Showing papers by "Michael I. Bennett published in 2009"

How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis.

Abstract: This review aimed to quantify the benefit of patient-based educational interventions in the management of cancer pain. We undertook a systematic review and meta-analysis of experimentally randomised and non-randomised controlled clinical trials identified from six databases from inception to November 2007.Two reviewers independently selected trials comparing intervention (formal instruction on cancer pain and analgesia on an individual basis using any medium) to usual care or other control in adults with cancer pain. Methodological quality was assessed, and data extraction undertaken by one reviewer with a second reviewer checking for accuracy. We used random effects model to combine the effect estimates from studies. Main outcome measures were effects on knowledge and attitudes towards cancer pain and analgesia, and pain intensity. Twenty-one trials (19 randomised) totalling 3501 patients met inclusion criteria, and 15 were included in the meta-analysis. Compared to usual care or control, educational interventions improved knowledge and attitudes by half a point on 0–5 rating scale (weighted mean difference 0.52, 95% confidence interval 0.04–1.0), reduced average pain intensity by over one point on 0–10 rating scale (WMD −1.1, −1.8 to −0.41) and reduced worst pain intensity by just under one point (WMD −0.78, −1.21 to −0.35). We found equivocal evidence for the effect of education on self-efficacy, but no significant benefit on medication adherence or on reducing interference with daily activities. Patient-based educational interventions can result in modest but significant benefits in the management of cancer pain, and are probably underused alongside more traditional analgesic approaches.

Diagnosis and management of neuropathic pain

Abstract: #### Summary points Neuropathic pain arises from damage, or pathological change, in the peripheral or central nervous system. It is usually a chronic condition that can be difficult to treat because standard treatment with conventional analgesics does not typically provide effective relief of pain. Patients with neuropathic pain commonly present to primary care professionals, but making a diagnosis may be difficult. Neuropathic pain is usually associated with substantially greater impairment of quality of life compared with other types of chronic pain, and the disorder is a large cost burden on healthcare services. In this review, we provide an overview of published evidence to help clinicians recognise and manage patients with neuropathic pain. A group of specialists of the International Association for the Study of Pain defines neuropathic pain as “pain arising as a direct consequence of a lesion or disease affecting the somatosensory system.”1 In contrast to inflammatory or nociceptive pain, which is caused by actual tissue damage or potentially tissue damaging stimuli, neuropathic pain is produced either by damage to, or pathological change in, the peripheral or central nervous system, the system that normally signals pain. As such, the term neuropathic pain represents a varying set of symptoms rather than a single diagnosis. Damage to the somatosensory system can provoke a range of responses; an absence of sensation and pain is probably a more common response than new onset of …

Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period

Abstract: Chronic pain following thoracic surgery is common and associated with neuropathic symptoms, however, the proportion of patients with neuropathic pain in the immediate postoperative period is unknown. We aimed to determine the proportion of patients who have neuropathic symptoms and signs immediately after, and at three months following thoracic surgery. The study was designed as a prospective observational cohort study. We identified patients with pain of predominantly neuropathic origin using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score in the immediate postoperative period and the self-report LANSS (S-LANSS) version three months after surgery. One hundred patients undergoing video assisted thoracic surgery (VATS) or thoracotomy completed LANSS scores preoperatively and in the immediate postoperative period. Eighty-seven percent completed three months S-LANSS follow-up scores. Eight percent of patients had positive LANSS scores in the immediate postoperative period; 22% of patients had positive S-LANSS scores three months following surgery. There was a significant association between positive scores in the acute and chronic periods (relative risk (RR) 3.5, [95% confidence interval (CI) 1.7-7.2]). Identifying pain of predominantly neuropathic origin in the postoperative period with a simple pain score can help identify those at risk of developing chronic pain with these features following thoracic surgery.

Analysing the SF-36 in population-based research. A comparison of methods of statistical approaches using chronic pain as an example.

Abstract: Background The Medical Outcomes Study 36 Item Short-Form (SF-36) questionnaire is one of the most widely used measures of health related quality of life in medical research, including studies on pain-related conditions. Although scores in each of its eight domains rarely conform to a normal distribution, it is most widely analysed using simple parametric statistical techniques. Some have suggested a need for more complex or non-parametric analytical approaches, and this quandary faces researchers recurrently when using the SF-36. In this study of chronic pain, we compared results arising from the SF-36 between three study sub-samples, using conventional parametric, non-parametric, bootstrapping and log transforming methods. Methods Respondents to a postal survey conducted in Aberdeen, Leeds and London (n = 3002, response rate 52%) were categorized in three groups according to previously validated questionnaires: those with chronic pain of predominantly neuropathic origin (POPNO, n = 241), those with chronic pain (non-POPNO, n = 1179), and those with no chronic pain (n = 1537). SF-36 scores were compared between these groups, using: ANOVA and t-tests; Kruskall–Wallis and Mann–Whitney U-tests; bootstrapping methods; and log transformation with ANOVA. Results There were highly significant differences between the three groups, with lower scores in all SF-36 domains found those with chronic pain (P < 0.001). Those with chronic POPNO had lower scores in all domains than those with chronic pain (non-POPNO) (P < 0.001). These results were the same after applying each statistical method Conclusions In this study, the choice of statistical approach had no influence on the results. We conclude that the conventional approach, using straightforward parametric tests, is both simplest and the best for allowing comparison with other studies. We are likely to adopt this in future studies.

The impact of neuropathic pain on relationships

Abstract: Aim This paper is a report of a study exploring the impact of neuropathic pain on family, social and working relationships among patients at a pain clinic serving a large urban area Background Neuropathic pain is a particularly distressing type of chronic pain which is extremely difficult to manage successfully It produces a range of unpleasant symptoms and adversely affects patients' quality of life, but little is known about its personal impact Method A descriptive and exploratory approach was used and 10 participants participated in three focus groups in 2005 Because of the low response rate of 20% from the initial sample, a second sample of 16 patients was invited to participate However, only one person responded and therefore it was not possible to convene an additional group Findings The unpleasant and bizarre nature of neuropathic pain underpinned much of its impact in terms of respondents' difficulties in maintaining a range of relationships For closer relationships, key difficulties centred on the reduction in quality and/or number of personal relationships For more distant relationships and those with professionals, frustration at the invisibility of their pain and their own failure to communicate symptoms and its consequences were central Conclusion More extensive work is needed to improve our understanding of how neuropathic pain is experienced, how it affects close and more distant kinds of relationships, and how healthcare professionals might best support people with persistent neuropathic pain to maintain personal and social relationships, and to communicate their pain effectively

Cancer pain management at home (II): does age influence attitudes towards pain and analgesia?

Abstract: Goals of work Older patients experience a higher prevalence of pain, including cancer pain, than other age groups and tend to receive poorer pain management. The reasons for unnecessary suffering resulting from pain among older patients are not well understood. This study aimed to identify barriers to cancer pain management for older patients living at home and to compare these with a younger control group. Patients and methods Patients newly referred to community-based palliative care services were interviewed about their pain and related issues. Data included pain impact (BPI), mood (HAD), health (EuroQol), and barriers to reporting of pain and analgesic use (Barriers Questionnaire). Main results Fifty-eight patients aged 75 or over and 32 people aged 60 or under were interviewed. Both groups reported that beliefs about the use of analgesics was the greatest barrier to effective pain management. Older patients reported that beliefs about the use of analgesics and communicating with medical staff were significantly more important barriers to pain management than for younger patients. Overall, factors such as communication with medical staff and fatalism were ranked lower than barriers related to medication. Younger patients reported significantly greater sleep disturbance due to pain and greater anxiety. Conclusions Older age appears to influence attitudes towards pain and analgesia. Factors such as poorer knowledge about taking analgesia, reluctance to communicate with medical staff, poorer performance status, and being more likely to live alone suggest that older patients may require greater support in the management of their cancer pain than younger patients. Targeted interventions are needed to test this proposition.

Cancer pain management at home (I): do older patients experience less effective management than younger patients?

Abstract: Goals of work We wanted to examine whether older cancer patients living at home experienced poorer pain management than younger patients, and if so, what were the potential explanations for this. Materials and methods We interviewed 90 new referrals to community palliative care services who were aged 75 years and above or aged 60 years and below. We asked about pain intensity, pain relief and pain quality, access to and type of analgesic medication and, finally, sources of support and self-management strategies. Main results Older and younger cancer patients who were living at home had very similar experiences of pain, pain relief, access to and use of analgesia, contact with health care professionals and use of additional pain management strategies. As a whole, participants had more frequent contact with family members, community nurses and pharmacists than with general practitioners. Conclusions In this sample, the experience and management of pain in older cancer patients was no different from that in younger patients. This suggests that delivering improvements in cancer pain management in the community is appropriate for all age groups. In addition, focussing efforts on patients, carers and non-medical health care professionals may prove to be the most successful strategy.

How to improve end of life care in acute hospitals.

Abstract: This article highlights the need to improve care for older people dying in acute hospitals It discusses the role that nurses have to play in promoting better care and making necessary changes easier

Pain in older people with cancer: attitudes and self-management strategies.

Abstract: Cancer is predominantly a disease of older people. It is also frequently a painful condition. However, the ageing process brings with it any number of other painful conditions, so it can be difficult to quantify the number of older people who are in pain solely because of cancer. In this article, we present a review of the literature concerning issues specifically related to the management of pain in older people. Three main areas are considered: the use of analgesics; the attitudes of older people in relation to pain management and their utilization of pain management strategies. We suggest that although a great deal is known about the efficacy of analgesia, there is relatively little information relating to the subjective experience of older individuals as they engage with treatment processes. This is important because social, psychological and cultural factors can have a significant influence on the effective management of cancer pain in this age group.

The Brief Pain Inventory: revealing the effect of cancer pain

Abstract: The science of pain assessment was born in the 1970s when visual analogue and numbered scales were adapted by psychologists from educational research settings and applied to patients with pain. This period also saw the publication of the well known McGill Pain Questionnaire that examined use of verbal descriptors for both the sensory and affective dimensions of pain. Within a short time, research in pain was progressing quickly, affirming the quote attributed to Lord Kelvin: “when you can measure what you are speaking about, and express it in numbers, you know something about it”. Publication of the Brief Pain Questionnaire in 1983, by Daut and colleagues,1 marked the start of the modern era of cancer-pain measurement and inspired better recognition of the effect of pain on the lives of patients with cancer. The Brief Pain Questionnaire also helped to focus attention on the neglected area of cancer-pain management; WHO did not publish the first guidelines advocating regular administration of opioids to patients with cancer pain until 1986.2 This treatment approach was regarded with scepticism by the medical community at that time, and is a view which sometimes prevails today. The 1983 paper reported on a new questionnaire—tested in more than 1200 patients with cancer who attended the Wisconsin Cancer Center and found to be acceptable, reliable, and valid. Although the Brief Pain Questionnaire incorporated existing numbered scales, it was an important step forward in pain measurement because it introduced two new concepts. The first idea reflected the simple observation that the intensity of cancer pain can vary, and measuring both maximum and average pain within the previous week is important. This understanding helped to identify the concept of cancer breakthrough pain. The second concept recognised that pain interferes with aspects of everyday living such as walking, sleeping, mood, and relations with other people. Measuring this interference is essential to understand the experience of cancer pain and monitor the effectiveness of treatment.

Management of pain.

Abstract: Pain is a common symptom that patients describe and clinicians have to manage. Management plans are tailored to the complexity of the pain. This may require a multi-modal approach while involving the wider multidisciplinary team.

Institutional report - Thoracic oncologic Can chronic neuropathic pain following thoracic surgery be predicted during the postoperative period?

Abstract: Chronic pain following thoracic surgery is common and associated with neuropathic symptoms, however, the proportion of patients with neuropathic pain in the immediate postoperative period is unknown. We aimed to determine the proportion of patients who have neuropathic symptoms and signs immediately after, and at three months following thoracic surgery. The study was designed as a prospective observational cohort study. We identified patients with pain of predominantly neuropathic origin using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score in the immediate postoperative period and the self-report LANSS (S-LANSS) version three months after surgery. One hundred patients undergoing video assisted thoracic surgery (VATS) or thoracotomy completed LANSS scores preoperatively and in the immediate postoperative period. Eighty-seven percent completed three months S-LANSS follow-up scores. Eight percent of patients had positive LANSS scores in the immediate postoperative period; 22% of patients had positive S-LANSS scores three months following surgery. There was a significant association between positive scores in the acute and chronic periods (relative risk (RR) 3.5, w95% confidence interval (CI) 1.7–7.2x). Identifying pain of predominantly neuropathic origin in the postoperative period with a simple pain score can help identify those at risk of developing chronic pain with these features following thoracic surgery. 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.