Cliff Richardson

Making pain visible: an audit and review of documentation to improve the use of pain assessment by implementing pain as the fifth vital sign.

Pain has been promoted as the fifth vital sign for a decade, but there is little empirical evidence to suggest that doing so has affected the care of individuals suffering pain. This was a three-stage audit of pain assessment in one large teaching hospital in the Northwest of England. Stage one measured the baseline pain assessment activity on surgical and medical wards and identified that the pain assessment tool was not visible to nurses. Stage two redesigned the patient observation charts held at the end of the bed and piloted two versions for clinical utility. Version 2 which had pain assessment alongside the early warning score was adopted and introduced throughout the hospital. Stage three audited pain assessment and management 8 months after the introduction of the new charts. Pain was assessed more regularly at the stage three audit than at the baseline audit. On average, pain was assessed alongside other routine observations 70% of the time across surgical and medical wards. Medical wards appeared to improve their pain assessment using the philosophy of pain being the fifth vital sign better than surgical wards, because they assessed pain alongside routine observations in >90% of cases. Stage three identified that where a high pain score was recorded, analgesia was delivered in the majority of cases (88%). Introducing the philosophy of pain as the fifth vital sign and making pain assessment more visible on the patient observation chart improved the uptake of pain assessment. Pain management strategies were stimulated when high pain scores were identified.

Nurses' in the multi-professional pain team: A study of attitudes, beliefs and treatment endorsements

Background and Aim It is widely accepted that chronic pain is best treated by a multidisciplinary team. Team approaches are best facilitated if all members understand their own and each others role. Roles and responsibilities have inherent values and beliefs which need to be understood if the team is going to function optimally. Little is known about the attitudes and beliefs of the pain team or the individual professionals within it. All members of the pain team therefore need to critically examine the values and beliefs they bring to these teams. The aim of this study was to start this process for nurses. This was done uniquely by: finding out what components of pain management nurses endorse as important; investigating their beliefs about pain management; and exploring whether nurses beliefs differ in relation to other service providers.

Re-thinking pain educational strategies: Pain a new model using e-learning and PBL.

Despite some high profile reorganisation including the introduction of acute pain teams, many patients still experience unnecessary pain. Traditional teaching and learning strategies seem to have made little impact in clinical practice. This paper explores the possible reasons for this and identifies the need to help postregistration students transfer (re-contextualise) what they are learning to practice. A new, more flexible pain management module utilising a blended face to face/e-learning approach within a problem-based learning philosophy was introduced to increase knowledge in pain management whilst also attempting to overcome the barriers to knowledge transfer into practice. This is done by challenging attitudes and encouraging students to explore their clinical practice alongside theoretical concepts.

A study to assess the feasibility of undertaking a randomized controlled trial of adherence with eye drops in glaucoma patients

Background Adherence with therapy could influence the progression of glaucoma and ultimately affect the onset of visual impairment in some individuals. This feasibility study evaluated the measures to be used for a future randomized controlled trial assessing the effects of group-based education on adherence with eye drops. Methods People diagnosed with glaucoma within the previous 12 months attending a regional ophthalmology clinic in the North West of England were recruited. A two-session education program delivered one week apart had been devised as part of a previous project. A combined adult learning and health needs approach to education was taken. Outcomes measured were knowledge of glaucoma, self-report of adherence, illness perception, beliefs about medicines, patient enablement, and general health (Short Form-12). Adherence was also measured objectively using a Medical Events Monitoring System device. Results Twenty-six participants consented to undertake the educational program and 19 produced analyzable data. Knowledge of glaucoma, illness perception, beliefs about medicine, and patient enablement all showed statistically significant improvements after education. Mean adherence with eye drops was maintained above 85% before and for 3 months after attendance at the educational program. Self-report exaggerated adherence by at least 10% when compared with the objective Medical Events Monitoring System data, and in fact the kappa agreement was zero. Conclusion All questionnaires other than the Short Form-12 were considered to be valuable measures and use of a Medical Events Monitoring System device was considered to be an objective surrogate measure for adherence with eye drops. A multicenter, randomized, controlled equivalence trial of group versus individualized education using adherence as the primary outcome is the next step.

Pain relief during panretinal photocoagulation for diabetic retinopathy: a national survey.

AimsPanretinal photocoagulation (PRP) for proliferative retinopathy is known to be painful for some people; however, few studies have explored the effects of pain on the procedure within clinical practice.MethodsThis was a national survey of all Ophthalmic Units within the UK undertaken in late 2006. A questionnaire with 14 questions was developed, piloted, and sent to all NHS units in the UK.ResultsA 77% response rate was achieved. The vast majority of responses (96%) were from doctors. A large proportion (79%) of units see up to 20 cases a week and most patients require up to 5 sessions of PRP. Eighty-eight percent said that the procedure is painful. Once present, pain can affect the number and strength of burns delivered and indirectly increases the number of sessions required to complete the therapy. Sub-tenons anaesthesia was the most commonly used analgesic and there is some tentative evidence to support its effect. Few units have a pre-emptive analgesic protocol. Some respondents were using laser with lower exposure and reported reduced pain.ConclusionsPRP is painful; however, most units do not deliver pain relief pre-emptively. There may be a case to support the routine use of sub-tenons anaesthesia until the full effects of new laser techniques become known.

Phantom Limb Pain; Prevalence, Mechanisms and Associated Factors

This chapter reviews the literature regarding phantom limb pain (PLP) following limb amputation. Controversies exist over the incidence and prevalence, causes, mechanisms and management of PLP. Owing to a lack of effective treatment for the condition, interest has turned to the potential to pre-empt PLP. Pre-emption needs targets, and interest has focused upon pre-amputation pain. A lack of success with pain pre-emption has led to interest in other factors which may be associated with PLP. To ensure rigour, before addressing factors that are associated with PLP, it is necessary to tackle controversies within PLP. Each area of controversy will be reviewed with the final section concentrating on those aspects, inherent within an individual, that play a role in PLP development and/or maintenance.

Exploring the Role of Cortical Reorganization in Postamputation Phantom Phenomena, Including Phantom Limb Pain in Lower Limb Amputees: A Cross-Sectional Study of the Patterns of Referral of Sensations into the Phantom

Abstract: Background: Cortical reorganization and pain memory are theories to explain phantom limb pain and other postamputation phantom phenomena. This study was undertaken to identify evidence of cortical reorganization in lower limb amputees and to find evidence for the pain memory theory. Methods: This was a qualitative interview study using structured questionnaires with lower limb amputees. Participants were asked to identify body areas and activities that stimulate postamputation phantom phenomena to confirm the cortical reorganization theory. We tested the pain memory theory by comparing traumatic amputees with surgical amputees. Results: A total of 122 participants (response rate 42%) were recruited. Prevalence of postamputation phantom phenomena was similar to previous studies with phantom pain reported as 84%. Twenty (16.3%) identified body regions that could stimulate postamputation phantom phenomena and 32 (26%) identified activities that could stimulate postamputation phantom phenomena. Not all body areas or activities were related to somatotopic regions adjacent to the leg on the sensory homunculus. Overall, 47 (38.2%) exhibited attributes suggestive of cortical reorganization into areas adjacent to the leg. No associations were found between presence of pain or length of time in pain before amputation and the presence of phantom pain (p = .1–1.0). No statistical difference was found between surgical and traumatic amputees for any postamputation phantom phenomena (p = .3–1.0). Conclusions: The cortical reorganization and pain memory theories for the development and maintenance of postamputation phantom phenomena have only limited support from our data. Taking this into account, it may be worth reopening the debate on the mechanism for postamputation phantom phenomena, including phantom limb pain. The cortical reorganization theory and memory theory for the mechanism of phantom limb pain are questioned by these results. Both may play a role, but neither can explain the presence of postamputation phantom phenomena on their own.