reason underlying poor recovery in this subset of patients. Researchers have
hypothesised that patients therefore may have maladaptive cognitive tendencies prior to the operation that leave them markedly vulnerable to this surgery2. The two main psychological factors that
have been specifically implicated are pain catastrophisation 3-7 and
kinesiophobia 3. Whilst the role of pain catastrophisation in poor
outcome following TKA is firmly established, the research on kinesiophobia is more conflicting 5. Sullivan in 20118 found that
within a multivariate regression analysis of TKA outcome, whilst
pain catastrophisation was a significant predictor, kinesiophobia
was not. Also worth noting is that this body of literature has been
mainly conducted on US or Canadian samples.
General practitioners are encouraged to look for evidence of depression in their patients with chronic disease. In those with a new diagnosis of depression an assessment of severity should be made and
repeated at 5 -12 weeks. The PHQ-9 is one of the validated instruments that GPs commonly use to assess their patients clinical state.
Depression is common in patients with chronic pain. Whether the
depression follows the establishment of chronic pain or the chronic
pain is a manifestation of a form of depression is a question that has
vexed physicians. Whichever is the case, attempting to treat the pain
without considering and managing the depression is unlikely to be
successful.A formal assessment of depression is important in all patients attending the pain clinic. Using an assessment tool which the
GPs are currently using in their practice seems sensible as we rely on
the GP to initiate treatment.
71
Abstracts
Methods
This study reports on longitudinal findings from a cohort of 75 patients.
Patients attending pre-assessment prior to their knee replacement were
recruited to the study. If subjects chose to consent they were given an
envelope and asked to complete the pack before their operation and
return it. The pack included four psychological standardized questionnaires: the hospital and anxiety depression scale (HADS)9, the pain
catastrophisation scale10, the multidimensional health locus of control
scale (MHLC)11 and the tampa scale of kinesiophobia (TSK)12.
Six months after the date of their recruitment, subjects were posted
a second questionnaire pack. This pack included the following outcome measures; the HADS, an assessment of satisfaction of post
operative functioning (satisfaction survey)13 and a measure of perceived physical health (the SF-12)14. Subjects were asked to complete this following their operation.
Results
Pain catastrophisation correlated with post surgical patient satisfaction, r(47) = -.297, p<0.05. Anxiety correlated with satisfaction
levelr(47) = -.28, p<0.05.
An assessment of the SF-12 revealed a significant correlation with
internal locus of control r(48) = .28, p<0.05, depression r(48) =
-.25, p<0.05 and kinesiophobiar(48) = .348, p<0.05.
Multiple regression was carried out using 7 predictor variables- pain
catastrophization, anxiety, chance locus of control, internal locus of
control, depression, kinesiophobia and powerful other situated locus
of control. The initial model accounted for 33% of the variance, and
there were two significant predictors, kinesiophobia and internal locus of control. This model was significant, F(7, 42) = 2.99, p<0.05.
A model that emerged from these findings was analysed; it involved
kinesiophobia, internal locus of control and powerful other locus of control
(two MHLC subscales). This model accounted for 27% of the variance,
F (3, 51) = 6.405, p<0.01)
Conclusion
This study found that high levels of kinesiophobia, internal locus
of control, and powerful other situated locus of control predicted a poorer post-operative outcome (as measured by the SF-12)
6 months post surgery. Our patient group had a high initial TSK
score compared with previous studies, which could partially explain this difference. Pain catastrophisation interestingly appeared
to have a unique role in predicting lower satisfaction, along with
anxiety. These findings will inform a future screening tool to identify vulnerable patients in a UK TKA pre-assessment setting, and
in terms of tailoring an effective psychological intervention for this
subgroup.
128
Influence of very early change in catastrophisation
after an initial visit with a physical therapist for lbp
on self reported outcome at three months.
Jonathan Field2 ,3, David Newell3
1Back2Health - private practice, Petersfield, Hampshire, UK, 2University of Portsmouth, Portsmouth, Hampshire, UK, 3AECC, Bournemouth,
Hampshire, UK
Background
Psychological factors such as catastrophic thinking (CAT) measured
at presentation are found to have significant influences on future
disability, pain and self reported improvement in LBP patients
(Gauthier et al., 2006).
It has been suggested that change within a few days or weeks of starting physical therapy may be a powerful predictor of outcome after a
course of care (Axen, I. et al., 2002, Bolton, J.E. & Hurst, H., 2011).
In a preliminary study we found that psychological variables assessed
a few days after an initial visit with a physical therapist provided greater prognostic utility than when assessed at baseline (Field, J. et al.)
This study describes changes in CAT in a patient population over a
period of a few days during which they have had an initial visit with
a physical therapist. It also explores any relationship between these
changes and patients self reported outcome at three months.
Methods
Consecutive patients meeting the inclusion criteria who presented
privately to one of 33 physical therapists (chiropractors, osteopaths
and physiotherapists) using the Care Response system to collect patient reported outcomes in the UK were invited to participate via
emails sent at the time of booking their initial appointment. Inclusion
criteria were; aged 16-70, presenting with LBP and having access to
the internet and email. Patients were subsequently excluded if they
were not offered treatment or if LBP was not their primary complaint.
Assessment questionnaires including the Pain Catastrophising Scale
(PCS) were completed online, before and two days after, the initial
visit. A follow up assessment of patients global impression of change
(PGIC) was sent by email link 90 days after the initial visit.
Not responders to an emailed invitation to complete an assessment
were sent a reminder after two days and were subsequently contacted by phone.
Results
412 subjects were recruited with a mean age (SD) of 46.3 (12.6),
with 56.8% being female. Just over half (53.6%) had pain of less
than six weeks duration and 35.7% reported leg pain. Completed
assessments sent at 2 and 90 days were received from 95.4% and
78.2% of participants respectively.
PCS scores at presentation; 13.0(11.0), had reduced (p>0.01) by 2
days following the initial visit; 9.9 (10.4), with 66.9% of individuals
having some improvement.
ROC analysis utilising percentage change in PCS against dichotomised PGIC scores gave an AUC of 0.69 (CI 0.57-0.81). A PCS
change score of 40% was identified as providing an optimum balance
of sensitivity and specificity.
For the population as a whole having less than a 40% improvement
in PCS increased the odds of reporting a poor outcome by 3.85 (CI
1.83-8.10). For those with above median PCS at initial assessment
this increased to 8.17 (CI 2.34-28.45).
Conclusion
This population of LBP patients presenting privately for physical
therapy had generally low levels of CAT. Despite this, lack of improvement in PCS scores was found to significantly reduce the chance of a
good recovery. Unsurprisingly this risk was greater in those with more
negative thoughts and belief regarding their pain at presentation.
Preliminary studies suggest that very early changes in psychological
variables in populations like this are not related to early change in
pain or expectation of recovery.
Further work is indicated to explore reasons behind early change
in CAT.
129
The design and development of a new task for investigating the interruptive effect of pain: a proof of concept study using mobile technology
72
Edmund Keogh, David Moore, Geoffrey Duggan, Stephen Payne,
Lisa Austin, Efthymia Mitella, Christopher Eccleston
Background
Pain is known to have an interruptive effect on people lives. Research
shows that pain distracts and interferes with everyday actives, and
it is this interruption that can prove to be particularly problematic.
Laboratory-based research has been used to identify the specific
components of attention that are most affected by pain. However,
these studies tend to use tasks that are confined to the laboratory,
and tend not to reflect the activities that we perform day to day. We
have therefore started a programme of research that seeks to design
and develop new tasks of attentional interruption, which not only
reflect real world activities, but do so by exploiting recent developments in mobile technologies, and their ability to measure behaviour
remotely.
Methods
Ethical committee approval was gained. A rapid review of pain
and cognate literature was conducted to identify relevant everyday cognitive tasks. This was combined with knowledge from existing laboratory work on the nature of pain interruption (executive functioning, working memory, task switching), to develop a
new task. It was designing for deployment on a mobile device,
specifically an android-based tablet PC (Samsung Galaxy Tab 2
10.1). The new task also went through a usability testing phase
with 18 health adult volunteers. This was to consider ease of use,
how understandable the task instructions were, as well as design
issues. We also examined whether the task could be used under
laboratory conditions with 20 healthy adults. Half of the participants were asked to complete the task while experiencing a painful heat sensation and the other half experienced no pain heat
sensation.
Results
A new task was designed around a shopping game, where the goal
was to search the shelves of a virtual supermarket looking for items
on a shopping list. Thus the task involved remembering a shopping
list (working memory), performing a visual search for items (attention and planning) and remembering to terminate the task before
the end of a time limit (prospective memory). Attributes that were
considered important outcome variables included the ability to record the number of items correctly placed into a shopping basket, as
well as a measure of the searching behaviour employed (number of
switches between shelves). Usability testing indicated that the new
task was understood, and could be easily performed on the mobile
device. Ceiling and floor effects were minimal, and the task was successfully deployed in an experimental setting. However, no effect of
pain was found on task outcomes.
Conclusion
Whilst laboratory tasks of attention can be used to investigate
attentional interference from pain, surprisingly few studies directly reflect everyday attentional activities. This proof of concept study demonstrates that it is possible to (1) design tasks that
potentially reflect a common everyday activity (shopping), and
(2) use mobile technologies to enable remote testing. There is
still considerable work to be conducted before we can objectively
record everyday interference effects. However, we consider this
an interesting first step into a potentially fruitful avenue for future research that considers the interfering effects of pain outside
the laboratory.

130
The role of affective and attentional state in
mediating the relationship between sleep disturbance
and pain severity.
Lee Harrison, Marcus Munafo, Sue Wilson
Universtiy of Bristol, Bristol, UK
Background
Sleep disturbance is a commonly reported problem amongst two
thirds of chronic pain patients. There is a complex relationship between chronic pain and sleep; pain can disrupt sleep and, conversely,
poor sleep can increase and exaggerate pain intensity. The mechanism underlying this relationship remains unclear, but the consensus is that the relationship is bi-directional and dynamic. This cyclic
relationship not only exacerbates affective states but also induces
both somatic and non-somatic attentional problems. Both sleep disturbance and heightened pain severity are also associated with increased levels of anxiety and depression. This study aims to evaluate
the recursive relationship between these concomitant disorders and
their subsequent impact on pain levels.
Methods
A total of 242 patients were recruited from an outpatient clinic
(Frenchay Hospital, UK) and provided with a self-report questionnaire booklet. Questionnaires included were; the Brief Pain Inventory, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire and Pain Vigilance and Awareness Questionnaire. Hierarchical
linear regression analyses were used to assess the relationship between pain, sleep, mood and pain-related awareness. Instead of using
the global scores of the PSQI to assess sleep, the three component
scores (daily disturbance, efficiency and perceived quality) were used
to examine what factors of sleep contribute to alterations in mood,
pain-related awareness and pain itself. In case of clinical relevance
both demographic (age and gender) and illness duration data were
entered and controlled for in the early steps of the analyses.
Results
Participants (n = 221) were aged between 20 and 84 (mean = 51.8,
S.D = 15.2), mainly female (59%) and the majority of white ethnicity (94.1%). Regression analyses found that the model with all variables included significantly predicted the most variance in pain severity, accounting for 28% [R2= .283, F (1, 214) = 12.81, p <.001].
When looking at the contribution of the independent variables, both
mood ( = .289, t = 3.60, p <.001) and pain-related awareness ( =
.27, t = 4.00, p <.001) significantly contributed to the model. The
addition of mood to the model reduced the contribution of painrelated awareness and importantly, caused sleep disturbance to no
longer be a significant predictor ( = .068, t = .890, p =.374). The
influence of sleep appears to be mediated by both mood and painrelated awareness. Structural equation modelling was used to further
explore this mediation.
Conclusion
Sleep disturbance was found to contribute to increased negative mood
states and to heightened pain-related awareness, but did not directly influence pain severity. Instead, the relationship between sleep disturbance
and heightened pain severity is mediated by negative mood states and
maladaptive attention processes. Results suggest these affective and attentional states may be critical in amplifying the affects of sleep deprivation in chronic pain patients and may play a central role in prolonging
and exacerbating pain states. Developing an understanding of the way
73
Abstracts
these factors influence the effects of sleep disruption could be critical in
facilitating treatment options for patients.
interference effects. Further research is required to ascertain why,

when an individual is in pain, some tasks are more susceptible to
load effects, whereas others are immune.
131
The interruptive effect of pain on divided attention: a
test of the effect of memory load
David Moore, Christopher Eccleston, Edmund Keogh
Background
Attentional interference is an important factor when considering the
negative impact of pain on peoples lives. Research in experimental
and clinical settings indicates that people are typically slower and less
accurate at performing tasks when they are in pain. We have previously shown that this interference effect tends occur on tasks that
place greater demands on cognitive processes, and that there may
be particularly so for executive function tasks (Moore et al., 2012).
More recently, we have also found that increasing the cognitive load
within a task results in greater pain-related interference on attention span and attentional switching tasks, but not divided attention
(Moore et al., in prep). This study sought to refine the divided attention task, and further examine the role of cognitive load. A new
version of a divided attention task was developed, and tested under
different cognitive load and pain conditions.
Methods
Ethical committee approval was gained. Twenty three (12 female)
healthy adult participants were recruited into the study. The divided
attention paradigm involved participants performing a single primary
task, with or without a secondary concurrent task. The primary task
required participants to attend to target numbers presented at random locations on a computer screen. The secondary task required
participants to remember either 3 letters (low load condition) or 7
letters (high load condition). There was also third (control) condition, where no secondary task was involved. Participants completed
the three versions of the task under two counterbalanced conditions:
once in pain and once without pain. The pain protocol involved an
oscillating heat sensation between 10C above and below individual
pain thresholds.
132
Investigating the interruptive effect of pain using
tasks of everyday attention
David Moore, Geoffrey B. Duggan, Stephen J. Payne, Christopher
Eccleston, Edmund Keogh
Background
Cognitive disruption and pain are central issues within aging, and a
common feature of health complaints. We have argued that it is the interruptive aspect of pain that people find particularly problematic. Using carefully controlled laboratory-based studies we are beginning to
identify the core components of pain-related attentional interference.
For example, Moore et al. (2012) have shown attentional interruption
is more likely to occur on complex cognitive tasks, especially those
that involve executive functions. Whilst such investigations reveal the
specific aspects of attention that are most affected by pain, the tasks
used tend to lack ecological (real world) validity. This work now needs
to be extended to examine attentional interference using real world,
ecologically relevant, tests of performance. The aim of this study was
to examine attentional interference using tasks of everyday attention.
Methods
Following ethical committee approval, sixty two adult participants
(22 male) were recruited from the University of Bath staff and student population. The present study used two tasks that have previously
been used to examine real world measure of everyday performance,
but which also involved executive function processes. The first was the
breakfast task designed by Craik and Bialystok (2006), which measures multitasking, planning and prospective memory. The second was
a scrabble task designed by Payne, Duggan and Neth (2007), which
is designed to measure how people choose to switch between tasks to
maximise performance. Half of the participants were asked to complete
the tasks while experiencing an experimentally-induced painful heat
sensation; the other half performed the tasks in a no pain condition.
Results
Results
To investigate the effect of pain on divided attention performance

mean accuracy and reaction times were entered into a within groups
ANOVA. Analysis indicated that the load manipulation was successful,
F(2,44)=5.34, p<.01). Follow-up analysis revealed that that participants performance was slower in the high load (mean 536) compared
to no load condition (mean 524), whereas there were no differences
between the low load (mean 528) and no load conditions. However, pain did not seem to have an overall effect on performance, F(1,
22)=3.17, p>.05. Furthermore, there was no interaction between pain
and load conditions, F(2,44)=.40, p>.05. This indicates that pain did
not affect divided attention performance under either load condition
ANOVA was conducted on the data derived from both tasks, with
pain condition serving as the between-groups factor. For the breakfast task pain significantly impaired planning ability and divided
attention to engage with both tasks. Pain did not, however, affect
prospective memory. For the scrabble task there were no differences between the pain and non-pain groups on actual performance.
However, participants in the pain condition perceived that they had
spent no more time on the easy list than on the hard one, whereas
participants in the no pain group correctly perceived that they had
spent more time on the easy list compared to the hard one.
Conclusion
Conclusion
Although increasing memory load has been found to affect the relationship between pain and attention, this effect may be limited to
certain tasks. Within the context of divided attention, these results
suggest that pain does not have a detrimental effect on performance,
and that memory load does not increase interference by pain. This
is in contrast to other executive type tasks such as switching and attention span, where increasing task load/complexity increases pain
The findings of this study provide evidence for attentional interruption by pain using two measures that are thought to have more
ecological (real world) validity. The findings suggest that pain may
prevent people from fully engaging with complex tasks. They suggest
pain might alter ones awareness of their own performance and time
allocation as well as their ability to plan effectively. This experiment
opens the way for further research which examines the real world
impact of pain on performance.
74
133
Hospitals NHS Foundation Trust, Gloucester, UK,

Teaching Hospitals NHS Foundation Trust, Bradford, UK,
3NHS Kirklees, Kirklees, UK, 4Birmingham Community NHS Trust, Birmingham, UK, 5Cardiff University, Cardiff, UK
The dark history behind the princess and the pea: pilot
study to determine importance of previous threat history in aetiology of fibromyalgia
Isobel Rice, Cara Haines, Gary Lee, Lucy Cowans
Isle of Wight Chronic Pain Service, Isle of Wight, UK
Background
Clinical experience within our pain service shows fibromyalgia is
often preceded by periods of sustained personal threat. Pain is
now understood as the conscious correlate of a threat input to
the brain. There is general agreement that underpinning FMS are
adaptive changes to the central nervous system and that central
structures associated with general threat processing are particularly affected.
We posit that exposure to sustained periods of environmental
threat (common to FMS) lead to augmented threat processing.
Methods
22 Patients and members of the local fibromyalgia support group
were asked to participate in an anonymous questionnaire survey.
Information was gathered regarding age of onset of fibromyalgia
and which broad category of threat was sustained, and the age it
occurred. Threats were categorised broadly into neglect, medical
misendeavour, verbal abuse, violence, sexual abuse, and other serious threat. Patients were to tick all boxes that applied; thus multiple
threats could be registered
Results
All patients surveyed felt they had suffered stressful life events, 95%
had occurred before diagnosis. 82% suffered direct severe personal
threat before the onset of pain.
67 threats were registered; the number of reports per patient
varied from 1 to 9. 40% of these occurred before 18 years old;
82% involved verbal abuse; 68% violence; and 55% sexual abuse.
36% of reports involved childhood sexual abuse, with 41% of patients having experience violence or sexual abuse in childhood.
These figures are significantly higher than the nationally quoted
statistics1.
Conclusion
Whilst this survey is small the results are startling and have prompted us to undertake a more extensive national survey. They underline
the importance of taking a history of previous threat when considering a diagnosis of a central hypersensitivity syndrome such as fibromyalgia. These results lend weight to the theory that exposure to
prolonged periods of personal threat can lead to augmented pain
processing.
References:
1. Radford, Lorraine, Corral, Susana, Bradley, Christine, Fisher, Helen,
Bassett, Claire, Howat, Nick and Collishaw, Stephan (2011) Child
abuse and neglect in the UK today. London: NSPCC.
1Gloucestershire
2Bradford
Background
The Pain Management Plan (PP) is a cognitive behavioural, selfmanagement support programme for people living with long-term
pain, in the form of an interactive, accessible, pictorial workbook.
This workbook is designed to be supported by a trained facilitator
who introduces the concept of pain self-management. The facilitator
acts as a guide to understanding the impact of pain on the individual and enabling them to develop a range of self management
skills needed to manage pain effectively. This abstract reports on an
evaluation of the facilitator training.
Methods
Training took the form of a one-day interactive workshop, delivered
by the clinicians who contributed to the development of the PP, and
aimed at clinical staff already experienced in the management of pain.
The workshops presented the rationale and evidence for the PP, an
introduction to the content of the workbook, usage of an introductory
Health Needs Assessment and six role-plays to practice working with
the PP. Participants were asked to self-rate their own knowledge and
skills in 15 domains covered in the training pre and post workshop.
One week after training, all participants were also invited to complete
an online survey to rate their confidence in using the programme and
to comment on the workshop design and content.
Results
Data were collected from 94 participants, attending 5 workshops
around England between December 2011 and December 2012.
Participants (N=58) from 3 of the workshops self-rated their knowledge and skills, pre and post training, on a Likert scale ranging from
1 (no confidence) to 10 (complete confidence). They reported a
mean improvement in all aspects of the training, with the greatest
improvements seen in using Health Needs Assessment tools (mean
pre-workshop score = 3.89, mean post-workshop score = 8.34), and
in understanding the 5-areas CBT model (mean pre-workshop =
5.30, mean post-workshop = 8.19).
Participants (N=68) from 4 of the workshops gave feedback online,
reporting high levels of confidence in using the programme. Feedback on the training indicated that it was valued, with participants
reporting most positively about the printed materials (71%), and
least about the time available to practise interactive skills during the
workshop (62%).
Conclusion
The results show that after attending a PP skills training workshop,
participants report a greater understanding of the skills needed to
deliver the programme and high levels of confidence in using it. The
feedback provided highlights how the training might be improved
with more time allocated to practising the interactive skills needed
by the facilitators to support the people using the PP programme.
135
134
Prevalence and relationship between self-stigmatization and self-esteem in chronic pain patients
Training health professionals to use the pain management plan cbt workbook
Dominic Hegarty1,2, Mary Wall2
Polly Ashworth1, Robb Hunt1,5, Patrick Hill4, Frances Cole2 ,3
1Cork University Hospital, Cork, Ireland, 2University College Cork, Cork,

Ireland
Abstracts
75
Background
widespread across many care environments and patient sub-groups.

As pain is a subjective experience, its assessment normally needs
to involve the person in pain. Those who care for people in pain
routinely make assessments of pain that inform its management. If
the health professional under or over estimates the patients pain,
this can lead to sub optimal care. We aimed to review the research
evidence to assess the degree of concordance between patient and
health professional assessment of pain.
Stigma and poor self-esteem (defined as the internalized cognitive,

emotional, and behavioural impact of others negative attitudes
on a person) are associated with many chronic health conditions;
however, they have not being quantified in chronic pain patients to
date. Stigmatization and poor self-esteem has indirect but strongly
negative implications for clinical efforts to combat the diseases or
conditions concerned (van Brakel, 2006). We sought to estimate the
prevalence of perceived stigmatisation and self-esteem in individual
diagnosed with chronic pain and its relationship with general health
markers.
Methods
Using a cross-sectional, anonymous and convenience sampling study
design, which was approved by the local research ethics committee,
160 adult patients (n=160, >18 years old, chronic pain > 3 months)
attending a chronic pain clinic were asked to complete a set of validated questionnaires which included; Stigmata Scale for Chronic
Illness (SSCI), Rosenbergs Self-esteem Scale (RSES); Hospital
Anxiety Depression Scale (HADS); Brief Pain Inventory short form
(BPI); and the General health survey (SF12v2). Data was recorded
using Microsoft Excel and analyzed using SPSS.
Results
Our study population (n=160) was 69.1% female (mean age 59.9 +
15.2 years), with a mean duration of pain of 7.7 + 8.8 years (range
0.5-56 years) reported a mean pain intensity score (Visual analogue
score (VAS)) of 6.1 + 1.7. 77% of patients (123/160) had a lowered
self-esteem (RSES score = 17.2 + 14.5) with a mean SSCI score
of 50.8 + 19.0 (normal range 24-120). An inverse relationship between stigmatization and self-esteem (Pearson correlation, r = .58,
p<0.001) and self-esteem and pain interference (r = .48, p<0.001)
was identified. Partial correlation analysis demonstrated a weak a
relationship between stigmatization and self-esteem (r= .174, p =
.04). A positive correlation between stigmatization and anxiety (r =
.228, p < .05) and an inverse relationship between self-esteem and
depression existed (r = .234, p <.05).
Conclusion
The prevalence of self-stigmatization and poor self-esteem identified
in this study is greater than those levels reported in mental illness
and HIV patients. It is recognised that stigma about chronic illness
may determine how and even whether people seek help, their level
of engagement with treatment and the clinical outcome (Hayward
& Bright, 1997). For these reasons identification of chronic pain patients with low self-esteem and feelings of stigmatization would allow
us specifically target and tailor management interventions in order to
improve clinical outcome.
136
Measuring pain: patient and healthcare professional
concordance, a systematic review.
Category: Reviews
Tim Seers3, RA Moore2, Sheena Derry2, Kate Seers1
1University
of Warwick, Coventry, UK, 2University of Oxford, Oxford,

UK, 3Imperial College, London, UK
Methods
We undertook an initial scoping search of the literature, and built
up our search iteratively. The search was undertaken in Medline,
EMBASE, CINAHL, Cochrane CENTRAL, Cochrane Database
of Systematic Reviews, Psychinfo, and was limited to studies reporting data since 1990 in order to make any comparisons and conclusions of contemporary value. Electronic searches were backed
up by considerable eclectic searching using review articles, reference lists, and electronic suggestive applications in PubMed and
Google Scholar as studies looking at pain assessment can be hard
to locate. Inclusion criteria: any study design that used any type of
pain measurement. The data had to measure concordance between
patients and professionals from individual paired results, average
discrepancy or any statistical measure of concordance. Pain scores
were considered concordant if patient-professional scores were
within 1cm on a 10 cm visual analogue scale or 1 point on a 0-11
numerical rating scale.
Results
We have currently identified 53 studies, with 12,151 patients. Most
studies (39/53; 74%) had small samples,between 20 and 199 patients evaluating their pain. The majority of data (54.6%) were
derived from five large studies with more than 500 patients. Pain
assessments took place in a number of different settings, including
various hospital departments (inpatients and outpatients), community, and primary care, and all used standard pain scales for
measurement.
From the studies identified so far, the proportion of pain assessments where health professionals were concordant with patients, or
over- or underestimated their pain showed a wide variation. Concordant assessments ranged from 24-67% of assessments, underestimation from 12.2-65% and overestimation ranged from 1-34%.
Conclusion
The findings so far suggest that underestimation of pain by health
care professionals remains a significant problem. Overestimation
also occurs, but is less common. The lack of concordance is not
limited to one area of practice or profession. Underestimating pain
can result in inadequate pain management, and over estimation may
put patients at increased risk from adverse events if the dosage is
increased in response to this assessment. It is important to be aware
that health professionals regularly underestimate pain, and unless
the patient is involved in the assessment, this situation is unlikely
to improve.
137
Background
A population study into the prevalence and genetic

profile of patients with chronic pain who do not
respond to oral codeine: oral transudate subset
results
Pain is highly prevalent throughout all areas of healthcare and is an

important component of patients quality of life. Current evidence suggests that underestimation of patients pain by healthcare providers is
Category: Translational Pain Research

Helen Radford1,2, Karen Simpson1,3, Suzanne Rogerson1,3, Mark
Johnson2 ,3, Pauline Fitzgerald2, Steve Martin2
76
1Pain Management Services, The Leeds Teaching Hospital NHS Trust,
Leeds, UK, 2Faculty of Health and Social Sciences, Leeds Metropolitan
University, Leeds, UK, 3Leeds Pallium Research Group, Leeds, UK
Background
Approximately 5-10% Caucasians are poor metabolisers (PM) of
codeine and other CYP2D6 substrates because of non-functioning
CYP2D6 gene alleles; 10-15% are intermediate metabolisers (IM)
who have weakened enzyme activity1. Normal extensive metabolisers
(EM) account for 70%; however 1-3% are ultra metabolisers (UM)
with multiple copies of functioning alleles. The ability to predict the
clinical efficacy of codeine and identify these genetic variations using an easy, repeatable, cost effective clinical test would be valuable.
Benefits may include better patient concordance due to improved
clinical response, increased safety and reduced costs. This development may be a step towards tailoring analgesic management to the
individual2. This study assessed the proportion of chronic pain patients who lacked an analgesic response to codeine. We conducted
salivary CYP2D6 genotyping and correlated this to measurements of
urine and oral transudate morphine metabolites to determine if this
could predict codeine non-responsiveness in a clinical setting.
Methods
Caucasian patients aged 18-80 years attending a Pain Management
clinic were recruited after informed consent (n=23). Participation
lasted 15 days. Baseline pain assessments and concomitant medications were recorded and any prohibited analgesic medications (codeine and CYP2D6 inhibitors) were ceased. Two days later saliva was
collected via the OrageneDNA Self-Collection Kit. A baseline urine
sample was also collected. Then 2 hours after oral dosing with 30mg
Codeine Phosphate a sample of oral transudate was obtained via an
Orasure Intercept device for measurement of codeine and morphine
metabolites. The patient was given a pain diary and asked to take oral
codeine 30mg QDS for 5 days. On day 4 the patients collected another urine sample and returned on day 5 to provide a further urine

sample, oral transudate sample and complete final pain assessments.
Patients were followed up a week later to assess any adverse events.
Results
Genotype frequencies (n= 23); PM (8.3%), IM (25%), EM (66.7%),
UM (0%). Baseline NRS mean pain scores: 6.1 (SD 1.5, median 6,
range 3-10). Day 4 mean scores: 5.8 (SD 1.8, median 5, range 2-9).
19 (80%) had suboptimal analgesic response to codeine (< 30% reduction in NRS).
Urine analysis conducted (n=21); 3 samples were excluded as
missing/leaked. Genotype PM urine samples (9.5%) were negative
for morphine metabolites on day 4; IM and EM samples ranged
from low to high positive for morphine metabolites (table 3). Five
samples recorded <500 ug/L morphine (23%). 80% codeine responders had high morphine metabolites. Urine morphine metabolites were grouped and scored using a novel approach similar to a
gene activity score (table 4); this showed a strong correlation (0.82)
to the actual genotype.
Oral transudate morphine metabolites did not correlate with
genotype; 1 EM genotype produced a low positive morphine metabolite result (2.8 ug/L).
Conclusion
Prevalence of PMs was as expected from the literature; 10% higher
proportion of CYP2D6 IM genotypes were observed than expected.
Genotyping is expensive and difficult to conduct in a clinical setting.
Phenotyping using urine morphine metabolites is cheaper. PM status can be predicted accurately using this method. Low morphine
metabolites ( 500 ug/L) indicate a poor analgesic response. If no
CYP2D6 inhibitors are identified in concomitant medication this
would clinically indicate the IM genotype. Oral transudate sampling
was not effective in identifying CYP2D6 phenotype following codeine
dosing. Larger study and further refinement of urine grouping methods is ongoing.

British Pain Society

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

British Pain Society

Enviado por

Direitos autorais:

Formatos disponíveis

444364

BJP0010.1177/2049463712444364AbstractsBritish Journal of Pain

Bournemouth, United Kingdom

British Pain Society Scientific/Abstract Committee were:

Volume 7 Supplement 1 April 2013

Assessment & Measurement

Experimental (Basic) Science

Interventional Pain Management

Non-Pharmacological Pain Management

BJP0010.1177/2049463713481587British Journal of PainLucas

This study shows that providing information leaflets may directly

Category: Acute Pain

British Journal of Pain 7(2) Supplement 1

Acute Pain Service, Department of Anaesthesia, St Georges Healthcare

Category: Acute Pain

Acute neuropathic pain (ANP) is defined as pain arising as a direct

Metropolitan University, Manchester, UK, 2South Devon

British Journal of Pain 7(2) Supplement 1

The long-term aim is to improve the quality of pain management for

After institutional approval between April 2012 and June 2012

27% of patients were found to be experiencing pain greater than

in the lower abdomen occurring at the onset of menstruation in the

Hospital,Torquay, UK, 2Nuffield Research Placement, Devonshire,

British Journal of Pain 7(2) Supplement 1

An Audit To Evaluate The Efficacy Of Transversus

Category: Acute Pain

United Hospital, Bath, UK, 2University of Bristol, Bristol, UK,

British Journal of Pain 7(2) Supplement 1

of Bristol, Bristol, UK, 2University of Warwick, Coventry, UK

College London, London, UK, 2Chelsea and Westminster

Children and infants experience pain1. Inadequate analgesia and the

evaluate their practice in pain assessment and its importance, to help

British Journal of Pain 7(2) Supplement 1

following strict aseptic precautions is of utmost importance. The

Area 1 Clinicians Hands: Two out of 4 samples from clinicians

Service evaluation- adequacy of aseptic techniques in

Category: Assessment & Measurement

British Journal of Pain 7(2) Supplement 1

and it can be adapted to meet the requirements of the Rasch model

Rasch analysis of the fatigue severity scale and an

Category: Assessment & Measurement

Kettering General Hospital, Kettering, UK

Pain Clinic - Patient Satisfaction Survey was developed as a unique

British Journal of Pain 7(2) Supplement 1

Patients highly valued the service provided. NPS should be included

Is the brief pain inventory (bpi) a useful patient

Category: Assessment & Measurement

The BPI has been used as part of a service evaluation to investigate

There was an increase in the number of patients presenting with

Marsden Hospital, London, UK, 2Department of Primary care

Category: Cancer Pain

British Journal of Pain 7(2) Supplement 1

Marsden NHS Foundation Trust, London, UK, 2Kings College

From October 2011 to date, over 1400 outpatients have been

1. Uniformity in training should be rolled out across the country.

Using social media to assess public perception of

The survey clearly illustrates lack of uniformity in paediatric chronic pain

1HCA Healthcare International, London, UK, 2The Wellington Hospital,

British Journal of Pain 7(2) Supplement 1

Evidence supports continuing education to improve knowledge,

Intermediate level pain training - survey of sesa

interested in something else (10)

Helen Laycock1,2, Emma Casely1, Carsten Bantel1,2

and Westminster Hospital, London, UK, 2Imperial College,