Journal of Pain Management

The use of hydromorphone is increasing but little is known about its effects during painful episodes in adolescents with sickle cell disease. This pilot study examined the intensity, location, and quality of pain and evaluated the amount of relief and side effects from PCA hydromorphone during acute painful episodes in five adolescents with sickle cell disease. Data suggest that hydromorphone may provide a better alternative than morphine, the most commonly prescribed opioid in patients with sickle cell disease. Hydromorphone may provide improved pain control and recovery from acute painful episodes in patients with sickle cell disease.

Morphine given by Patient Controlled Analgesia (PCA) is widely used in hospital settings to manage severe pain during acute painful episodes. Wide variations in prescription patterns occur and some patients are often self-administering sub- or low- therapeutic doses. In this preliminary study, a descriptive design with repeated measures was used to examine the effects of different PCA morphine regimens on the intensity, location and quality of pain as well as on the perceived amount of relief and side effects in patients with sickle cell disease (N=13; mean age 13.7 years; eight males; five females). The preliminary data showed that a regimen with a high background infusion rate and low intermittent push dose (Regimen B) may provide better response to PCA morphine. The difference in trends between the worst and least pain intensity ratings were narrower in this regimen, suggesting that pain peaks and troughs were not occurring as in a regimen with an around the clock nurse administered dosing schedule (Regimen C). The amount of morphine that was administered per day was not significantly different (p > 0.05) among the three morphine regimens. The combination of a high background infusion rate and low intermittent push dose (as in Regimen B) within the first 24 hours of admission, may provide improved response and possibly shorter recovery from the painful episode than the regimen that would routinely be prescribed with lower background infusion rate and high intermittent push dose (as in regimen A).

Fibromyalgia has been recognized as a central pain disorder with evidence of neuroanatomic and neurophysiologic alterations. Previous studies with techniques of noninvasive brain stimulation--transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS)--have shown that these methods are associated with a significant alleviation of fibromyalgia-associated pain and sleep dysfunction. Here we sought to determine whether a longer treatment protocol involving 10 sessions of 2 mA, 20 min tDCS of the left primary motor (M1) or dorsolateral prefrontal cortex (DLPFC) could offer additional, more long-lasting clinical benefits in the management of pain from fibromyalgia. METHODS: Forty-one women with chronic, medically refractory fibromyalgia were randomized to receive 10 daily sessions of M1, DLPFC, or sham tDCS. RESULTS: Our results show that M1 and DLPFC stimulation both display improvements in pain scores (VAS) and quality of life (FIQ) at the end of the treatment protocol, but only M1 stimulation resulted in long-lasting clinical benefits as assessed at 30 and 60 days after the end of treatment. CONCLUSIONS: This study demonstrates the importance of the duration of the treatment period, suggesting that 10 daily sessions of tDCS result in more long lasting outcomes than only five sessions. Furthermore, this study supports the findings of a similarly designed rTMS trial as both induce pain reductions that are equally long-lasting.

Although sex differences in anxiety sensitivity or the specific tendency to fear anxiety-related sensations have been reported in adults with clinical pain, there is a dearth of relevant research among children. This study examined sex differences in anxiety sensitivity across unselected samples of 187 children with chronic pain (71.7% girls; mean age = 14.5) and 202 non-clinical children (52% girls; mean age = 13.6). Girls in the chronic pain and non-clinical samples reported elevated anxiety sensitivity relative to boys irrespective of clinical status. Girls with chronic pain also reported heightened fears of the physical consequences of anxiety compared to non-clinical girls but there were no such differences for psychological or social concerns. Among boys, anxiety sensitivity did not differ between the chronic pain and non-clinical groups. Future longitudinal research may examine whether specific fears of anxiety-related somatic sensations constitutes a sex-based vulnerability factor in the development of chronic pain.

Fibromyalgia is a poorly understood disorder that likely involves central nervous system sensory hypersensitivity. There are a host of genetic, neuroendocrine and environmental abnormalities associated with the disease, and recent research findings suggest enhanced sensory processing, and abnormalities in central monoamines and cytokines expression in patients with fibromyalgia. The morbidity and financial costs associated with fibromyalgia are quite high despite conventional treatments with antidepressants, anticonvulsants, low-impact aerobic exercise and psychotherapy. Noninvasive brain stimulation techniques, such as transcranial direct current stimulation, transcranial magnetic stimulation, and electroconvulsive therapy are beginning to be studied as possible treatments for fibromyalgia pain. Early studies appear promising but more work is needed. Future directions in clinical care may include innovative combinations of noninvasive brain stimulation, pharmacological augmentation, and behavior therapies.

Methods of cortical stimulation including epidural motor cortex stimulation (MCS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are emerging as alternatives in the management of pain in patients with chronic medically-refractory pain disorders. Here we consider the three methods of brain stimulation that have been investigated for the treatment of central pain: MCS, rTMS, and tDCS. While all three treatment modalities appear to induce significant clinical gains in patients with chronic pain, tDCS is revealed as the most cost-effective approach (compared to rTMS and MCS) when considering a single year of treatment. However, if a 5-year treatment is considered, MCS is revealed as the most cost-effective modality (as compared to rTMS and tDCS) for the neuromodulatory treatment of chronic pain. We discuss the theory behind the application of each modality as well as efficacy, cost, safety, and practical considerations.

To determine which of the previously proposed functional interference cluster models is most appropriate in patients with bone metastases and to determine if the cluster structures identified at baseline differed between responders and non-responders following palliative radiotherapy. METHODS: The confirmatory test data set consists of breast and prostate cancer patients treated with palliative radiotherapy between May 2003 to January 2007. Worst pain and functional interference scores were assessed using Brief Pain Inventory at baseline, 4, 8 and 12 weeks post radiation treatment. The baseline cluster structure of the confirmatory dataset was compared to each of the previously proposed baseline cluster models. Maximum likelihood CFA was used to account for possible correlation amongst the factor components. A MIMIC model was used to determine the invariance of the cluster models between responders and non-responders during follow-up. RESULTS: A total of 169 eligible patients were analysed. There were 91 male and 78 female patients with a median age of 68 years. The median KPS was 70. A single 8 Gy and 20 Gy in 5 fractions were used in 97% of all analysed patients. The RTOG model, in which relationships with others and sleep comprised the mood-related interference cluster and walking ability and normal work comprised the physical-interference cluster, provides the best fit for the sample data. The follow-up cluster structure is not similar across the responder groups indicating that cluster structures shift following radiation treatment, as evidenced by pain response. CONCLUSION: Although differing slightly this analysis confirms pretreatment symptom clusters exist for patients with bone metastases from breast or prostate cancer based on the RTOG 9714 data. This could help formulate symptom management interventions at initial diagnosis. Symptom clusters dissolve or change after treatment which may be a function of the treatment or population and requires further study.

There is limited evidence to date of the effectiveness of minimally-invasive brain stimulation in controlling postoperative pain. Two studies have provided preliminary evidence that transcranial magnetic stimulation (TMS) can significantly reduce post-operative pain, and no studies have been published on the effects of transcranial direct current stimulation (tDCS) on postoperative pain. The evidence supporting the role of brain stimulation in producing general anesthetic effects is also limited but there is a possibility that appropriately targeted electrical stimulation might have a role in the future if the technology permits such stimulation in a non-invasive manner. The present article provides a brief overview of the available evidence supporting the role of minimally invasive brain stimulation technology in perioperative medicine. More studies and well-controlled trials are needed to establish a clear role for minimally-invasive brain stimulation technologies in the perioperative arena.

Chronic or recurrent pain is a widespread health issue that affects a large proportion of the population, including adults and children. Family factors in the development of pain have received increasing attention of late as research has shown that pain tends to run in families, A burgeoning literature has also demonstrated the influence of parental factors in children's responses to chronic and laboratory pain. This review attempts to integrate: first,) the literature documenting an association between parent and child pain both within the clinical chronic pain and laboratory pain literatures; and second,) research accounting for likely mechanisms explaining the parent-child pain association. To this end, we present a conceptual model that incorporates a number of parent and child specific characteristics, such as parental responses, coping and gender role socialization as well as broader socio-demographic factors such as parent and child age and sex, family functioning, socioeconomic status, and race/ethnicity. It is anticipated that consideration of such variables will lead to needed research exploring the mechanisms of parent-child pain relationships, and to interventions designed to prevent and ameliorate child pain sensitivity when it correlates with poor adaptation to pain.

This paper uses a mixed-methods approach to examine the impact of pain-associated functioning limitations on children's lives and the strategies they develop to try to continue functioning. Forty-five children ages 10-18 completed standardized questionnaires and participated in semistructured interviews prior to intake at a university-based tertiary clinic specializing in the treatment of pediatric chronic pain. All the children reported that pain limited their functioning in everyday activities and that these limitations caused them frustration and distress. Qualitative analysis identified three distinct functioning patterns or groups, which were designated as Adaptive, Passive, and Stressed. The groups did not differ significantly in demographics or clinical pain characteristics. Adaptive children continued to participate in many activities and were more likely to realize that focusing on pain would heighten their perception of pain. Children in this group reported more effective use of distraction and of other independently developed strategies to continue functioning. Passive children had given up most activities, tended to use passive distraction when in pain, and were more likely to feel isolated and different from peers. Stressed children described themselves as continuing to function, but were highly focused on their pain and the difficulties of living with it. The qualitative groupings were supported by quantitative findings that Stressed children reported a higher degree of social anxiety than did Passive children and were more likely than the other groups to report experiencing pain throughout the day. Finally, Adaptive children were rated by their parents as having better overall health compared to Passive children.

This study examined the relationship between race, laboratory-based coping strategies and anticipatory anxiety and pain intensity for cold, thermal (heat) and pressure experimental pain tasks. Participants were 123 healthy children and adolescents, including 33 African Americans (51% female; mean age =13.9 years) and 90 Caucasians (50% female; mean age = 12.6 years). Coping in response to the cold task was assessed with the Lab Coping Style interview; based on their interview responses, participants were categorized as 'attenders' (i.e., those who focused on the task) vs. 'distractors' (i.e., those who distracted themselves during the task). Analysis of covariance (ANCOVA) revealed significant interactions between race (African-American vs. Caucasian) and lab-based coping style after controlling for sex, age and socioeconomic status. African-American children classified as attenders reported less anticipatory anxiety for the cold task and lower pain intensity for the cold, heat and pressure tasks compared to those categorized as distractors. For these pain outcomes, Caucasian children classified as distractors reported less anticipatory anxiety and lower pain intensity relative to those categorized as attenders. The findings point to the moderating effect of coping in the relationship between race and experimental pain sensitivity.

Little is known about how sociodemographic factors relate to children's chronic pain. This paper describes the pain, health, and sociodemographic characteristics of a cohort of children presenting to an urban tertiary chronic pain clinic and documents the role of age, sex and minority status on pain-related characteristics. A multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Two hundred and nineteen patients and their parents were given questionnaire packets to fill out prior to their intake appointment which included demographic information, clinical information, Child Health Questionnaire - Parent Report, Functional Disability Index - Parent Report, Child Somatization Index - Parent Report, and a Pain Intensity Scale. Additional clinical information was obtained from patients' medical records via chart review. This clinical sample exhibited compromised functioning in a number of domains, including school attendance, bodily pain, and health compared to normative data. Patients also exhibited high levels of functional disability. Minority children evidenced decreased sleep, increased somatization, higher levels of functional disability, and increased pain intensity compared to Caucasians. Caucasians were more likely to endorse headaches than minorities, and girls were more likely than boys to present with fibromyalgia. Younger children reported better functioning than did teens. The results indicate that sociodemographic factors are significantly associated with several pain-related characteristics in children with chronic pain. Further research must address potential mechanisms of these relationships and applications for treatment.

Pain is a common problem among persons living with HIV. In this population, pain often co-occurs with psychological symptoms, as well as illicit drug abuse. Recently, the misuse of prescription drugs, including the misuse of opioid medications for pain relief, has emerged as a significant public health problem. The purpose of this article is to review the literature on the associations among pain, illicit drug use, and symptoms of depression and anxiety in the misuse of prescription medications in HIV disease. Although relatively little attention has centered on the management of pain, psychological symptoms and other distressing, yet treatable symptoms in HIV, the fact that drug abuse behaviors now constitute a primary risk factor for HIV infection requires a shift in focus for clinicians and researchers alike. There is currently little agreement regarding the medical provision of opioids to persons with a history of illicit drug use. Thus, additional research is required to ensure adequate treatment of pain and psychological symptoms in persons living with HIV while minimizing the risk of prescription drug misuse.

Objective: In this case study, we describe a new program to disrupt the cycle of social isolation and chronic pain by emphasizing social coping skills via peer mentorship. The program aimed to utilize peers who have learned to self-manage their own chronic pain to assist patients with social coping skills to reduce isolation caused by chronic pain conditions. Study group: Children and adolescents with chronic pain. Methods: This case describes the experience of a 17 year-old, African American boy with diffuse chronic body pain as a participant ("the mentee") in the program; his mentor was a 19 year-old girl with chronic pain associated with rheumatoid arthritis. The mentor received six hours of training and she mentored the patient in 10 weekly sessions. Results: The mentee connected very well with his mentor through sharing similar pain experiences. He demonstrated improvements in positive affect, sleep, social coping, and perception of bodily pain on a variety of quantitative measures. Qualitative data from interviews also suggested that the mentee learned important social coping skills through peer mentorship. Conclusions: A peer mentoring approach to chronic pain may help alleviate social isolation in adolescents and result in improvements in a number of associated symptoms.

Children with autism are a special group of individuals with different needs. They need to be active and they need to receive special attention to decrease the symptoms of autism. COVID-19 pandemic was an unexpected situation, which lead to quarantine. There was no more opportunity for gathering of children and it had some side effects on physical and psychological characters of children with autism. This paper has tried to have a look at this issue and suggest solutions for this group of children. It should be noted that, all of the published researches in this field, confirmed the need for doing regular physical activity at home to prevent from physical and psychological side effects.

In the COVID-19 situation, some athletes continue exercise in different places, such as parks. They become worried and depressed about losing physical fitness during quarantine. They hurt their legs, because of doing exercises in ground condition due to sports injuries such as periostitis and physical pain. Social pain, stress, and losing physical fitness are complaints of the athletes. The current study provides some suggestions for athletes with a sports injury at home. This commentary suggests possible home-based exercises to avoid stress, depression, physical inactivity, and social pain among athletes.

The purpose of this study is to review the coordinated, multidisciplinary approach to the management and care of cancer patients with metastatic bone disease at the one-stop bone metastases clinic (BMC) at the Odette Cancer Centre. Patients with symptomatic bone metastases are referred to the BMC and assessed by a team consisting of specialists in various disciplines such as interventional radiology, orthopedic surgery, palliative medicine, and radiation oncology. At initial consultation, patient demographics, reasons for referral, and case disposition were recorded. From June 2006 to December 2008, a total of 254 patients with bone metastases were seen at the BMC. The median age was 64 years (range 29-94) and median KPS score was 70 (range 10-100). The majority of patients arrived from home (85%), while 5% of patients came from a hospital. Approximately 16% of patients had 2 or more reasons for referral, yielding a total of 295 reasons. Bone pain was the main reason for referral (69%), followed by a pathological fracture (10%) and impending fracture (8%). Out of 254 patients, only 240 case dispositions were recorded, with 3 patients receiving 2 treatment recommendations. Almost a third of patients (28%) received palliative radiation, 20% needed further investigation and/or imaging, 17% were referred to other support /specialist services such as palliative care or physiotherapy, and 15% of patients were offered surgery. A co-ordinated multidisciplinary clinic is useful in managing symptomatic bone metastases in cancer patients.

The femur is the most common site for long bone metastases. Complications from long-bone metastases include severe pain, compromised functionality, and most importantly, the possibility of impending pathological fractures. Although radiotherapy is an effective treatment for palliative pain control, surgery is utilized to treat metastatic lesions causing bio-mechanical instabilities. We report a unique case of a breast cancer patient with multiple bony metastases, including an impressive asymptomatic 20cm long lesion in the left femur that did not require surgical intervention. Pre and post radiation treatment was assessed by magnetic resonance imaging (MRI), showing a response to radiotherapy treatment.

Bone metastases may cause severe debilitating pain that significantly impacts mobility and decreases quality of life. In particular, osteolytic lesions may create a significant potential fracture risk in weight bearing regions and if left unattended may necessitate complex orthopedic surgical intervention. Radiofrequency ablation (RFA) assisted cementoplasty is an efficacious method in palliating and stabilizing such lesions and can produce durable pain control in cancer patients. RFA alone imparts significant improvements in pain reduction; however, if used in adjunct with cementoplasty, it improves stabilization and may enhance pain relief. The combination of RFA assisted osteoplasty or vertebroplasty with radiation may have a synergistic effect that combines pain control with the added benefit of stabilization. We present the case of a prostate cancer patient with a focal lytic deposit in the acetabular region causing severe and pain on weight bearing, resulting in loss of mobility.

A 63-year-old female patient presented with spinal abnormalities. Differential diagnosis includes diffuse infiltration with metastases versus inflammation. Cerebrospinal fluid (CSF) from three lumbar punctures was clear. Although leptomeningeal disease may have been the cause, we suspected otherwise following review of spine and brain magnetic resonance imaging (MRI) as well as the patient’s anti-inflammatory response to a steroid.

To compare the clinician predicted survival (CPS) with the actual survival (AS) of patients with advanced cancer. Methods: Participants were asked to estimate the median survival as well as the upper and lower range of expected survival in whole months from the time of referral to the outpatient radiotherapy clinic for five real cases presented in the survey. Secondly, the participants were asked to rank the five most important prognostic factors they considered in answering the previous questions. Finally they were asked to provide some basic information concerning time spent in their field of expertise so one could compare and contrast the survival estimates according to different disciplines, and according to their years of experience. Results: The response rates to the survey from physicians, nurses and radiation therapists were 50%, 53% and 59% respectively. In general, the survival prediction from all disciplines was not accurate. The predictions tended to be optimistic in patients with short-lived survival (≤ 6 months) and pessimistic in patients with longer survival (≥ 9 months). There did not appear to be significant differences in the direction of survival prediction among the three disciplines. The accuracy of survival prediction did not depend on the experience of the health care professionals. Conclusions: Survival predictions are important, but, given the poor predictions of the clinicians, it is necessary to develop better predictive models for survival using clinical parameters rather than relying on intuition and clinical judgment alone.

We present a case of a 45 year-old premenopausal patient with breast cancer who developed multiple sites of bone metastases. She presented with severe pain in her right femur and hip with inability to weight-bear. Imaging demonstrated extensive lytic destruction of the femoral neck and acetabulum. A combined approach with right hip hemiarthroplasty to treat the high risk proximal femoral lesion, cementoplasty to stabilize the acetabular lesion and palliative radiation was used. The patient suffered minimal procedural morbidity and was discharged after a 2 day inpatient stay. She had significant pain relief and rapidly regained functional independence with full weight bearing.

The research question for the Cochrane Nursing Care Field (CNCF) was if diclofenac decrease acute pain and post-administration adverse effects in children compared to a placebo or any other treatment? The review revealed that Diclofenac was effective in treating acute post-operative pain in children. When given during the peri-operative period, Diclofenac significantly decreased the number of children requiring additional pain medication by half, and significantly reduced the incidence of nausea and/or vomiting. Diclofenac was twice as effective as Paracetamol for pediatric surgical pain, and while it causes similar types of serious adverse reactions as in adults, they are rare and occur in fewer than 3 in 1,000 children who received the drug. Intramuscular injections should be avoided due to the risk of serious injection site tissue damage. More research is recommended to determine optimal dosing in children, as this aspect of drug administration was not a focus of any of the studies.

Prostate adenocarcinoma is one of the leading causes of death in men. Bone metastases are common in patients with prostate cancer, typically being characterized as osteoblastic. Evidence shows that although osteoblastic activity is dominant, osteolytic activity is also present. Treatment for bone metastases is often multi-disciplinary and palliative, targeting pain management as well as preventing deteriorating quality of life. This report presents the case of a patient who was found to have rare osteolytic lesions rather than the typical osteoblastic lesions. The patient received radiation treatment to the lesions of the spine, right hemipelvis including the hip to mid-femur and left mid femur. In the most recent CT scan, the radiated sites showed increased sclerosis within the osteolysis and periosteal new bone formation. Radiotherapy helped alleviate the pain and promote healing in the affected bones.

Due to aging population, the number of patients diagnosed with cancer is expected to be increasing worldwide. Various cancer treatments were known to cause different morbidities in physical, functional and psychological aspects which can either be short term or long time lasting for years. All these adversely affect patient’s daily activities, social life and overall quality of life. This review mainly focuses on patients receiving adjuvant treatments and the effects of exercise in modulating the above-mentioned treatmentrelated morbidities. A total of 15 articles were included after removal of duplicates and exclusion of studies based on pre-defined criteria. Currently available evidences suggested that exercise during cancer treatments was safe and feasible. Improvements were observed in objectivelymeasured outcomes include physical fitness, muscular strength and body composition. Few studies evaluated effect of exercise on treatment completion rate but all showed encouraging results with less likelihood and amount of chemotherapy dose reduction. Evidences on patientreported outcomes were less consistent except for reduction in cancer-related fatigue. Benefits in different sub-domains of health-related quality of life were demonstrated in different studies but not for overall quality of life, which could be explained by the complex interaction between physical, mental, social and functioning components in the overall well-being of patients. However, majority of studies had relatively short follow-up which ended at the time of completion of exercise program in which long term benefits from earlier exercise started during treatment period remained unanswered.

The present study investigated the impact of narcotic administration on quantity and frequency of recidivism by patients presenting to the Emergency Department (ED) with a primary complaint of chronic pain. This study explored the relationship between narcotic administration, gender, prescribing physician and subsequent ED visits. We analyzed the data from the twelve months of medical records for 80 patients (278 visits) who presented at the ED of a general medical center in a rural area. Results indicated that the number of visits by those who received narcotics was significantly higher than for those who did not receive narcotics. There was also a significant difference in prescribing patterns, with females being more likely than males to receive a narcotic. Observable differences were found between the frequency of days between visits for those who received narcotics vs. those who did not, and the differential pattern of narcotic administration between providers. These findings raise the question that the receipt of a narcotic may reinforce visits to the ED. This study concluded that an established protocol for treating patients with chronic pain who present in the ED may be useful.

Objectives of our study was to evaluate the effect of the combination of the two drugs in patients with knee osteoarthritis. Methods: A randomized, double-blind comparative study was conducted on 28 patients. G1 (n: 14) received morphine (2mg) and methylprednisolone (80mg); G2 (n: 14) received intra-articular methylprednisolone (80mg). The following parameters were evaluated: time to first analgesic request; pain intensity at rest and during movement; knee extension and flexion angle before blockade and after 30 and 60 min and 1 week; paracetamol dose. Results: There was no difference in pain intensity at rest before injection (G1: 3.3 ± 3.2; G2: 4.2 ± 3.1) or after 1 week (G1: 1.2 ± 2.4; G2: 1.2 ± 2.0), and a significant reduction in pain was observed after 1 week in G2. No significant difference in pain intensity during movement was observed before injection (G1: 7.9 ± 2.2; G2: 8.3 ± 1.4) or after 1 week (G1: 3.3 ± 2.9; G2: 3.6 ± 2.9); and pain intensity reduced in both groups after 1week. The two groups did not differ in terms of time to first supplementation or total paracetamol dose used. No difference in the flexion or extension angle was observed between groups or before injection and after 1 week. Conclusions: No difference in the analgesic effect was observed for the combined intra-articular administration of morphine (2 mg) and methylprednisolone (80 mg) in patients with knee osteoarthritis.

Intact hypothalamic-pituitary-adrenal (HPA)-axis plays an important role in trauma due to stress upon major surgery. Normal HPA-axis function may be impaired in patients receiving epidural glucocorticoid injection (EGI) for acute pain. We aimed to identify these putative at-risk patients and examined the effect of EGI on the HPA-axis. Methods: We enrolled 28 patients with acute low-back pain who received EGI due to lumbar disc herniation. Baseline and stimulated plasma cortisol concentrations were measured before and 14 days after EGI. Stimulated cortisol concentrations were measured 30min after intravenous low-dose (1mcg) ACTH (adrenocorticotropic hormone) infusion. Normal responses to ACTH were defined as stimulated plasma cortisol concentration > 550nmol/L or a cortisol increase of at least 250nmol/L. Results: Baseline and stimulated cortisol concentrations were different between day 0 and day 14 (p < 0.01). Seven patients (27%) had a normal response to ACTH, but in comparison to day 0, the stimulated plasma cortisol levels were significantly lower at day 14 (p = 0.02). Nineteen patients (73%) had a substantially deficient adrenal response to ACTH after EGI (day 14). This group revealed significantly lower stimulated cortisol concentrations prior to EGI (p < 0.05) and thereafter (p < 0.001) compared to normal responders. Discussion: The HPA-axis suppression in 73% of the patients could be characterized by significantly reduced plasma cortisol levels after low-dose ACTH infusion prior to EGI. Given their particularly low cortisol response upon ACTH following EGI, these patients apparently inherent at risk to suffer adrenal insufficiency in stressful events after EGI.

Pain is a difficult phenomenon to measure especially in individuals with intellectual and developmental disabilities (IDD), thereby compromising pain management for this population. Despite that fact, measures that evaluate pain in adults with IDD are scarce. Recently two scales have been constructed to evaluate pain behaviors in adults with IDD, the Non-Communicating Adult's Pain Checklist (NCAPC) and the Pain and Discomfort Scale (PADS). Aim: The aim of the present article was to compare the NCAPC and PADS in evaluating procedural pain in adults with IDD, in regards to reliability, sensitivity, clinical usability and internal consistency. Procedure: 52 vignettes were randomly picked out of a pull of videos of 228 individuals recorded during annual flew vaccination. Two observers separately scored pain behaviors using the PADS and the NCAPC. Results: Both scales showed high interrater reliability (PADS ICC1,3 = 0.86-0.87, NCAPC ICC1,3 = 0.81-0.84), Sensitivity to pain behaviors in adults with IDD (SRM PADS = 0.52, SRM NCAPC = 0.57), high correlation among the scales (r1 = 0.9, r2 = 0.95), and high internal consistency (PADS α = 0.74-0.78, NCAPC α = 0.78-0.85). Discussion: Most findings are favorable for the NCAPC accept for interrater reliability. These results are probably due to the fact this scale was constructed from this group of client's pain reactions. The fact that both scales show very similar outcomes validate both scales as appropriate for measuring pain in adults with IDD. The fact that two inexperienced observers were able to use both scales and come up with such good psychometric results, support the clinical usability of both scales, hopefully contributing to better pain management in this population.

It is suspected that those with intellectual disabilities (ID) experience more pain, more frequently then the general population, yet there are currently no well-validated measures for pain assessment in adults with ID. This research aimed to respond to this need by validating the Non-Communicating Children's Pain Checklist - Revised (NCCPC-R) for use with adults with ID during chronic or recurrent pain. Staff at a regional residential facility observed participants (N = 16) during two conditions (pain; no-pain) for 5-minute periods. The two staff independently completed both the NCCPC-R and a 10 cm visual analogue scale (VAS) of pain. Analyses indicated 6 of the 30 items should be removed from the NCCPC-R. Internal consistency (Cronbach's alpha = .86), inter-rater reliability (ICC = .83) and construct validity (t(15) = 7.03 p < .001) of a new 24-item scale indicate good psychometric properties. A cut-off score of 10 provided 94% sensitivity and 87% specificity for pain. Our results indicated revisions should be made to the NCCPC-R to improve psychometric properties when used for chronic or recurrent pain in adults with ID. Our new scale, which we have called the Chronic Pain Scale for Nonverbal Adults with Intellectual Disabilities (CPS-NAID), displays good psychometric properties in this pilot study. Future studies should include both the NCCPC-R and the CPS-NAID to confirm the results we found here.

Dementia affects over 47 million people globally, and this number is projected to exceed 100 million by 2050. Dementia in the elderly is characterized by progressive cognitive and functional decline. As there is no cure for dementia, care is focused on pain management as many individuals experience pain from comorbidities. However, clear guidance on evidence-based pain management strategies for dementia patients is lacking. The purpose of the review was to examine pain management strategies in the older adults with dementia because often pain and pain medications can lead to exacerbations in cognitive symptoms. A selective literature search was conducted using Ovid MEDLINE, Embase Classic, Embase and Cochrane Central Register of Controlled Trials. Subject headings/keywords included: “older adults,” “dementia,” “pain,” and “pain management.” The search produced 1,033 articles, of which 11 were included in the final review. There is evidence that pharmacological pain management strategies employing acetaminophen as a first line treatment or as part of a stepped care approach i n patients with dementia reduced pain and dementia-associated behavioural symptoms, and improved activities of daily living. There is mixed or limited literature regarding the use of other pharmacological agents including opioids to manage pain. There is mixed or limited evidence to support non-pharmacological strategies such as the Namaste Care Program, music intervention, ear acu-pressure, and massage therapy for pain management in this population. Stepped-care approaches with acetaminophen show promise to reduce pain and dementia-associated behavioural symptoms. Other pharmacological/non-pharm-acological management strategies require additional research to determine their effectiveness for managing pain.

Persistent musculoskeletal pain affects more than half of the older population. Whether due to arthritic or non-arthritic causes, pain is a major cause of disability even when other impairments, diseases, and symptoms are taken into account. Accumulating evidence implicates pain as a cause of falls in older adults. Older adults who have persistent pain and pain-related disability are particularly vulnerable to falls, which can lead to injuries, hospitalizations, institutionalization, and death. Studies have examined arthritis as a possible risk factor for falls with mixed results, and a few studies have begun to address the problem and consequences of chronic pain more broadly in the older population. In this review, we examine the literature about persistent pain and falls in older adults, discuss possible mediators of the pathway from pain to disability and falls including the role of pain management, and identify future directions for research.

Chronic low back pain (CLBP) is common in older adults. Findings from younger patients may not be generalizable to older adults with this condition. Objective: To investigate the evidence from RCTs for the effectiveness of physiotherapeutic interventions on pain and function in older adults with non-specific CLBP. Study group: Studies including older adults (≥65years) with non-specific CLBP of ≥3 month's duration were included. Methods: The Cochrane Back Research Groups' guidelines were used as a methodological template for this systematic review. A literature search of EMBASE, CENTRAL, Medline, AMED, CINAHL and PEDro was performed up to November 2010. Two reviewers assessed the quality of included articles and the evidence for interventions was qualified using the GRADE system. Results: Three moderate quality RCTs were included. They investigated the following: mindfulness meditation, Percutaneous Electrical Nerve Stimulation [PENS], Exercise, and PENS and Exercise combined. Outcome measures for pain and function were reported for the short and medium-term only. There was limited evidence that compared to control/placebo interventions mindfulness meditation, exercise, and PENS combined with exercise have no effect on pain or function in older adults with non-specific CLBP. There was conflicting evidence that PENS compared to placebo is effective for pain and function. Conclusions: This systematic review identified only three studies that have investigated the effect of physiotherapeutic interventions on older adults with CLBP. There was insufficient research upon which to make firm clinical recommendations. Further research is needed on this severely under investigated and growing clinical population, to guide clinical practice.

Advance directives (AD) document treatment decisions of a person when he or she still possesses mental capacity, in preparation for loss of such capacity due to disease. AD is commonly used in patients with advanced cancer. Objectives: To identify common factors influencing AD completion in Chinese cancer patients, and to examine the implementation of completed ADs in our unit. Methods: This retrospective analysis included patients with advanced cancer without active oncological treatment, recruited in a local palliative care unit between October 6th 2014 and September 30th 2015. Data collected included demographic characteristics, pain control, risk assessment for suicidality and complicated caregiver bereavement, and score in Hospital Anxiety and Depression Scale. Univariate analyses evaluating factors associated with AD completion and non-completion were conducted. Results: 47 patients were deemed eligible for analysis, 25 (53.2%) of whom completed an AD. All ADs were carried out as per patients’ preferences. Though no statistically significant predictive factors were identified, age, family influence and patients’ knowledge on ADs were found to potentially influence patients’ decisions regarding AD completion. Conclusion: A high rate of AD completion in our study suggests that discussion of AD in Chinese patients with advanced cancer is feasible, and education and family engagement in care-planning may increase AD completion.

The role of exercise as an intervention for advanced cancer patients remains understudied. The benefit of prescribed exercise programs in early-stage cancer is generally well accepted; however, physical activity regimens are an infrequent component of care in hospice and palliative cancer clinical settings. This chapter is a review of 18 studies, including pilot uncontrolled single-group trials, pilot randomized control trials (RCTs), and single case reports, on exercise as an adjunctive and palliative therapy in augmentting the physical and psychosocial function of patients with advanced cancer. Exercise has been shown to improve pain, fatigue, insomnia, psychological symptoms, quality of life, shortness of breath, functional capacities, and bone density in advanced cancer patients. Overall, the literature has endorsed Winningham’s conception of palliation and the prescription of tailored exercise rehabilitation programs that take into consideration indiv-idual cancer-type, health status, treatment, and preferences. However, low adherence rates and significant clinical heterogeneity in both disease profile and exercise modality between studies have frustrated the establishment of standardized clinical guidelines for this patient population. Therefore, additional RCTs of adequate sample size investigating the effects of exercise on the biopsychosocial wellbeing of advanced cancer patients need to be conducted to clarify best practice protocols.

To examine if there is a gender difference in Edmonton Symptom Assessment System (ESAS) symptoms in patients with advanced cancer. Methods: Consecutive advanced cancer patients referred for outpatient palliative radiotherapy at the Rapid Response Radiotherapy Program (RRRP) completed the ESAS prior to radiation treatment. Baseline demographics were obtained for each patient. Correlation between gender, demographics, and the ESAS items was calculated using univariate logistic regression analysis. Results: A total of 1,107 patients were referred to RRRP from January 1999 to January 2002 and July 2007 to October 2008. There were 601 (54%) male and 506 (46%) female patients. The median age was 69 years (range 21 - 95). Males were older (male median age=70 years; female median age=66 years; p<0.0001). The most common primary cancer sites were lung (32%), breast (22%), and prostate (21%). Females reported significantly higher mean scores (± SD) for tiredness (5.1 ± 3.0 versus 4.7 ± 3.0, p=0.027), nausea (1.6 ± 2.6 versus 1.1 ± 2.1, p=0.0004) and anxiety (3.4 ± 3.2 versus 2.7 ± 3.0, p=0.0017). Conclusions: There is a gender difference in certain symptom distress scores in patients with advanced cancer. Our findings should be validated in future studies.

Due to the poor prognosis associated with cancerous and non-cancerous advanced lung disease, the main intention of treatment is to improve the patient's quality of life (QOL). A treatment option that may achieve this goal is oxygen therapy. Currently, there is little literature analyzing the QOL of patients with advanced lung cancer receiving oxygen therapy for dyspnea. However, research has been conducted on patients with chronic obstructive pulmonary disease (COPD) suffering from dyspnea. The similarities of symptoms and underlying pulmonary function between patients with advanced lung cancer and COPD suggest that these populations could be similarly impacted by oxygen therapy. A systematic, computerized literature search was performed using the Ovid search engine for the following databases: MEDLINE® (1950 to September Week 1, 2010), EMBASE (1980 to 2010 Week 37) and PsychINFO (1967 to September Week 2, 2010). Search strands were designed to retrieve articles on patients with advanced lung cancer or COPD, oxygen therapy, QOL and survival. Based on the 12 articles reviewed, studies have contrasting conclusions with regards to the patients' QOL when using oxygen therapy. Further research is suggested to explore the impact of oxygen therapy on patients with advanced lung disease.

A retrospective single centre review on the effectiveness and durability of haemostatic radiotherapy in advanced stomach cancer. Method: Patients with advance stomach cancers were intended to be treated with haemostatic radiotherapy. All of them developed evidences of low grade gastrointestinal bleeding and were haemodynamically stable. Symptom response, duration of haemostatic control, median survival and radiotherapy waiting time were evaluated. Results: From April 2006 to April 2009, twenty-eight patients, with median age of 76.5 years old were included. Pre-treatment haemoglobin ranged 3.5-11 g/dL (median 6.9g/dL). Patients received radiotherapy using either conventional technique with anterior-posterior opposing photon fields, or 3-D CT based planning technique. The median survival was 68 days, the rate of bleeding control was 65.2% (15/23), and the median duration of response was 60 days (11 to 479 days). Five patients deteriorated and died before commencement of radiotherapy. Median survival for patient with radiotherapy waiting time less than or equal to 14 days was 72 days (95%CI 45.1 - 98.9 days), compared to 43 days (95%CI 14.1 - 71.2 days) for patient with radiotherapy waiting time more than 14 days. Median survival was significantly longer in patient with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 1 compared with PS 2 or 3. Conclusion: Radiotherapy is effective in controlling low grade gastrointestinal bleeding in advanced and metastatic cancer of the stomach. Careful patient selection is required to maximize its benefit. Waiting time for radiotherapy should be as short as reasonably achievable.

Survival prediction is crucial in advanced cancer populations for clinical, ethical and organization reasons. Among a myriad of tools, Edmonton Symptom Assessment Scale (ESAS) is a previously-validated tool for prognostication. Objective: To review the effectiveness and limitations of different survival prediction tools, report our single center experience of using ESAS as survival predictor, and develop a simple prognostic tool suitable for clinical practice in a community palliative care center. Methods: All deceased patients aged 18 years of age or older, having a diagnosis of advanced, metastatic or incurable malignancies, and an ESAS completed in their first encounter at the Tuen Mun Hospital in Hong Kong between September 2011 and October 2011 were included. Patient demographic and clinical data was collected retrospectively based on a rigorous chart review. Overall survival and a multivariate analysis evaluating prognostic factors was conducted. Results: ESAS records of 85 patients were included in our analysis. Median Karnofsky Performance Scale (KPS) score was 60 (range 30-100). Median ESAS score was 10 (range: 0-51), and median survival was 6.4 weeks (95% Cl: 5.3-9.6 weeks). Multivariate analysis suggested ESAS (hazard ratio [HR] 3.94) and KPS (HR 1.95) independently predicted overall survival. Three groups were stratified based on these prognostic factors: median survival of group 1 (ESAS < 25 and KPS ≥ 60), group 2 (either ESAS ≥ 25 or KPS < 60) and group 3 (ESAS ≥ 25 and KPS < 60) were 105 days, 20 days and 10 days, respectively. (p < 0.0001). Conclusions: Our finding suggest that ESAS offers promising potential as a prognostication tool predicting survival. Its ease of use and dual role as both a symptom assessment and a survival estimation tool allows the ESAS to be seamlessly integrated into daily clinical practice.

This paper reviews the conventional and advanced CT and MR techniques used to diagnose and monitor brain metastases. Advances in imaging technology have resulted in improvements in anatomic imaging for diagnosis and localization, but have also permitted the development of methods to non-invasively elucidate tumor biology and physiology. These technologies show great promise in improving the accuracy of preoperative diagnosis, evaluating tumor aggressiveness and biology and predicting and monitoring treatment response.

External beam radiotherapy (EBRT) given to advanced lung cancer patients undergoing palliative care is intended to relieve the symptoms that disrupt a patient's overall Quality of Life (QOL). This treatment, however, may also pose unwanted toxicities and side effects. This report presents five cases in which patients have been diagnosed with advanced lung cancer or lung metastases and were subsequently treated with external beam radiotherapy. In an attempt to assess the efficacy of the treatment, diaries were given to the patients to fill out at baseline, during treatment and 10 days after treatment. The diary collected data on the medications taken by the patient and evaluated the perceived severity of the following acute toxicity symptoms: coughing, hemoptysis, dysphagia, chest pain and dyspnea. In addition, the patients completed QOL questionnaires, European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative (QLQ-C15-PAL) along with the EORTC QLQ-Lung Cancer (QLQ-LC13). Four of the patients had a generally improved or stabilized QOL, while one felt intensified symptoms and a worsened QOL. The information gathered from these assessments can provide clinicians with a greater understanding of the experience of EBRT through the patients' perspective and can therefore guide future modifications in EBRT treatment.

Quality of life for advanced cancer patients is of utmost importance. To address this concern, 8 cancer centres across Canada have established palliative radiotherapy clinics dedicated to providing rapid access to radiotherapy for patients suffering from debilitating symptoms. The first of such clinics was the Rapid Response Radiotherapy Program (RRRP), established in 1996 at Toronto Sunnybrook Odette Cancer Centre. Since then, there has been much progress in initiating similar programs elsewhere across Canada, but a current detailed summary of their status is lacking. This report reviews and summarizes the emergence and current status of rapid access palliative radiotherapy programs in Canada and a similar specialized clinic in Australia since the time of their inception.

The aesthetic perception may induce a specific effect on central pain processing. The aim of the present study, was to evaluate the pain rating and Laser Evoked Potentials (LEPs), obtained during the vision of International Affective Pictures System images (IAPS), rated under an aesthetic point of view as beautiful, neutral or ugly. Six out off 24 healthy subjects, evaluated in a previous experimental task, were required to attribute to the same IAPS images, seen six months before, an aesthetic judgment, giving a subjective aesthetic rating from 0 (maximum of the ugliness) to 10 (maximum of the beauty). We considered the LEPs from the hand stimulation, obtaining for each case the averaging of the evoked potentials recorded during the vision of the IAPS images, judged as beautiful (rating 7-10 B), ugly (rating 1-4 Ug) or neutral (rating 5-6 Ne), in three separate blocks of at least 10 artefact-free responses. The aesthetic rating attributed to the IAPS pictures, correlated in a significant way to their affective content. The laser pain significantly correlated with the aesthetic rating attributed to the IAPS pictures. The vertex LEPs appeared significantly reduced during the vision of beautiful IAPS pictures, in respect to basal condition and the ugly pictures vision condition. These preliminary results suggest that the visual context is able to influence pain when the emotive impact matches with physical features, and confirm the aesthetic appraisal as a fundamental function able to influence the most important expressions of human brain.

Radiotherapy is currently the mainstay treatment for brain metastases. This treatment provides effective initial palliation of neurological symptoms. However, radiotherapy has limitations in maintaining local control, particularly with large volumes of intracranial disease. Potential radiosensitizers, agents when given in combination with radiation to increase the cytotoxic effects of radiation, have been evaluated in numerous clinical studies. This paper summarizes clinical studies in which both cytotoxic and non-cytotoxic radiosensitizers have been evaluated in combination with whole brain radiotherapy. In addition, this paper highlights how advances in our understanding of the pathophysiology of brain metastases, and effects of ionizing radiation on tumour cells, have enabled the development of newer chemotherapeutic agents that may improve tumour response through various mechanisms: targeting of molecular pathways involved in tumour development, progression and DNA repair, and increased ability to penetrate the blood-brain barrier therefore improved bioavailability in the brain.

This study was conducted to characterize the aggressiveness of end-of-life care in patients with lung cancer in an oncology department in Hong Kong. Methods: This retrospective cohort composed of patients diagnosed with locally advanced or metastatic lung cancer and received primary treatment from 2007-2009. 216 patients who died of lung cancer within the studied period were evaluated in terms of aggressiveness of cancer-care in end-of-life. Results: One hundred and forty of the 216 patients (64.8%) underwent palliative chemotherapy. 16.4% started a new chemotherapy regimen within 30 days of death and 22.1% received chemotherapy within 14 days of death. 22.9% experienced grade 3/4 toxicities and 21.4% were admitted at least twice during last line of treatment. By multivariate analysis, more extensive disease, age less than 65 and longer survival from diagnosis was positively associated with chemotherapy use. Patients with reasonable performance status were more likely to receive chemotherapy within 14 days of death. 135 patients (62.5%) had been referred to hospice and around twenty percent of patient stayed in hospice before death for 3 days or fewer. For other indicators of aggressive end-of-life care, 20% were admitted to acute bed and 24.5% visited emergency room at least twice in last month of life. Conclusion: Among patients who died of lung cancer, a significant proportion was found to receive palliative chemotherapy near end-of-life. This can be contributed by the increase in availability of new chemotherapy options. Improvement in hospice service and development of simultaneous care model allows high-quality end-of-life care.

It is well known that a dysfunction of the prefrontal cortex in dementia produces disinhibited behaviour, reflected in agitation/aggression. The role of the prefrontal cortex in pain inhibition might be less known but implies that frontal lesions in dementia may lead to an increase in pain experience. Hence, in patients with dementia, a dysfunction of the prefrontal cortex may lead to a co-occurrence of agitated behaviour and pain. We argue that physical activity may decrease agitation and pain in dementia, by strengthening the inhibitory function of the prefrontal cortex.

Recent alterations to the criminal code following the passing of Bill C-14 have made Medical Aid in Dying (MAID) legal in Canada. With the new legislation in place, institutional questions arise concerning how MAID should be provided within the health care system. Alternatively, what are the limitations of conscientious objection to MAID? Palliative Care Units (PCUs) are in dire need of the answers to these questions, as they face contrary obligations towards patients requesting MAID. MAID seems to contradict some of the principle values of palliative care, while palliative care patients are also in a condition where they more likely to be eligible for MAID. Yet, examining some of these value contradictions more closely, there are more commonalities between MAID and palliative care than it would first seem. As a result, if PCUs conscientiously object to MAID as departments, then they are neglecting to fulfill their responsibility to honor their own missions and values. These commonalities in value between MAID and palliative care have clinical implications, as many of the patients who would prefer palliative care are also patients who would consider pursuing MAID concurrently. Three cases where patients could request both MAID and palliative care are outlined. They reveal a risk that a departmental conscientious objection to MAID in the PCU comes at the expense of patients receiving necessary palliative care.

Post-traumatic stress disorder (PTSD) is a mental illness that commonly affects military and police service veterans after experiencing traumatic events throughout their service. Alcohol and tobacco are often overused by this population to help relieve the symptoms of PTSD. The objective of this paper is to examine if alcohol and tobacco use in military and police service veterans with PTSD changed after using medical cannabis for PTSD symptom management. A retrospective chart review was conducted to analyse information about alcohol, tobacco, and medical cannabis use, as well as previously attempted PTSD treatment methods. 101 patients (average age 43 years, 96.0% male, 60.4% married, and 81.2% with children) who visited a single treatment center between January 2014 and April 2016 were included in this study. The most common treatments patients tried prior to using medical cannabis included self-treatment with non-medical cannabis (87.8%), medication for depression (86.6%) and anxiety (85.4%), and psychotherapy (82.9%). At baseline, 81.2% consumed alcohol (average 8.1 drinks/week) and 84.2% smoked tobacco cigarettes (average 2.7 packs/week). At follow-up, 67.3% consumed alcohol (average 5.5 drinks/week) and 67.3% smoked tobacco cigarettes (average 2.5 packs/week). The use of medical cannabis was correlated with a reduction in alcohol and tobacco use. However, statistical significance was not reached (p = 0.11 and p = 0.65, respectively). Medical cannabis has the potential to reduce alcohol or tobacco use in PTSD patients. Further investigation is required to understand how medical cannabis can alleviate PTSD-related symptoms, and to identify its impact on other lifestyle factors, such as tobacco and alcohol consumption.

Neuropathic pain is typically acccompanied by a constelation of signs and symptoms that gives to this condition a very distinct presentation. Allodynia - pain sensation induced by non-noxious stimuli, along with hyperalgesia - an exagerated response to noxious stimuli, are common findings in neuropathic pain, and are frequently accompanied by dysesthesias, paresthesias, after-sensations, and less frequently by changes in coloration and temperature of the affected area. Both hyperalgesia and allodynia are of special interest becuase they seem to be sensory expressions of very complex underlying phenomena. This article discusses neural mechanisms in the development and maintenance of allodynia, and the role of peripheral- and central sensitization in sensory disturbances present in neuropathic pain.

There are limited therapeutic treatment options for established heterotopic ossification. The most common treatment option is surgical resection of the bone formed followed with prophylactic radiation treatment to prevent reoccurrence. However, this presents an issue when a patient is not a surgical candidate: how is established heterotopic ossification treated then? Here, we present the case of a 55-year-old male with extensive heterotopic ossification in the pelvis area causing significant pain. Since this patient was not a surgical candidate, his options were limited. A single dose of 8 Gy of radiation was prescribed to the painful area and this patient experienced significant pain relief despite no interval radiological change in the established heterotopic ossification. Further studies should be conducted to assess and understand the efficacy of radiation to palliate pain caused by heterotopic ossification.