Robert Ashford

A systematic literature review of psychological characteristics as determinants of outcome for spinal cord stimulation therapy

&NA; Psychological factors are deemed important when considering patients for suitability for Spinal Cord Stimulation (SCS). However, there is to date no consensus on which psychological characteristics or tests to undertake. This review analyses the literature to determine findings concerning the psychological characteristics observed and their impact on SCS efficacy for chronic pain. A search in the databases Cochrane, EBSCOhost (CINAHL, MEDLINE, PsycINFO and PsycARTICLES) and a hand search of reference lists from selected articles were performed, resulting in nine relevant articles. The Minnesota Multiphasic Personality Inventory was the most commonly used tool for assessing psychological factors. Only one study used a semi‐structured interview instead of questionnaires. Studies lacked long term followup. Depression was identified in six studies as a factor that reduces efficacy, also as a characteristic that can improve after successful SCS by two studies. One study did not include patients with depression, due to previous research indicating depression as a contra‐indication. Hypochondriasis and hysteria had conflicting results for prediction of efficacy. Mania was predicted by only two studies as a positive indicator for success. Further long term studies of psychological factors on outcome from SCS are needed.

A Narrative Review of the Impact of Disbelief in Chronic Pain

Although the experience of being believed is frequently alluded to in chronic pain literature, few studies have specifically explored this phenomenon and even fewer reviews have been offered. This narrative review sought to explore the wider social context in which individuals with chronic pain may experience disbelief toward their pain. Articles were obtained through a search of eight databases and a hand search of the references of full-text papers. Key results within the articles were noted and integrated to form three main themes: stigma, the experience of isolation, and the experience of emotional distress. The experience of stigma can occur in a number of ways. It may be through actual or perceived encounters with others; it can be through the use of psychologic explanations of pain; it can come through a perceived challenge to ones integrity and subsequently affect an individuals identity; and such stigma may be influenced by negative female stereotypes. The loss of relationships associated with being disbelieved can lead to the experience of isolation. This may be self-initiated, particularly when an individual has been given a contested diagnosis. Finally, disbelief can lead to emotional distress. This can take the form of guilt, depression, and anger. Throughout the article, implications for health care professionals, working with individuals living with chronic pain, are discussed.

Long-term intrathecal drug administration for chronic nonmalignant pain.

Background: Chronic pain of nonmalignant origin requires effective long-term treatments, as for many patients pain management will be necessary throughout the rest of their lives. Intrathecal drug delivery systems (IDDS) have become a recognized therapy for the management of severe and otherwise intractable chronic pain. However, it is still not clear whether this treatment can be effective for periods up to 10 years or longer, given the paucity of long-term follow-up. This study sought to examine the effectiveness of IDDS following an average of 13 years postimplantation. Methods: Twenty patients participated in a longitudinal study with an average follow-up of 13.5 years (range: 10.4 to 17.9) after IDDS implantation. Investigation was carried out by means of a questionnaire before IDDS and after an average of 4 and 13 years of IDDS therapy. Assessment of pharmacological data and complications/side effects was performed. Results: Statistically significant improvements between baseline and 4-year assessment were observed for the following sensory and psychosocial variables: pain intensity, pain relief, coping, self-efficacy, depression, quality of life, housework, mobility, sleep, and social life (all P<0.001). No statistically significant changes were detected between assessments at averages of 4 and 13.5 years. Conclusions: This study, with one of the longest follow-up intervals reported in the IDDS literature, shows that IDDS has the potential to be a life-long pain management solution in appropriately selected patients with chronic nonmalignant pain.

Hypogonadism and low bone mineral density in patients on long-term intrathecal opioid delivery therapy

Objectives This study aimed to investigate the hypothalamic-pituitary-gonadal axis in a sample of male patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain and the presence of osteopaenia and/or osteoporosis in those diagnosed with hypogonadism. Design Observational study using health data routinely collected for non-research purposes. Setting Department of Pain Management, Russells Hall Hospital, Dudley, UK. Patients Twenty consecutive male patients attending follow-up clinics for intrathecal opioid therapy had the gonadal axis evaluated by measuring their serum luteinising hormone, follicle stimulating hormone, total testosterone, sex hormone binding globulin and calculating the free testosterone level. Bone mineral density was measured by DEXA scanning in those patients diagnosed with hypogonadism. Results Based on the calculated free testosterone concentrations, 17 (85%) patients had biochemical hypogonadism with 15 patients (75%) having free testosterone <180 pmol/L and 2 patients (10%) between 180 and 250 pmol/L. Bone mineral density was assessed in 14 of the 17 patients after the exclusion of 3 patients. Osteoporosis (defined as a T score ≤−2.5 SD) was detected in three patients (21.4%) and osteopaenia (defined as a T score between −1.0 and −2.5 SD) was observed in seven patients (50%). Five of the 14 patients (35.7%) were at or above the intervention threshold for hip fracture. Conclusions This study suggests an association between hypogonadism and low bone mass density in patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain. Surveillance of hypogonadism and the bone mineral density levels followed by appropriate treatment may be of paramount importance to reduce the risk of osteoporosis development and prevention of fractures in this group of patients.

The presentation of depression in the British Army

BACKGROUND The British Army is predominately composed of young men, often from disadvantaged backgrounds, in which Depression is a common mental health disorder. OBJECTIVES To construct a predictive model detailing the presentation of depression in the army that could be utilised as an educational and clinical guideline for Army clinical personnel. METHOD AND PARTICIPANTS Utilising a Constructivist Grounded Theory, phase 1 consisted of 19 interviews with experienced Army mental health clinicians. Phase 2 was a validation exercise conducted with 3 general practitioners. RESULTS Depression in the Army correlates poorly with civilian definitions, and has a unique interpretation. CONCLUSION Young soldiers presented with symptoms not in the International Classification of Disorders and older soldiers who feared being medically downgraded, sought help outside the Army Medical Services. Women found it easier to seek support, but many were inappropriately labelled as depressed. Implications include a need to address the poor understanding of military stressors; their relationships to depressive symptoms and raise higher awareness of gender imbalances with regard to access and treatment. The results have international implications for other Armed forces, and those employed in Young Mens Mental Health. The results are presented as a simple predictive model and aide memoire that can be utilised as an educational and clinical guideline. There is scope to adapt this model to international civilian healthcare practice.

Randomized Double-Blind Sham-Controlled Crossover Study of Short-Term Effect of Percutaneous Electrical Nerve Stimulation in Neuropathic Pain

BACKGROUND Percutaneous electrical nerve stimulation (PENS) is an electrical neuromodulation technique that has shown its therapeutic potential in various chronic pain conditions over the past few years, but well-blinded controlled studies are lacking. PATIENTS AND METHODS A randomized double-blind sham-controlled crossover trial on 31 patients with chronic pain with surface hyperalgesia to investigate the efficacy of PENS. RESULTS For the active PENS therapies, the median numerical rating scale (NRS) for pain changed from 7.5 (standard deviation [SD] ± 1) (range 6-10) before therapy to 0.5 (range 0-8.5) after therapy (Z = -4.206, P < 0.0005 [two-tailed]). The mean pain pressure threshold (PPT) measured with the von Frey aesthesiometer changed from 202 gm (SD ± 137 gm) (range 55-800 gm) before therapy to 626 gm (SD ± 228 gm) (range 45-800 gm) after therapy (Z = -4.373, P < 0.0005 [two-tailed]). There was a statistically significant difference between the changes in NRS for the active (3.9 [±3.2][0-8]) compared with the sham (0.1 [±0.4][0-1.5]) therapies, U = 40, Z = -3.484, P < 0.0001 (two-tailed). There was a statistically significant difference between the changes in PPT for the active (310 gm [±267 gm][0-670 gm]) compared with the sham (8 gm [±4 gm][0-15 gm]) therapies, U = 48.5, Z = -2.699, P = 0.007 (two-tailed). CONCLUSION PENS therapy appears to be effective in providing short-term pain relief in chronic pain conditions. Studies, involving larger sample sizes and longer follow-up are recommended.

Translational Research and Context in Health Monitoring Systems

Context has been applied to a broad range of domains and systems ranging from location-based tourist applications to motion capture. An area relatively under-represented in the literature is health-monitoring systems. This paper considers the application of context in health monitoring and the role of translational research, a concept that relates to the translation of basic research into clinical practice. This paper posits that intelligent Context-aware systems provide an effective basis for translational research with benefits reflected in improved quality of life for patients, reduced load on clinicians, and efficiency improvements. Case studies are presented to illustrate a number of health monitoring issues and how context can be effectively applied. The paper concludes with a discussion, consideration of practical applications, challenges, and open research questions.

Influence of a latent period in QALY anaylsis: Pilot study of intrathecal drug delivery systems for chronic non-malignant pain

Cost effectiveness of a treatment is an important factor in decision making in the United Kingdom. Preceding most interventional health care treatments there is a waiting period between decision and procedure where health care costs may be lessened. Intrathecal drug delivery systems (IDDS) are a recognised pain management therapy for chronic non-malignant pain. To our knowledge, the period of time between being placed on a waiting list for IDDS and the implant (latent period) has not been taken into consideration for cost effectiveness analysis. A retrospective longitudinal analysis of all pain related costs for a period no less than 4 years was undertaken by assessment of medical records of 12 consecutive patients implanted with IDDS for chronic non-malignant pain. The total cost of patient care for 2 years before latent, the latent period itself and 2 years after the implant of an IDDS was computed, according to the National Health Service tariff. An EQ-5D questionnaire was filled by all participants before and after IDDS implant. Total costs were converted to cost per day for comparison with latent period. The average duration of the latent period was 263 ± 176 days (range 3–489). The cost of conventional treatments during the pre-implant phase excluding the latent period was significantly higher (M = £5,005.86, SE = £918.56) compared with the costs of the same phase including the latent period (M = £4,086.35, SE = £959.09, t(11) = 2.23, p = 0.05, r = 0.56). The cost per day changed significantly over the different periods (χ2(2) = 24.00, p < 0.05). The variability and significantly lower costs of the latent period may influence cost effectiveness evaluations and consequently decision making, if not considered. Further studies analysing the influence of a latent period on the cost effectiveness of other treatments are warranted.

Brain activity modifications following spinal cord stimulation for chronic neuropathic pain: A systematic review

Spinal cord stimulation (SCS) is believed to exert supraspinal effects; however, these mechanisms are still far from fully elucidated. This systematic review aims to assess existing neurophysiological and functional neuroimaging literature to reveal current knowledge regarding the effects of SCS for chronic neuropathic pain on brain activity, to identify gaps in knowledge, and to suggest directions for future research.

Qualitative exploration of psychological factors associated with spinal cord stimulation outcome

Background and aim: Spinal cord stimulation (SCS) is a last resort treatment for chronic pain consisting of an implantable pulse generator connected to leads placed in the epidural space of the spinal cord. Effective in reducing chronic pain, however, efficacy has been found to decrease over time. Psychological factors affecting outcome of SCS have been investigated through quantitative methods, but these have failed to provide confident predictors. We aimed to investigate via a qualitative approach, the experience of SCS following 1 year of therapy. Methods: Thirteen chronic non-cancer pain participants were interviewed. All participants had been trialled with SCS. The majority had gone on to full implantation with varying degrees of pain relief. Thematic analysis was employed to analyse the data from the interviews. Results: Interviews resulted in findings that previous quantitative studies had failed to uncover. Two emergent core themes surfaced: ‘coping with pain’ and ‘SCS treatment’. The effect of emotion upon coping was recurrent. Participants divided the SCS experience into information provision, independence and unexpected experiences. Conclusion: The findings provide context for the patients’ experience of SCS. This research suggests that improved preparation prior to SCS including information provision, CBT and contact with expert patients may be of value.