Showing papers on "Pain assessment published in 2016"

Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites

Abstract: Black Americans are systematically undertreated for pain relative to white Americans. We examine whether this racial bias is related to false beliefs about biological differences between blacks and whites (e.g., “black people’s skin is thicker than white people’s skin”). Study 1 documented these beliefs among white laypersons and revealed that participants who more strongly endorsed false beliefs about biological differences reported lower pain ratings for a black (vs. white) target. Study 2 extended these findings to the medical context and found that half of a sample of white medical students and residents endorsed these beliefs. Moreover, participants who endorsed these beliefs rated the black (vs. white) patient’s pain as lower and made less accurate treatment recommendations. Participants who did not endorse these beliefs rated the black (vs. white) patient’s pain as higher, but showed no bias in treatment recommendations. These findings suggest that individuals with at least some medical training hold and may use false beliefs about biological differences between blacks and whites to inform medical judgments, which may contribute to racial disparities in pain assessment and treatment.

A Guide to Pain Assessment and Management in the Neonate.

Abstract: Newborn infants experience acute pain with various medical procedures. Evidence demonstrates that controlling pain in the newborn period is beneficial, improving physiologic, behavioral, and hormonal outcomes. Multiple validated scoring systems exist to assess pain in a neonate; however, there is no standardized or universal approach for pain management. Healthcare facilities should establish a neonatal pain control program. The first step is to minimize the total number of painful iatrogenic events when possible. If a procedure cannot be avoided, a tiered approach to manage pain using environmental, non-pharmacologic, and pharmacologic modalities is recommended. This systematic approach should decrease acute neonatal pain, poor outcomes, and provider and parent dissatisfaction.

Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/OMERACT recommendations

Abstract: Although pain reduction is commonly the primary outcome in chronic pain clinical trials, physical functioning is also important. A challenge in designing chronic pain trials to determine efficacy and effectiveness of therapies is obtaining appropriate information about the impact of an intervention on physical function. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) and Outcome Measures in Rheumatology (OMERACT) convened a meeting to consider assessment of physical functioning and participation in research on chronic pain. The primary purpose of this article is to synthesize evidence on the scope of physical functioning to inform work on refining physical function outcome measurement. We address issues in assessing this broad construct and provide examples of frequently used measures of relevant concepts. Investigators can assess physical functioning using patient-reported outcome (PRO), performance-based, and objective measures of activity. This article aims to provide support for the use of these measures, covering broad aspects of functioning, including work participation, social participation, and caregiver burden, which researchers should consider when designing chronic pain clinical trials. Investigators should consider the inclusion of both PROs and performance-based measures as they provide different but also important complementary information. The development and use of reliable and valid PROs and performance-based measures of physical functioning may expedite development of treatments, and standardization of these measures has the potential to facilitate comparison across studies. We provide recommendations regarding important domains to stimulate research to develop tools that are more robust, address consistency and standardization, and engage patients early in tool development.

Chronic Pain and Cognitive Behavioral Therapy: An Integrative Review

Abstract: Cognitive behavioral therapy (CBT) is often used to treat chronic pain; however, more information is needed about what are the most efficacious dose and delivery methods. The aims of this review were to determine (a) which CBT doses, delivery methods, strategies, and follow-up periods have been explored in recent intervention studies of individuals with chronic pain and (b) whether the outcomes described in the selected studies were consistent with recommendations by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. The CINAHL, EMBASE, PubMed, PsycInfo, and SCOPUS databases were searched for randomized controlled trials published from 2009 to 2015 testing CBT for adults with chronic pain. Thirty-five studies were included in this review. Results revealed that CBT reduced pain intensity in 43% of trials, the efficacy of online and in-person formats were comparable, and military veterans and individuals with cancer-related chronic pain were understudied.

Pregabalin for pain in fibromyalgia in adults.

Abstract: Background This review updates part of an earlier Cochrane review on 'Pregabalin for acute and chronic pain in adults' (Moore 2009), and considers only fibromyalgia pain. Antiepileptic drugs have been used in pain management since the 1960s. Pregabalin is an antiepileptic drug also used in management of chronic pain conditions, including fibromyalgia. Pain response with pregabalin is associated with major benefits for other symptoms, and improved quality of life and function in people with chronic painful conditions. Objectives To assess the analgesic efficacy and adverse events of pregabalin for pain in fibromyalgia in adults, compared with placebo or any active comparator. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE for randomised controlled trials from inception to May 2009 for the original review and to 16 March 2016 for this update. We also searched the reference lists of retrieved studies and reviews, and online clinical trial registries. Selection criteria We included randomised, double-blind trials of eight weeks' duration or longer, comparing pregabalin with placebo or another active treatment for relief of pain in fibromyalgia, and reporting on the analgesic effect of pregabalin, with subjective pain assessment by the participant. Data collection and analysis Two review authors independently extracted data and assessed trial quality and potential bias. Primary outcomes were participants with moderate pain relief (at least 30% pain relief over baseline or much or very much improved on Patient Global Impression of Change scale (PGIC)) or substantial pain relief (at least 50% pain relief over baseline or very much improved on PGIC). Where pooled analysis was possible, we used dichotomous data to calculate risk ratio and number needed to treat (NNT), using standard methods. We assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 'Summary of findings' tables. Main results Our searches identified two new published studies with classic design, and one new published study with an enriched enrolment randomised withdrawal (EERW) design. We included eight studies. Five (3283 participants) had a classic design in which participants were randomised at the start of the study to pregabalin (150, 300, 450, or 600 mg daily) or placebo, with assessment after 8 to 13 weeks of stable treatment. No studies included active comparators. Studies had low risk of bias, except that the last observation carried forward (LOCF) imputation method used in analyses of the primary outcomes could overestimate treatment effect. Pregabalin increased the number of participants experiencing substantial benefit (at least 50% pain intensity reduction after 12 or 13 weeks' stable treatment (450 mg: RR 1.8, 95% CI 1.4 to 2.1, 1874 participants, 5 studies, high quality evidence)). Substantial benefit with pregabalin 300 to 600 mg was experienced by about 14% of participants with placebo, but about 9% more with pregabalin 300 to 600 mg (22% to 24%) (high quality evidence). Pregabalin increased the number of participants experiencing moderate benefit (at least 30% pain intensity reduction after 12 or 13 weeks' stable treatment) (450 mg: RR 1.5, 95% CI (1.3 to 1.7), 1874 participants, 5 studies, high quality evidence). Moderate benefit with pregabalin 300 to 600 mg was experienced by about 28% of participants with placebo, but about 11% more with pregabalin 300 to 600 mg (39% to 43%) (high quality evidence). A similar magnitude of effect was found using PGIC of 'very much improved' and 'much or very much improved'. NNTs for these outcomes ranged between 7 and 14 (high quality evidence). A small study (177 participants) compared nightly with twice-daily pregabalin, and concluded there was no difference in effect. Two studies (1492 participants began initial dose titration, 687 participants randomised) had an EERW design in which those with good pain relief after titration were randomised, double blind, to continuing the effective dose (300 to 600 mg pregabalin daily) or a short down-titration to placebo for 13 or 26 weeks. We calculated the outcome of maintained therapeutic response (MTR) without withdrawal, equivalent to a moderate benefit. Of those randomised, 40% had MTR with pregabalin and 20% with placebo (high quality evidence). The NNT was 5, but normalised to the starting population tested it was 12. About 10% of the initial population would have achieved the MTR outcome, similar to the result from studies of classic design. MTR had no imputation concerns. The majority (70% to 90%) of participants in all treatment groups experienced adverse events. Specific adverse events were more common with pregabalin than placebo, in particular dizziness, somnolence, weight gain, and peripheral oedema, with number needed to harm of 3.7, 7.4, 18, and 19 respectively for all doses combined (high quality evidence). Serious adverse events did not differ between active treatment groups and placebo (very low quality evidence). Withdrawals for any reason were more common with pregabalin than placebo only with the 600 mg dose in studies of classic design. Withdrawals due to adverse events were about 10% higher with pregabalin than placebo, but withdrawals due to lack of efficacy were about 6% lower (high quality evidence). Authors' conclusions Pregabalin 300 to 600 mg produces a major reduction in pain intensity over 12 to 26 weeks with tolerable adverse events for a small proportion of people (about 10% more than placebo) with moderate or severe pain due to fibromyalgia. The degree of pain relief is known to be accompanied by improvements in other symptoms, quality of life, and function. These results are similar to other effective medicines in fibromyalgia (milnacipran, duloxetine).

Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population.

Abstract: Objective. The Defense and Veterans Pain Rating Scale (DVPRS 2.0) is a pain assessment tool that utilizes a numerical rating scale enhanced by functional word descriptors, color coding, and pictorial facial expressions matched to pain levels. Four supplemental questions measure how much pain interferes with usual activity and sleep, and affects mood and contributes to stress. Methods. Psychometric testing was performed on a revised DVPRS 2.0 using data from 307 active duty service members and Veterans experiencing acute or chronic pain. A new set of facial representations designating pain levels was tested. Results. Results demonstrated acceptable internal consistency reliability (Cronbach’s alpha = 0.871) and test-retest reliability (r = 0.637 to r = 0.774) for the five items. Excellent interrater agreement was established for correctly ordering faces depicting pain levels and aligning them on the pain intensity scale (Kendall’s coefficient of concordance, W = 0.95 and 0.959, respectively). Construct validity was supported by an exploratory principal component factor analysis and known groups validity testing. Most participants, 70.9%, felt that the DVPRS was superior to other pain rating scales. Consclusion. The DVPRS 2.0 is a reliable and valid instrument that provides standard language and metrics to communicate pain and related outcomes.

Inventory of Personal Factors Influencing Conditioned Pain Modulation in Healthy People: A Systematic Literature Review.

Abstract: Background: Conditioned pain modulation (CPM) is believed to play an important role in the development and exacerbation of chronic pain, because dysfunction of CPM is associated with a shift in balance between pain facilitation and pain inhibition. In many patients with central sensitization, CPM is less efficacious. Besides that, efficacy of CPM is highly variable in healthy people. Consequently, it seems that several individual variables may influence CPM. A systematic review examining personal factors influencing CPM was conducted. Methods: This systematic review follows the PRISMA guidelines. Pubmed and Web of Science were searched using different synonyms of CPM. Full-text clinical reports addressing the influence of personal factors on CPM in healthy adults were included. Checklists for RCTs and case-control studies provided by the Dutch Institute for Healthcare Improvement (CBO) and the Dutch Cochrane Centre were utilized to assess methodological quality. Levels of evidence and strength of conclusion were assigned using the CBO guidelines. Results: Forty-six articles were identified that reported the influence of personal factors on CPM. Quality assessment revealed 10 studies with a methodological quality less than 50% wherefore they were excluded (21.8%), resulting in a general total methodological quality score of 72.5%. Overall younger adult age, male gender, ovulatory phase, positive expectations, attention to the conditioning stimulus, and carrier of the 5-HTTLPR long allele result in better CPM. Conclusion: It is advised for future studies to take these factors into account. Further research regarding the influence of oral contraceptives, catastrophizing, information about conditioning stimulation, distraction, physical activity, and genetics on CPM magnitude is required.

A Review of Pain Assessment in Pigs

Abstract: There is a moral obligation to minimize pain in pigs used for human benefit. In livestock production pigs experience pain caused by management procedures, e.g. castration, and tail docking, injuries from fighting or poor housing conditions, “management diseases” like mastitis or Streptococcal meningitis, and at parturition. Pigs used in biomedical research undergo procedures which are regarded as painful in humans, but do not receive similar levels of analgesia, and pet pigs also experience potentially painful conditions. In all contexts, accurate pain assessment is a prerequisite in: a) the estimation of the welfare consequences of noxious interventions; and b) the development of more effective pain mitigation strategies. This narrative review identifies the sources of pain in pigs, discusses the various assessment measures currently available, and proposes directions for future investigation.

Pain Assessment in Elderly with Behavioral and Psychological Symptoms of Dementia.

Abstract: Background: Pain is under-detected and undertreated in people with dementia. The present study investigates the prevalence of pain in people with dementia hospitalized in nursing homes that are members of National Association of Third Age Residences (ANASTE) Calabria, and evaluates the association among pain, mood, and behavioral and psychological symptoms of dementia (BPSD).

Research design considerations for single-dose analgesic clinical trials in acute pain: IMMPACT recommendations

Abstract: This article summarizes the results of a meeting convened by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) on key considerations and best practices governing the design of acute pain clinical trials. We discuss the role of early phase clinical trials, including pharmacokinetic-pharmacodynamic (PK-PD) trials, and the value of including both placebo and active standards of comparison in acute pain trials. This article focuses on single-dose and short-duration trials with emphasis on the perioperative and study design factors that influence assay sensitivity. Recommendations are presented on assessment measures, study designs, and operational factors. Although most of the methodological advances have come from studies of postoperative pain after dental impaction, bunionectomy, and other surgeries, the design considerations discussed are applicable to many other acute pain studies conducted in different settings.

Systematic pain assessment in horses

Abstract: Accurate recognition and quantification of pain in horses is imperative for adequate pain management The past decade has seen a much needed surge in formal development of systematic pain assessment tools for the objective monitoring of pain in equine patients This narrative review describes parameters that can be used to detect pain in horses, provides an overview of the various pain scales developed (visual analogue scales, simple descriptive scales, numerical rating scales, time budget analysis, composite pain scales and grimace scales), and highlights their strengths and weaknesses for potential clinical implementation The available literature on the use of each pain assessment tool in specific equine pain states (laminitis, lameness, acute synovitis, post-castration, acute colic and post-abdominal surgery) is discussed, including any problems with sensitivity, reliability or scale validation as well as translation of results to other clinical pain states The review considers future development and further refinement of currently available equine pain scoring systems

Pain assessment in context: a state of the science review of the McGill pain questionnaire 40 years on.

Abstract: The McGill pain questionnaire (MPQ) and its later derivative the short form-MPQ have been used widely both in experimental and clinical pain studies. They have been of considerable importance in stimulating research into the perception of pain and now, with the publication of its latest variant, the short form-MPQ-2, it is appropriate to appraise their utility in the light of subsequent research into the nature of pain and the purpose of pain assessment. Following a description of the content and development of the questionnaires, issues of validity, reliability, and utility are addressed, not only in terms of the individual pain descriptors and the scales, but also in terms of methods of quantification. In addition, other methods of pain depiction are considered. In the second part of the review, advances in pain measurement and methodology, in the elucidation of pain mechanisms and pathways, in the psychology of pain, and in the nature of pain behavior are presented and their implications for pain assessment in general and the MPQ family of measures in particular will be addressed. It is suggested that pain assessment needs to be cast in its social context. We need to understand the influences on pain expression using a socio-communication model of pain that recognizes the function of pain and the importance of both innate pain responses and the effects of social learning. The review concludes with recommendations for future use of the MPQ and identifies a number of research challenges which lie ahead.

The Ongoing Opioid Prescription Epidemic: Historical Context.

Abstract: In March 2016, the Centers for Disease Control and Prevention (CDC) issued a new set of guidelines for prescribing opioids for chronic pain.1 In April, several health care organizations, led by Physicians for Responsible Opioid Prescribing, petitioned the Joint Commission for Accreditation of Health Care Organizations, calling for “an end to mandatory pain assessment,” suggesting that this practice “foster[s] dangerous pain control practices,” leading to overprescription of opioids.2 These actions reflected a reversal in the trend toward more liberal prescribing of opioids for nonacute, nonterminal pain; but far from resolving this long-disputed question, they only signaled a new round of the debate. “We must appreciate that severe constant pain will destroy the morale of the sturdiest individual. . . . But . . . we are often loathe to give liberal amounts of narcotics because the drug addiction itself may become a hideous spectacle,” surgeon Warren Cole wrote 60 years ago in a small book on cancer pain.3 Cole’s dilemma was reflected daily in doctors’ offices and inpatient wards across the United States through the 1970s; physicians and nurses were trained to give minimal opioids for pain, often even less than prescribed, unless death seemed imminent. Chronic pain, a few studies noted, was badly undertreated, in part because of the “special emotional significance [of opioids] that interferes with their rational use.”3 Kathleen Foley at Memorial-Sloan-Kettering Cancer Center in New York City was one of a small group of pain management specialists to whom the strictures against opioids made little sense. Foley was influenced first by the work of her mentor Raymond Houde, whose extensive crossover studies of analgesics in cancer patients had repeatedly shown the superiority of morphine and challenged the “misconception that drugs with this capability enslave, demoralize, and lead the unwitting patient down the primrose path to addiction.”3 She was also impressed by the hospice studies of Cicely Saunders and Robert Twycross in the United Kingdom, who used regular heroin dosage to “[free the patient] from the day- and nightmare of constant pain,” which they viewed as far more disabling than dependence on the drug.3 Foley published two highly influential articles in 1981 and 1986, reporting on the low incidence of addictive behavior in small groups of cancer and noncancer patients. These articles, along with a one-paragraph 1980 letter reporting addiction to be rare among inpatients, became the rather fragile foundation of a 20-year campaign for the long-term use of opioids in chronic noncancer pain led by Foley and her close colleague Russell Portenoy. As Foley pointed out, there were “no published long-term data” that gave evidence of high addiction rates among pain patients; but there had been in fact no long-term controlled studies of opioids for chronic pain at all. Furthermore, Foley and Portenoy observed that “the intensive involvement of a single physician” was essential to successful treatment; the prescription alone was not enough.3 For many physicians and chronic pain patients, however, the idea that long-term opioids were potentially safe and that patients could be trusted to manage their prescriptions was a welcome revelation. As one patient stated, “The doctor trusts me . . . he’s also given me back my self-esteem and the ability to control myself. I’m empowered.”4 Opioid manufacturers such as Purdue Pharma supported presentations by Portenoy and other respected authorities championing chronic opioid therapy; when the US Drug Enforcement Administration prosecuted physicians who wrote high-dosage prescriptions, some for known addicts, colleagues rallied to their defense in the media and in medical journals.4 The dimensions of the problem were and are immense. An estimated 25 million adult Americans, according to the most recent data, suffer daily from pain, and 23 million others suffer from severe recurrent pain, resulting in disability, loss of work productivity, loss of quality of life, and reduced overall health status. The best-known alternative to opioids is a multidisciplinary team approach involving reliance on physical and psychological therapies, including cognitive-behavioral therapy, relaxation and pain coping skills training, and self-hypnosis. While such methods can be highly successful, many third-party payers regard them as too costly; insurance coverage is usually inadequate, and only major medical centers can support such programs. Fewer than 200 000 patients currently participate in multidisciplinary treatment. But even among pain management specialists, many challenged the idea that chronic opioid therapy was safe, pointing to continuing instances of addictive behavior; the danger of overdose and risks not just of minor side effects, but of cognitive damage; and mirroring Foley’s argument back to her, the lack of randomized controlled trial evidence supporting long-term treatment.5 The debate created an ongoing and serious fracture within the field. The fracture became a seismic shock in the 2000s when Purdue’s aggressive marketing of its controlled-release opioid Oxycontin as safe for chronic pain intersected with the trafficking of cheap, very pure heroin in smaller cities across the West, Midwest, and Appalachia. Purdue advertised Oxycontin as nonaddictive because the drug was released within the body over 12 hours; recreational users quickly learned to get high by crushing or dissolving the pills, or simply taking very high doses. Overstressed and well-intentioned general practitioners, and a number of unscrupulous “pill mill” operators, wrote liberal prescriptions for the new analgesic. The ready supply of Oxycontin made diversion and sale, particularly by low-income patients on Medicaid or Medicare, attractive and easy; but when pill addicts found their drug too expensive, they sought an alternative. Traffickers of black-tar heroin had meanwhile arrived in Middle America with a new marketing approach, driving to meet buyers in safe locations and offering inexpensive product, often giving free samples to encourage customer loyalty.6 “When you’re paying 40 dollars a pill and then you hear you can pay 10 dollars for the same effect, of course you’re going to do it.” Hundreds of Oxycontin abusers, many of them middle-class adolescents and young adults, began to see heroin as “a less and less scary and taboo thing.”7 The result has been an alarming increase in heroin use across the country and an epidemic of drug overdose deaths, which increased 137% between 2000 and 2014; overdoses involving prescription opioids and heroin increased 200% in that period. Many who championed liberalized opioid therapy for chronic pain, including Portenoy, have now retreated from that position, acknowledging that their stance led to unanticipated abuse and tragedy. But as the CDC guidelines demonstrate, patients with severe chronic pain will still need opioids, and physicians will be called on to prescribe it, albeit with more caution and as Foley and Portenoy wrote 30 years ago, the physician’s “intensive involvement.” Prescription under strict guidelines may finally provide the evidence for or against long-term opioid therapy for chronic pain that has been so long lacking. In its absence, the availability and use of opioids, with often deadly results, has been too far governed by other factors: the shrewd targeting of a market niche by a pharmaceutical manufacturer, the cost-benefit calculations of insurance carriers, and the creative entrepreneurship of drug traffickers.

Ibuprofen May Not Increase Bleeding Risk in Plastic Surgery: A Systematic Review and Meta-Analysis.

Abstract: Background Nonsteroidal antiinflammatory drugs such as ibuprofen are common medications with multiple useful effects, including pain relief and reduction of inflammation. However, surgeons commonly withhold all nonsteroidal antiinflammatory drugs perioperatively because of bleeding concerns. However, not all nonsteroidal antiinflammatory drugs irreversibly block platelet function. The authors hypothesized that the use of ibuprofen would have no effect on postoperative bleeding in plastic surgery patients. Methods A literature review was performed using MEDLINE (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles on ibuprofen and bleeding. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and complications were extracted. Bias assessment and meta-analysis were performed. Results A total of 881 publications were reviewed. Four primary randomized controlled trials were selected for full analysis. Articles were of high quality by bias assessment. No significant difference was noted regarding bleeding events (p = 0.32), and pain control was noted to be equivalent. Conclusions Ibuprofen is a useful medication in the setting of surgery, with multiple beneficial effects. This meta-analysis represents a small set of high-quality studies suggesting that ibuprofen provides pain control equivalent to narcotics. Importantly, ibuprofen was not associated with an increased risk of bleeding. Further large studies will be necessary to elucidate this issue further, but ibuprofen is a safe postoperative analgesic in patients undergoing common plastic surgery soft-tissue procedures. Clinical question/level of evidence Therapeutic, II.

The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2–10 years old undergoing venous blood drawing—a randomized controlled study

Abstract: Recently, the utilization of medical clowns to reduce anxiety, stress, and even pain associated with hospitalization has become popular. However, the scientific basis of this benefit and outcome is scant. Venipuncture and IV cannulation are very common sources of pain in ill children. To reduce pain, one common approach is to apply a local anesthetic prior to the procedure. In the current study, we sought to compare the utilization of medical clowning in this process with two control groups: (1) local anesthetic cream (EMLA®, Astrazeneca, London, UK) applied prior to the procedure (active control) and (2) the procedure performed with neither clown nor EMLA (control group). We hypothesized that a medical clown will reduce pain, crying, and anxiety in children undergoing this procedure. Children aged 2–10 years who required either venous blood sampling or intravenous cannulation were recruited and randomly assigned to one of the three groups. Outcome measures consisted of the duration of the whole procedure (measured objectively by an independent observer), the duration of crying (measured objectively by an independent observer), subjective assessment of pain level (a commonly used validated scale), and anxiety level regarding future blood exams (by questionnaire). Analysis of variance (ANOVA) was used to compare between the groups. p < 0.05 was considered statistically significant. One hundred children participated. Mean age was 5.3 ± 2.5 years (range 2–10 years). The duration of crying was significantly lower with clown than in the control group (1.3 ± 2.0 vs 3.8 ± 5.4 min, p = 0.01). With EMLA, this duration was 2.4 ± 2.9 min. The pain magnitude as assessed by the child was significantly lower with EMLA than in the control group (2.9 ± 3.3 vs 5.3 ± 3.8, p = 0.04), while with clown it was 4.1 ± 3.5, not significant when compared with the other two modalities. Hence, duration of crying was shortest with clown while pain assessment was lowest with EMLA. Furthermore, with clown duration of cry was significantly shorter than in controls, but pain perception did not significantly differ between these groups. As expected, the duration of the entire process was shortest in the control group (5.0 ± 3.8 min), moderate with clown (19.3 ± 5.8 min), and longest with EMLA (63.2 ± 11.4 min, p < 0.0001 between all). Parental reporting of a beneficial effect was greater with clown than with EMLA (3.6 ± 0.8 vs 3.0 ± 1.1, p = 0.02). Parental assessment of child’s anxiety related to future blood tests as evaluated by telephone the following day revealed that it was significantly lower with clown than in the control group or EMLA (2.6 ± 1.2 vs 3.7 ± 1.3 or 3.8 ± 1.6, p < 0.01 for both). Conclusions: Distraction by a medical clown is helpful in children undergoing blood tests or line insertion. Although pain reduction was better with EMLA, both duration of cry and anxiety were lower with a medical clown. These results strongly encourage and support the utilization of medical clowns while drawing blood in children.

Healthcare Providers' Knowledge and Current Practice of Pain Assessment and Management: How Much Progress Have We Made?

Abstract: Context. Despite improvement in pain management and availability of clinical treatment guidelines, patients in Jordan are still suffering from pain. Negative consequences of undertreated pain are being recognized as a reason for further illnesses and poor quality of life. Healthcare providers (HCPs) are responsible for relieving pain of their patients. Objective. To evaluate the knowledge and attitudes of HCPs toward pain management in Jordan. Methods. A 16-item questionnaire with agree or disagree options was given to 662 HCPs in seven hospitals in Jordan who volunteered to participate in the study. Following data collection, the responses were coded and entered into SPSS. Results. There was a statistically significant difference ( ) in percentage scores between physicians (36%) and pharmacists (36%) versus nurses (24%). The level of knowledge was the best among physicians, followed by pharmacists specifically in the area of cancer pain management. Nurses scored the lowest for knowledge of pain assessment and management among HCPs. However, HCPs overall scores indicated insufficient knowledge specifically in relation to pain assessment and management among children.

The assessment and management of pain in patients with dementia in hospital settings:a multi-case exploratory study from a decision making perspective

Abstract: Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group. A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory. Staff generally relied on patients’ self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients’ ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient’s communication about their pain involved several members of staff, each having to make sense of the patient’s pain as in an ‘overall picture’. Information about patients’ pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a ‘patient specific picture of the pain’ required collective staff memory, ‘mental computation’ and time. There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient’s pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.