British Journal of Pain

Pain management for people with dementia is challenging. There is limited understanding on the experiences of pain management from people with dementia, but also from those who support them. This study synthesised the qualitative evidence to explore the perspectives of people with dementia, their family, friends, carers and healthcare professionals to pain management.

A systematic literature review was undertaken of published and unpublished literature databases (to 01 November 2021). All qualitative research studies reporting the perspectives of people with dementia, their family, friends, carers and healthcare professionals to managing pain were included. Eligible studies were appraised using the Critical Appraisal Skills Programme (CASP) qualitative appraisal tool. A meta-ethnography analysis approach was adopted, with findings assessed against the GRADE-CERQual framework.

Of the 3994 citations screened, 33 studies were eligible. Seven themes were identified from the data. There was moderate evidence from six studies indicating inequity of pain management for people with dementia. There was moderate evidence from 22 studies regarding anxieties on cascading pain information. There was moderate evidence from nine studies that familiarisation of the person with pain, their preferences, routines and behaviours were key factors to better pain management. Consistently, carers and healthcare professionals had a low opinion of the management of pain for people with dementia, with tensions over the ‘best’ treatment options to offer. This was associated with poor training and understanding on how pain ‘should’ be managed.

The findings highlight the challenges faced by people with dementia and pain, and those who support them. Improvements in education for people who support these individuals would be valuable across health and social care pathways. Supporting family members and relatives on pain experiences and treatment options could improve awareness to improve quality of life for people with dementia and pain and those who support them.

Based on studies showing that both chronic low back pain (LBP) and restless legs syndrome (RLS) have similar pathophysiological mechanisms, we aimed to investigate the prevalence of RLS in patients with chronic LBP and to define which demographic and clinical features are prominent in those with LBP accompanied by RLS.

One hundred and two eligible, volunteer participants with chronic LBP were enrolled in this study. Visual analog scale (VAS), the Oswestry Disability Index (ODI), Pittsburgh Sleep Quality Index, Beck Depression Inventory, and Short Form-36 scales were applied to the patients. All patients were evaluated face-to-face for RLS using the International RLS study group diagnostic criteria.

Most of our patients were women (52%). The mean age was 40.96±13.34 years and the mean disease duration was 46.16±41.98 months. RLS was detected in 36 (35.3%) of the patients with LBP. It was found that the female gender was more dominant in patients with RLS and the difference was statistically significant (p < 0.001). The amount of coffee intake was significantly higher in patients with RLS compared to those without RLS (p = 0.001). The disease duration for LBP was significantly higher in the patients with RLS (p = 0.003). VAS score, ODI score, PUKI score, and Beck depression score were significantly higher in the RLS group (p value were 0.048, 0.040, 0.007, and 0.043, respectively). In the evaluation of quality of life, all parameters except role emotional limitations and mental health were found to be significantly worse in the RLS group.

Demand on emergency departments (EDs) is rising, at least in part due to patients with conditions suitable for management in primary care. Pain experienced in the back region is a common reason for patients to seek help and much of the established literature on back pain suggests serious pathologies are rare and the majority of patients can be safely treated in primary care. Emerging international data suggests that patients who present to ED complaining of back pain do not reflect those in primary care, with a higher rate of serious pathologies and non-spinal causes. This exploratory study seeks to quantify the prevalence of people attending ED with back pain, to describe their characteristics and the characteristics of their attendance.

This observational study is a retrospective analysis of patients attending EDs within an NHS Trust in the North East of England presenting with back pain from 1/10/2017 to 30/09/2018.

Of 212,020 attendances, 3872 (2%) patients presented complaining of back pain on arrival. 36% of patients had no official diagnosis recorded, 5% were categorised as having a potentially serious spinal pathology, 22% had a non-spinal pathology diagnosis and 23% were categorised as simple backache. The majority (56%) had no recorded investigations, 19% received plain radiography, 5% received either CT/MRI, 18% had blood investigations and 17% had cardiac monitoring or electrocardiogram. Most individuals self-presented. NHS 111, primary care and community care referrals accounted for 24% of attendances.

Back pain was a relatively common ED attendance and represented a variety of conditions including non-spinal causes. This suggests that the population of patients with back pain attending ED are a different subgroup to those presenting to primary care. Care should be taken applying primary care guidance to this group and there may be a need for emergency care specific back pain guidelines.

In March 2020, Pain Management Services were obliged to cease face-to-face consultations. This abrupt change, in line with recommendations from the British Pain Society, aimed to protect patients and staff and allowed resource re-allocation. Pain services were obliged to switch to remote consultations using Video Tele-Conferencing Technology (VTC) and Remote Consultations (RC) either through telephone or video calls using a variety of media and software applications. Little is known about the patient experience of remotely delivered pain care especially when alternatives are removed. The aim of this work was to understand the patient experience of this necessary switch regarding pain self-management interventions during the initial stages of the COVID-19 pandemic.

A mixed-methods evaluation of the patient experience from three pain self-management interventions, taking place in a large community-based pain rehabilitation service along the South Coast of England, was performed. Experience-Based Design (EBD) methods were used to map patient experience at touch points through two interventions that were delivered in a structured format. Semi-structured recorded interviews were transcribed and analysed using thematic analysis for the third.

Fifty-eight patients took part covering the scope of the service. In general, educational and psychological sessions were well received, with physical rehabilitation components being less easy to convey remotely. Attrition rates were high for the pain management programme. Group pain education worked particularly well in an online format with hope being the predominant emotion experienced. Clear limitations were technical failures and the lack of ability to form relationships in a virtual world.

Remote digitalised interventions were acceptable to most patients. Attention should be paid to access and improving social aspects of delivery when considering such interventions. Physiotherapy may require more face-to-face necessitating a hybrid model and needs further investigation. EBD proved a highly suitable approach.

The current service evaluation aimed to explore the impact of COVID-19 on patients' experiences of pain management therapy. The study examined the barriers and benefits of the move from face-to-face to eHealth methods of delivery.

A service evaluation was conducted in an outpatient pain clinic in an NHS Trust in the East of England. A qualitative approach was taken using semi-structured interviews.

Participants were recruited through a health psychology service operating as part of a multidisciplinary pain management clinic. Six patients, aged 39–67, were interviewed one-to-one using the online platform Zoom^TM. During COVID-19, participants had individual or group pain management therapy via telephone or video conferencing. All interviews were transcribed using Otter.ai^TM and thematic analysis was performed. The study was approved by internal clinical governance for service evaluations and the authors adhered to the BPS Code of Human Research Ethics.

Three key themes emerged from the analysis; Benefits Aside From Pain Relief, Limited Their Experience, and COVID-19: A Double-Edged Sword.

Findings suggested patients were able to benefit from pain management therapy despite the impact of COVID-19 on daily routines and pain experience. Adopting eHealth methods during the pandemic was an effective means of accessing pain management therapy. These methods allowed patients to continue to benefit from peer support and learn about skills and resources regarding self-management, whilst also improving accessibility for those with chronic pain. Yet, these methods are not without their limitations. Technical issues and difficulties creating therapeutic connections with psychologists limited patients' experience of pain management therapy.

Health inequalities continue to exist for individuals from an ethnic minority background who live with chronic pain. There is a growing recognition that an individual’s experience of pain is shaped by their cultural beliefs, which may influence their decisions about managing their pain.

This service evaluation aimed to (a) understand experiences of service users from a Black, Asian or other ethnic minority background of being invited to and attending a group pain programme in one secondary care pain rehabilitation service. (b) Provide recommendations to develop culturally grounded services to better meet the diverse needs of all service users living with chronic pain.

Semi-structured interviews were conducted with five service users who had been offered a place on a group pain programme within the last 3 years. The interviews were recorded and transcribed verbatim. An interpretative phenomenological analysis was used to identify themes in the data.

The analysis produced three themes (1) Pain, Ethnicity and Coping: Perceptions of pain and coping in relation to ethnicity and intersectional factors, alignment to a self-management approach. (2) Communication for Decisions: Experiences of ethnicity and culture in relation to health professional communication about group pain programmes, participants’ expectations and fears. (3) Feeling Included: Experiences of feeling included or excluded in group pain programme, relationships and empowerment during the group pain programme.

The five service users shared a range of perspectives on how they felt ethnicity shaped their experience of the group pain programme. The findings suggest that adaptations to group pain programmes can make a meaningful difference for service users from ethnic minority backgrounds. 10 recommendations are suggested, including greater exploration of cultural beliefs during assessment, improving accessibility of information about the service and engaging more diverse attendees and facilitators.

Chronic pain is a leading cause of disability, often requiring multidisciplinary management. 2021 NICE guidance has questioned the quality of the evidence surrounding the efficacy of pain management programmes (PMPs), with only minor benefit demonstrated in psychological and physical outcomes. There is need for further high-quality evidence for the efficacy of PMPs for a range of chronic pain conditions and to identify barriers to successful management of chronic pain.

This service evaluation utilised routinely collected outcome data of 508 PMP attendees to investigate change in pain- and patient-related outcomes across two distinct PMPs; a standard and an intensive PMP, and establish their longer-term efficacy and appropriateness for patients with differing degrees of need.

More people with chronic widespread pain, fibromyalgia, and osteoarthritis were referred to the intensive PMP (reflecting greater disability and distress in these conditions). Those referred to the intensive PMP demonstrated greater distress (such as more severe depression and anxiety), lower pain acceptance and poorer physical function. Improvements were observed in all outcomes across both PMPs (including physical function, pain catastrophising and pain acceptance). Depression and disability demonstrated clinically meaningful improvements in the intensive PMP, and pain severity showed clinically meaningful improvement in both PMPs. However, depression severity, disability, pain severity, and pain interference significantly deteriorated at 6-month follow-up for those on the intensive PMP, with pain severity increasing to a clinically meaningful degree (by more than 10%), though these outcomes remained better than at baseline.

This evaluation identified that people with chronic pain most at risk of deterioration in physical and psychological wellbeing after completing a PMP require early identification to mitigate such deterioration. Established and emerging PMPs need to be tailored to the needs of this group, particularly at follow-up to reduce risks of pain severity increasing, alongside establishing/reinforcing safeguards against deterioration post-PMP.

This paper describes the development of an eight-week Compassion Focused Therapy for Pain Management (CFT-PM) group. This group was specifically designed for ‘strivers’ a sub-group of people with persistent pain who tend to engage in over-activity and resist making reasonable adjustments to their activity levels to accommodate their persistent pain. ‘Strivers’ tend to cope by ignoring their pain and pushing on through, in the shorter term leading to ‘boom and bust’ activity-related exacerbations of their pain. They also risk the development of additional persistent fatigue and burnout in the longer term.

117 people completed the CFT-PM group; The group was delivered in person (n = 84) but in online format from July 2020 (n = 33). 162 people started the CFT-PM group but 45 dropped-out (27.43%).

There was a significant effect for time across all measures: significant improvement was found for depression, self-compassion, pain-related disability, pain-related anxiety and pain self-efficacy. Pain numeric rating scores were approaching significance. There was a significant main effect of diagnosis; post-hoc t-test analysis found significant improvement for all diagnoses on all measures with the exception of spinal. There was also a significant interaction between time and format: post-hoc t-test analysis found greater improvement for virtual format on self-compassion and pain-related anxiety.

Findings suggests that CFT-PM may be a clinically effective group intervention with virtual format showing superior improvement. This approach might be less suitable for certain diagnoses; the spinal group may benefit more from traditional CBT-based PMPs. Limitations include the lack of random selection or allocation to treatment group. Future studies should adopt an experimental design to be able to draw firm conclusions regarding causation and efficacy. Despite these limitations, present findings suggest that CFT-PM may be an effective group intervention worthy of further investigation and clinical application.

Autologous conditioned serum is a product of blood origin, with fragmented evidence of therapeutic properties in osteoarthritis chronic pain. This pilot observational prospective study aimed to evaluate the feasibility of a treatment with conditional autologous serum (ACS) in patients with severe chronic pain and grade I-III osteoarthritis and to describe its cytokine content.

We prospectively collected data on consecutive patients affected by osteoarthritis grade I to III and treated with four weekly injections of ACS at our outpatient pain service. The primary outcome was pain intensity, measured with the visual analogic scale (VAS). Additional outcomes were symptoms evaluated using joint district-specific scales. The study also evaluated concentrations of 48 cytokines and chemokines involved in the balance pro-inflammation/anti-inflammation and tissue repair in the ACS.

We included 26 patients, mostly female (65.4%), with a median age of 63.5 years [IQR 58.25–73]. A median reduction of VAS of −3 cm [−5; −1.25] was observed 6 months after the first injection of ACS. The analysis showed a statistically significant difference between the values of VAS (p < .01; X² = 69.6; df = 6, N = 26) at the different time points. No adverse events were observed or reported by patients during the entire study period.

Conditional autologous serum may be a feasible option for patients with chronic pain due to grade I-III osteoarthritis refractory to other treatments. These preliminary findings should be confirmed in studies with adequate design.