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The International Classification of Diseases-11 (ICD-11) chronic pain classification includes about 100 chronic pain diagnoses on different diagnostic levels. Each of these diagnoses requires specific operationalized diagnostic criteria to be present. The classification comprises more than 200 diagnostic criteria. The aim of the Classification Algorithm for Chronic Pain in 1CD-11 (CAL-CP) is to facilitate the use of the classification by guiding users through these diagnostic criteria. The diagnostic criteria were ordered hierarchically and visualized in accordance with the standards defined by the Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. The resulting linear decision tree underwent several rounds of iterative checks and feedback by its developers, as well as other pain experts. A preliminary pilot evaluation was conducted in the context of an ecological implementation field study of the classification itself. The resulting algorithm consists of a linear decision tree, an introduction form, and an appendix. The initial decision trunk can be used as a standalone algorithm in primary care. Each diagnostic criterion is represented in a decision box. The user needs to decide for each criterion whether it is present or not, and then follow the respective yes or no arrows to arrive at the corresponding ICD-11 diagnosis. The results of the pilot evaluation showed good clinical utility of the algorithm. The CAL-CP can contribute to reliable diagnoses by structuring a way through the classification and by increasing adherence to the criteria. Future studies need to evaluate its utility further and analyze its impact on the accuracy of the assigned diagnoses.

Objective: Conditioned pain modulation (CPM) and manipulation induced analgesia (MIA) are two forms of endogenous analgesia. Many forms of analgesia can be influenced by the nature of the patient clinician interaction. The aim of this study was to evaluate the influence of an empathetic and supportive interaction on CPM and MIA in people with Lateral Epicondylalgia (LE). Methods: In a double-blind, randomised, controlled trial, 68 participants with LE were assigned to two groups: the empathetic and neutral interaction groups. The interactions were carried out by a trained, professional role play actor, playing the part of a research assistant (RA). The RA actor spent 15min prior to CPM and MIA assessment interacting with the participants in an empathetic or neutral manner. Immediately after the interaction, a blinded assessor measured pressure pain threshold (PPT) at the symptomatic elbow and ipsilateral wrist during CPM and MIA testing. Linear mixed models were used to evaluate differences in CPM and MIA responses between the interaction groups. Results: There was a significant difference in CARE scores between the groups (P<0.001), indicating that the intervention group experienced a more empathic interaction. Both groups showed a significant increase in PPT measures, indicative of a CPM and MIA analgesic response (P<0.001), however the analgesic responses were greater in the group that had experienced a supportive, empathetic interaction (post CPM, wrist: P<0.001; elbow: P=0.001), (post MIA wrist: P=<0.001; elbow: P=0.001). Discussion: A single session of empathetic interaction positively influenced both CPM and MIA responses in people with LE.

Objectives: Conditioned Pain Modulation (CPM) and Manipulation Induced Analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia (LE). Methods: Seventy participants with LE were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT. Results: There was a significant increase (CPM and MIA p<0.001) in PPT from baseline during the interventions (CPM mean 195.84 kPa elbow and 201.87 kPa wrist. MIA mean 123.01 kPa elbow 126.06 kPa wrist) and post the interventions (CPM mean 126.06 kPa elbow, 114.24 kPa wrist, MIA mean 123.50 kPa elbow, 122.16 kPa wrist). There were also significant moderate and positive partial linear correlations (r: 0.40–0.54, p<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (p<0.001) and the models explained between 73% and 85% of the variance in MIA PPT. Discussion: This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.

BACKGROUND: Whiplash-associated disorders (WAD) are an enormous and costly burden to Australian society. Up to 50% of people who experience a whiplash injury will never fully recover. Whiplash is resistant to treatment and no early management approach has yet been shown to prevent chronic pain. The early presence of central sensitization is associated with poor recovery. Pregabalin's effects on central sensitization indicate the potential to prevent or modulate these processes after whiplash injury and to improve health outcomes, but this has not been investigated. This paper describes the protocol for a feasibility study for a randomised controlled trial of pregabalin plus evidence-based advice compared to placebo plus evidence-based advice for individuals with acute whiplash injury who are at risk of poor recovery. METHODS: This double blind, placebo-controlled randomised feasibility study will examine the feasibility and potential effectiveness of pregabalin and evidence-based advice (intervention) compared to placebo and evidence-based advice (control) for individuals with acute whiplash injury at risk of poor recovery. Thirty participants (15 per group) aged 18-65 years with Grade II WAD, within 48 hours of injury and currently experiencing at least moderate pain (NRS: ≥ 5/10) will be recruited from Emergency Departments of public hospitals in Queensland, Australia. Pregabalin will be commenced at 75 mg bd and titrated up to 300 mg bd as tolerated for 4 weeks followed by 1 week of weaning. RESULTS: The feasibility of trial procedures will be tested, as well as the potential effect of the intervention on the outcomes. The primary outcome of neck pain intensity at 3 months from randomisation will be compared between the treatment groups using standard analysis of variance techniques. DISCUSSION: Feasibility and potential effectiveness data will inform an appropriately powered full trial, which if successful, will provide an effective and cost-effective interventi

Background: Partial thickness skin graft wounds are painful. Topically applied lidocaine has been used for analgesia in several clinical trials. This study compared the effectiveness of two different formulations of topical local anaesthetic for dressing changes of partial thickness skin graft donor sites.Methods: A double-blind randomised controlled, pilot trial was conducted in 29 patients undergoing split thickness skin graft surgery. Subjects were randomised to either a 3% lidocaine emulsion formulation ‘‘Treatment E’’ (NOPAYNETM) or a 4% aqueous solution ‘‘Treatment A’’ (XylocaineTM). Subjects received one spray per 3 cm2 of donor site area followed by up to two further spays as required. Endpoints included pain intensity measured by the numerical rating scale (NRS) up to 1 h after dressing change commencement, sting sensation, overall satisfaction and lidocaine plasma concentration.Results: The 60 min pain scores for E and A were 1.3 ±0.3 (mean ±SEM) and 1.8 ±0.4 (ƿ = 0.98) respectively. Nearly 90% of patients were very satisfied with their treatment. The mean plasma concentrations of lidocaine for A and E were 0.132 mg/l and 0.040 mg/l respectively (ƿ = 0.069).Conclusion: The topical local anaesthetic formulations achieved low pain scores during dressing changes. The safety profile was potentially improved with the emulsion formulation of lidocaine.

Introduction: High rates of trauma recidivism associated with alcohol use indicate the need to screen foralcohol consumption and related harm. Routine collection of prevalence data relating to alcohol use inAustralian trauma settings is not undertaken currently, and diverse screening approaches are usedacross different settings. This study sought to examine the feasibility of routine screening for alcoholrelated injury and harmful alcohol use, and determine the prevalence of alcohol related injury and riskyalcohol consumption amongst trauma patients in Western Australia.Methods: A step-down model of screening for alcohol-related injury and harmful alcohol consumptionwas developed and trialled. Over a four month period at a statewide trauma service, 729 non-headinjured trauma patients were screened using a two-item measure in emergency and acute surgicalsettings, and 538 patients who screened positive were subsequently administered a standardised selfreport measure of alcohol consumption.Results: There was a 49% compliance rate with the Emergency Department brief screening protocol foralcohol related injury. Of those screened, 77% were identified by clinical staff as potentially having had analcohol related injury or be engaging in risky drinking regularly. Sixty per cent of the screened patientswho subsequently completed a standardised self report measure were identified as drinking at harmfullevels (41% hazardous; 7% harmful; 12% dependent). Of these, 15% and 24% met the DSM-IV-TR criteriafor alcohol abuse and dependence respectively. Approximately 30% of patients diagnosed with analcohol use disorder were not identified by staff as having an alcohol-related injury or problem. Higheralcohol consumption was significantly associated with greater risk of depression and PTSD.Conclusions: Preliminary findings suggest a high prevalence of alcohol-related injury, and harmfulalcohol consumption. These findings point to an urgent need to develop reliable and economicalscree

Objective: High levels of alcohol-related harm are a salient feature of many rural communities in Australia. General practitioners (GPs) are uniquely placed to identify and treat patients with harmful alcohol use in remote settings, yet corresponding opportunities for education in effective brief psychological interventions for harmful alcohol use are limited. This study piloted a training model for alcohol screening and brief intervention for GPs working in Kalgoorlie-Boulder, a remote Western Australian community facing significant alcohol-related problems. Design: Observational pilot study. Setting: Primary care. Main outcome measure(s): Perceived role in responding to harmful alcohol use, and confidence and knowledge of alcohol screening and brief intervention; satisfaction with a short training session focused on alcohol screening and brief intervention; and impact of training on implementation of screening and brief intervention for harmful alcohol use. Results: Fifty per cent of GPs took up the training opportunity. GPs recognised their professional responsibility for conducting brief intervention but reported comparatively lower confidence and skills in implementing screening and intervention prior to training. The training improved knowledge and confidence in conducting alcohol screening and brief intervention. All GPs increased their frequency of alcohol screening, and 88% of GPs reported increasing the frequency of brief intervention at 6 months. Conclusions: Preliminary findings suggest that among participating GPs, subsequent compliance with identification and management of harmful alcohol use was improved. Further work examining methods to improve rural and remote GP participation in alcohol-related harm prevention training is required, as the potential impact on communities with disproportionately high alcohol-related difficulties is significant.

Purpose: Chronic pain, posttraumatic stress disorder (PTSD), and depression are common outcomes following traumatic injury. Yet, screening and early intervention to prevent the onset of these disorders do not occur routinely in acute trauma settings. This pilot study examined the clinical utility of screening and early multidisciplinary intervention for reducing disability following traumatic injury. Method: 142 non-severe head injured trauma inpatients (26% female, Injury Severity Score M = 9.65, M age = 36 years) were assessed for injury-related factors, pain, and psychological function within 4 weeks post injury. Patients were randomly allocated to a Multidisciplinary Intervention (MI) or Usual Care (UC) group. MI patients received assessment and treatment at one and 3 months post injury from pain and rehabilitation medicine doctors, physiotherapists, occupational therapists, and clinical psychologists. Outcomes at 6 months were then compared. Results: Acute pain intensity, posttraumatic adjustment, depression and acute trauma symptoms, and alcohol use predicted a significant 26%, 49%, 56%, and 30% of the variance in pain, depressive, and PTSD severity, and physical mobility respectively at 6 months. Despite MI group patients reporting no improvement in the severity of pain and psychological symptoms, these patients reported significantly improved relief from pain symptoms as a result of treatment at 6 months. Twenty four per cent of the UC group initially below the cut-off for being at risk of developing PTSD/Depression received new clinical diagnoses at 6 months compared with none of the 'not at risk' MI group attendees who remained asymptomatic.Conclusions: Early findings point to the value of early screening to identify patients at risk of treatable pain, physical, and psychological impairments. Moreover, early multidisciplinary intervention models following traumatic injury show promise for protecting against the onset of posttraumatic psychological disorder

Objective: To evaluate the process and outcome of a multidisciplinary inpatient goal planning rehabilitation programme on physical, social and psychological functioning for patients with spinal cord injury. Design: Clinical audit: quantitative and qualitative analyses. Setting: Specialist spinal injury unit, Perth, Australia. Subjects: Consecutive series of 100 newly injured spinal cord injury inpatients. Main measure(s): The Needs Assessment Checklist (NAC), patient-focused goal planning questionnaire and goal planning progress form. Results: The clinical audit of 100 spinal cord injured patients revealed that 547 goal planning meetings were held with 8531 goals stipulated in total. Seventy-five per cent of the goals set at the first goal planning meeting were achieved by the second meeting and the rate of goal achievements at subsequent goal planning meetings dropped to 56%. Based on quantitative analysis of physical, social and psychological functioning, the 100 spinal cord injury patients improved significantly from baseline to discharge. Furthermore, qualitative analysis revealed benefits consistently reported by spinal cord injury patients of the goal planning rehabilitation programme in improvements to their physical, social and psychological adjustment to injury. Conclusions: The findings of this clinical audit underpin the need for patient-focused goal planning rehabilitation programmes which are tailored to the individual’s needs and involve a comprehensive multidisciplinary team.

Very little is known about what influences patient satisfaction with burn pain management. The aim of this prospective study was to examine predictors of patient satisfaction with pain management following burn injury. Methods: Participants were 97 adult burn patients admitted to Royal Perth Hospital, Western Australia between June 2007 and February 2009. Key patient satisfaction domains were: pain treatment in hospital, pain medication provided, and improvement since hospitalisation. Acute pain medication use, pain severity, psychological symptoms, and patient expectations were assessed as potential predictors of patient satisfaction. Results: Patients reported moderate to high levels of satisfaction across all domains. Whether treatment matched patients' expectations was a significant predictor of satisfaction with pain treatment, pain medication and improvement (p < .001, p < .001, p < .05 respectively). Current pain at follow-up was a significant predictor of satisfaction with pain treatment and improvement (p < .01, p < .001 respectively). Acute pain medication use, depressive symptoms and reductions in average pain at three months were not significant independent predictors of patient satisfaction with pain management and improvement in this sample (p > .35). Yet, severity of posttrauma symptoms at three months was a significant predictor of satisfaction with pain medication and was moderately and positively associated with satisfaction with pain treatment (p < .05, p = .07, respectively). Discussion: These findings suggest that acute medication use and reductions in perceived pain symptoms are less closely related to patient satisfaction compared with treatment expectations, current pain and posttrauma symptoms. Collectively, these findings indicate a need to proactively address treatment expectations about pain management, and manage current pain and psychological distress following burn injury in order to improve patient satisfaction wi

Objective: Musculoskeletal pain has been associated with N-methyl-d-aspartate (NMDA) receptor-mediated mechanisms. This randomized controlled trial (RCT) investigated the effect of the NMDA receptor antagonist ketamine (25 mg sublingually) on modulating experimental muscle pain. Design: Two groups (N = 11/group) of age- and sex-matched healthy subjects performed eccentric exercise using the nondominant arm wrist extensors (time 0) to induce muscle soreness 24 hours later (time 1). Intervention: Immediately prior to exercise, subjects were administered either a 25 mg ketamine lozenge or a placebo. At time 1, experimental muscle pain was augmented by injection of hypertonic saline into the extensor carpi radialis brevis (ECRB) muscle of the exercised arm. Outcome Measures: Pressure pain thresholds (PPTs), muscle soreness, muscle pain intensity (electronic visual analog scale [VAS]), and maximal wrist extension force were assessed at time 0 (pre- and postexercise) and at time 1 (pre-, during, and post saline-induced pain). Results: Regardless of group, PPT was reduced at ECRB (P < 0.021) and at the common extensor origin (P < 0.034) at time 1 preinjection compared with time 0 pre-exercise. At time 1, elevated levels of muscle soreness and force attenuation were similar between groups compared with time 0 pre-exercise (P < 0.0001), and similar hypertonic saline-induced pain areas and pain intensity profiles were evident. Conclusion: In comparison with placebo, a single low-dose sublingual pharmacological intervention targeting the processes of sensitization via antagonism of NMDA receptors did not modulate the effects of acute experimentally induced mechanical hyperalgesia, suggesting a higher dose or repeat doses may be required.

Objectives: Acute burn pain management has advanced significantly, yet little is known about long-term pain outcomes after severe burn injury. Even less is known about patient satisfaction with pain management after burn injury. This study examined the long-term pain and psychological outcomes of burn survivors who were treated at the Burns Service of Western Australia between 1994 and 2005. Methods: Of 2114 burn survivors who were mailed standardized self-report measures of pain, depressive, and posttraumatic stress symptoms, 492 returned completed questionnaires. Of these, 18% reported persistent burn-related pain, and 27% and 14% reported clinically significant depressive and posttraumatic stress symptoms, respectively. Those with persistent pain reported significantly more severe depressive and posttraumatic stress symptoms compared with those with no pain. Interestingly, respondents with persistent burn-related pain recalled significantly higher levels of procedural and dressing change acute pain than those without pain symptoms. Linear multiple regression analyses revealed that the extent to which pain treatment expectations were met predicted overall satisfaction with pain treatment, beyond the effects of perceived pain improvement, current burn pain intensity, depression and posttraumatic stress symptoms, age, sex, and total burn surface area. Discussion: Collectively, these findings suggest a significant proportion of severely injured burn survivors continue to experience persistent pain and point to the need to identify and treat persistent pain more effectively. Moreover, assessing and managing pain treatment expectations during the early phase of recovery postburn may yield improved levels of patient satisfaction with treatment received. © 2011 by Lippincott Williams & Wilkins.

Objective. To assess the effects of preclinic group education sessions and system redesign on tertiary pain medicine units and patient outcomes. Design. Prospective cohort study. Setting. Two public hospital multidisciplinary pain medicine units. Patients. People with persistent pain. Interventions. A system redesign from a “traditional” model (initial individual medical appointments) to a model that delivers group education sessions prior to individual appointments. Based on Patient Triage Questionnaires patients were scheduled to attend Self-Training Educative Pain Sessions (STEPS), a two day eight hour group education program, followed by optional patient-initiated clinic appointments. Outcome Measures. Number of patients completing STEPS who subsequently requested individual outpatient clinic appointment(s); wait-times; unit cost per new patient referred; recurrent health care utilization; patient satisfaction; Global Perceived Impression of Change (GPIC); and utilized pain management strategies. Results. Following STEPS 48% of attendees requested individual outpatient appointments. Wait times reduced from 105.6 to 16.1 weeks at one pain unit and 37.3 to 15.2 weeks at the second. Unit cost per new patient appointed reduced from $1,805 Australian Dollars (AUD) to AUD$541 (for STEPS). At 3 months, patients scored their satisfaction with “the treatment received for their pain” more positively than at baseline (change score = 0.88; P = 0.0003), GPIC improved (change score = 0.46; P < 0.0001) and mean number of active strategies utilized increased by 4.12 per patient (P = 0.0004). Conclusions. The introduction of STEPS was associated with reduced wait-times and costs at public pain medicine units and increased both the use of active pain management strategies and patient satisfaction.

OBJECTIVES: A two-phase study was conducted to refine a version of Cleeland's Brief Pain Inventory (BPI, Short Form) for use in residential aged care facilities (RACFs). DESIGN: The Australian Pain Society modified Cleeland's BPI by changing numerical response options to word descriptors. In Phase I, this version was tested in RACFs to determine the feasibility of its use, its stability over time, and its internal consistency reliability. Minor modifications resulted. In Phase II, the refined version was abbreviated, and the internal consistency reliability of this Modified Residents' Verbal BPI was examined. SETTING: RACFs. PARTICIPANTS: Thirty-three residents of RACFs in Phase I, 149 in Phase II. INTERVENTION: The study revised and abbreviated the BPI to better fit it for use in RACFs, examining the reliability of the tool. MEASUREMENTS: Mini-Mental State Examination, Global Deterioration Scale, modified BPI. RESULTS: The abbreviated tool comprises three items assessing pain intensity and three assessing pain interference. It also includes an item to specify pain location and a movement protocol. Cronbach alpha coefficient for six intensity and interference items was 0.72 (N=106). CONCLUSION: This abbreviated tool requires further testing but has demonstrated adequate internal consistency reliability and is a brief, multidimensional tool that appears feasible for assessing pain in RACFs, including use with residents who have some cognitive impairment. It shows promise as a screening tool and may be useful to assess the effectiveness of pain relief interventions and to measure pain prevalence.

Contains fulltext : 57294.pdf (publisher's version ) (Closed access), Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Chronic post-surgical pain (CPSP) occurs in 12% of surgical populations and is a high priority for perioperative research. Systemic lidocaine may modulate several of the pathophysiological processes linked to CPSP. This systematic review aims to identify and synthesize the evidence linking lidocaine infusions and CPSP.The authors conducted a systematic literature search of the major medical databases from inception until October 2017. Trials that randomized adults without baseline pain to perioperative lidocaine infusion or placebo were included if they reported on CPSP. The primary outcome was the presence of procedure-related pain at three months or longer after surgery. The secondary outcomes of pain intensity, adverse safety events and local anesthetic toxicity were also assessed.Six trials from four countries (n=420) were identified. CPSP incidence was consistent with existing epidemiological data. Perioperative lidocaine infusions significantly reduced the primary outcome (odds ratio, 0.29; 95% CI, 0.18 to 0.48), although the difference in intensity of CPSP assessed by the short form McGill pain questionnaire (four trials) was not statistically significant (weighted mean difference, -1.55; 95% CI, -3.16 to 0.06). Publication and other bias were highly apparent, as were limitations in trial design. Each study included a statement reporting no adverse events attributable to lidocaine, but systematic safety surveillance strategies were absent.Current limited clinical trial data and biological plausibility support lidocaine infusions use to reduce the development of CPSP without full assurances as to its safety. This hypothesis should be addressed in future definitive clinical trials with comprehensive safety assessment and reporting.

Chronic post-surgical pain (CPSP) occurs in 12% of surgical populations and is a high priority for perioperative research. Systemic lidocaine may modulate several of the pathophysiological processes linked to CPSP. This systematic review aims to identify and synthesize the evidence linking lidocaine infusions and CPSP.The authors conducted a systematic literature search of the major medical databases from inception until October 2017. Trials that randomized adults without baseline pain to perioperative lidocaine infusion or placebo were included if they reported on CPSP. The primary outcome was the presence of procedure-related pain at three months or longer after surgery. The secondary outcomes of pain intensity, adverse safety events and local anesthetic toxicity were also assessed.Six trials from four countries (n=420) were identified. CPSP incidence was consistent with existing epidemiological data. Perioperative lidocaine infusions significantly reduced the primary outcome (odds ratio, 0.29; 95% CI, 0.18 to 0.48), although the difference in intensity of CPSP assessed by the short form McGill pain questionnaire (four trials) was not statistically significant (weighted mean difference, -1.55; 95% CI, -3.16 to 0.06). Publication and other bias were highly apparent, as were limitations in trial design. Each study included a statement reporting no adverse events attributable to lidocaine, but systematic safety surveillance strategies were absent.Current limited clinical trial data and biological plausibility support lidocaine infusions use to reduce the development of CPSP without full assurances as to its safety. This hypothesis should be addressed in future definitive clinical trials with comprehensive safety assessment and reporting.