Quantifying the impact of COVID-19 on chronic pain services in the Republic of Ireland.

INTRODUCTION: During the COVID-19 pandemic, most medical services were shut down and resources were redistributed. Closures included pain management departments where many staff were redeployed. The aim of this study was to assess the impact of COVID-19 on chronic pain services in the Republic of Ireland. METHODS: An online survey was sent to pain consultants working in public hospitals in the Republic of Ireland between the 22nd and 28th September 2020. RESULTS: We received responses from 18 consultants from all 15 public hospitals in the Republic of Ireland with chronic pain services. Procedural volume during lockdown fell to 26% of pre-COVID levels. This had recovered somewhat by the time of the survey to 71%. Similarly, in-person outpatient clinic volume fell to 10% of per-COVID numbers and recovered to 50%. On average, 39% of public hospital activity was made up for by the availability of private hospitals. This varied significantly across the country. The use of telemedicine increased significantly during the pandemic. Before COVID, on average, 13% of outpatient clinic volume was composed of telephone or video consultations. This increased to 46% at the time of the survey. CONCLUSION: This survey of consultant pain physicians in the Republic of Ireland has revealed how chronic pain services have been affected during the pandemic and how they have evolved.

A national survey of publicly funded chronic pain management services in Ireland.

BACKGROUND: Chronic pain management services have historically been under-resourced in Ireland. There is no agreed model of care for chronic pain management services in Ireland. Previous studies have assessed the extent of services in Ireland without examining waiting times for access to services. AIMS: This study aimed to quantify the extent of, geographical distribution of and waiting times for access to publicly funded chronic pain management services in Ireland. METHODS: Using the British Pain Society's Core Standards for Pain Management Services in the UK (2015) and International Association for the Study of Pain (IASP) recommendations, a questionnaire was devised. Publically funded departments in Ireland were contacted and questionnaires completed. Waiting list data was publicly available and obtained from the National Treatment Purchase Fund website. RESULTS: There was a 100% response rate. Sixteen publicly funded chronic pain management services were identified. There are 27 chronic pain management consultants (16.6 whole time equivalents (WTE)) practicing chronic pain management, amounting to 0.55 specialists (0.34 WTEs)/100,000 of the population. There are 21 WTE for non-consultant hospital doctors (NCHDs), 26.5 WTEs for nursing, 8 WTEs for physiotherapy and 6.2 WTEs for psychology, nationally. A percentage of 93.75% of departments (n = 15) provide interventional therapies, 37.5% (n = 6) provide advanced neuromodulation and 43.75% (n = 7) are managing intrathecal pump therapies. There are five pain management programmes nationally. As of January 2020, ~ 25% patients on waiting lists for outpatient appointments were waiting > 18 months, with ~ 17% patients on waiting lists for interventional treatments waiting > 12 months. CONCLUSIONS: Shortage of multidisciplinary staff is of particular concern for Irish services. Patient access is limited as evidenced by significant waiting lists. In order to improve access to care and bring services in line with international recommendations, increased resources are needed.

Patient's perceptions of physical examination in the setting of chronic pain.

INTRODUCTION: Despite its clinical utility, progressive reliance on imaging technology can lead to devaluing the physical examination in patients with chronic pain. The primary objective of this study was to determine whether chronic pain patients have a positive or negative perception of the physical examination. METHODS: After institutional ethics committee approval, 120 adult patients as a convenience sample who attended a chronic pain clinic were included. Participants completed a 10-item survey regarding their overall perception of the physical examination. Kruskal-Wallis and Mann-Whitney U test analyses were conducted to explore associations between test items and patient ages, gender, employment, pain diagnosis, and duration of pain. All cross-tabulations of categorical variables were analyzed using Fisher's exact test for associations. RESULTS: The majority of participants were male (51%), aged 50-70 (44%). The most common pain diagnosis was back pain (62%). Most patients (77%) indicated that the overall experience of being examined was highly positive. Patients believe in the value of the physical examination as a diagnostic tool (97%). Patients believe in the relational value of the physical examination (92%). Age, gender, employment, pain diagnosis, and duration of pain were not associated with a more positive perception of the physical examination. CONCLUSION: Patients with chronic pain indicate that the physical examination is a highly positive aspect of their care. There are some negative aspects of been examined which physicians should be aware of. This study adds to our knowledge regarding the physical exam in chronic pain patients. It will inform practice and training.

Hope and chronic pain-a systematic review.

BACKGROUND: Hope is considered as an important therapeutic factor in health and illness. Chronic pain affects a significant proportion of the world's population and causes great emotional and physical suffering to patients. OBJECTIVE: The aim of this systematic review is to explore the current literature on hope and chronic pain. METHODS: A comprehensive review of current literature on hope and chronic pain was undertaken. Several databases were used (incorporating EBSCO, MEDLINE, PUBMED). Search terms included 'hope' and 'hopelessness' in conjunction with 'chronic pain, 'pain management' and 'pain reduction'. Articles were included if they reported a study (1) exploring outcomes of hope as an intervention for chronic pain, (2) reported on hope specifically and not related concepts and (3) included a measurement of hope. RESULTS: A total of three articles were found which fit the inclusion criteria. Each article used different tools to measure hope. The review demonstrates a gap in the literature regarding hope as a therapeutic intervention for chronic pain specifically. CONCLUSIONS: The findings of this review demonstrate that hope is influenced by several patient factors and has a positive impact on patients with chronic pain. The current literature supports the usefulness of hope as a therapeutic intervention for not only chronic pain but many chronic illnesses.

Forgiveness and chronic pain: a systematic review.

BACKGROUND: Forgiveness is becoming increasingly recognized for its role in healthcare, having shown promising effects in patients suffering myriad diseases, from coronary artery disease to HIV to breast cancer. AIMS: To review the current literature examining forgiveness and its relationship specifically to chronic pain. METHOD: In July 2019, a search was carried out of electronic databases (Academic Search Complete, AMED, Biomedical Reference Collection, General Science, Medline, PsycArticles, PsycInfo, Social Sciences Full Text and SPORTDiscus). Further results were obtained from reference lists. Inclusion and exclusion criteria were applied using PRISMA guidelines for systematic reviews. RESULTS: The initial search yielded 354 results, and after duplicates were removed and inclusion and exclusion criteria applied, the final result was seven papers to be reviewed. Of the seven papers reviewed, five showed a relationship between lower levels of forgiveness and either increased experience or decreased tolerance for pain. One paper showed higher levels of empathy improving pain levels and suggests that forgiveness could enhance this experience of empathy. One study resulted in a higher level of pain among patients with higher forgiveness scores, although it was qualified that this particular patient population had a higher attachment anxiety, which may have impeded their ability to utilize forgiveness therapy. CONCLUSIONS: There is an association between the capacity to forgive and the experience of chronic pain. Further research should examine forgiveness as an intervention in a population of chronic pain patients to explore this relationship further.

Patient-rated physician empathy and patient satisfaction during pain clinic consultations.

BACKGROUND: Little is known about the influence of patient-perceived healthcare provider empathy on patient satisfaction in the setting of a hospital pain clinic consultation. The objective of this research was to examine the relationship between patient-rated physician empathy and patient satisfaction after a single new pain clinic consultation. METHODS: After institutional ethics committee approval, a sample of 140 adult patients completed a two-page questionnaire, directly after a pain clinic consultation. This included a brief sociodemographic questionnaire, the Consultation and Relational Empathy (CARE) measure and an overall satisfaction rating. RESULTS: The sample, N = 140 patients, was balanced for gender and 80% of participants ranged in age from 30 to 70. Of these patients, 80.7% had been living with chronic pain between 1 and 5 years. The data were deemed to be non-parametric and a Spearman's ranked order correlation analysis yielded a strong positive correlation between patient-rated physician empathy and patient consultation satisfaction. CONCLUSION: Patient-rated physician empathy was strongly correlated with patient satisfaction in a pain clinic consultation. Patient satisfaction plays a significant role in adherence to treatment and contributes to a positive working patient-physician therapeutic relationship. This research supports the growing body of research citing the importance of investing in, promoting and developing educational programs for physicians and medical trainees to enhance empathic communication skills within the clinical setting.

Duration of opening statement of patients attending a chronic pain clinic consultation.

BACKGROUND: The opening patient statement is an important part of the medical consultation. It is where after the initial solicitation the physician gets information about the patient's current problems and concerns. Previous research shows that 23-28% of patients are allowed to complete their opening statement un-interruptedly in the general practice setting. Interruption results in fewer patient concerns expressed and failure to gather potentially important patient information. OBJECTIVES: The objective of the study was to assess the duration of opening statements of patients attending a chronic pain clinic consultation. STUDY DESIGN: Prospective observational study SETTING: Chronic pain clinic. University teaching hospital METHODS: Following written informed consent, data was collected prospectively from 100 adult patients attending a chronic pain clinic consultation at a university hospital. We recorded the time of the opening statement following a standardized opening question by the pain physician. No verbal or non-verbal interruption by the physician was made during the patient's opening statement. RESULTS: Out of 100 adult patients, 37% (n = 37) were male and 63% (n = 63) were female. Mean age (years) was 54.4. The mean opening statement time was 89 s. LIMITATIONS: The study is limited by being a single-centered study. CONCLUSIONS: The duration of opening statements of patients attending a chronic pain clinic consultation when systematically studied takes a very short amount of time. It is important that all interruptions should be avoided. Our findings should encourage physicians to allow patients to complete their opening statements un-interruptedly in the chronic pain clinic.

Facilitators and barriers to green exercise in chronic pain.

BACKGROUND: Green exercise, defined as exercising in nature, demonstrates mental and physical health benefits. There is limited literature on green exercise as part of the treatment for chronic pain. Our objective was to investigate chronic pain patients' perceptions of green exercise and the possible barriers that may arise in employing it as part of their treatment regimes. METHODS: After institutional ethics committee approval, a convenience sample of 113 adult patients, who attended a chronic pain clinic, were included. Participants completed a questionnaire that included a variety of questions with responses reported using a Likert scale. RESULTS: The most frequent patient age was 50-70 years in 49% of respondents and the most frequent pain complaint was back pain (62%). Ninety-four percent of participants reported that nature improves their mood. Seventy percent of participants reported that green spaces were easily accessible to them on a regular basis. However, up to 38% reported that they would not be able to commit to three times a week of a green exercise regime. The majority (62% of participants) reported that they would like healthcare practitioners to discuss green exercise with them. CONCLUSION: Patients who suffer from chronic pain may be interested in green exercise as part of their treatment regime. Barriers that were identified included proximity to outdoor locations, time availability, and personal appraisal of the benefits of exercise for their condition. Green exercise should be considered as a part of a chronic pain treatment plan, and future studies should be directed to evaluating its efficacy in chronic pain.

The role of a companion attending consultations with the patient. A systematic review.

OBJECTIVE: To review the literature pertaining to communication patterns and dynamics of doctor-patient-companion or 'triadic' medical encounters as identified in both quantitative and qualitative studies. To consider the role of an attending companion in specialist groups using the context of chronic pain as a group example. METHODS: Studies were identified via database searches and reference lists. The eligibility of studies and data extracted were cross-checked with inclusion and exclusion criteria. RESULTS: Of the 1094 titles identified, 20 studies were included for review. Tables were created for patient settings and study outcomes. Results indicated that companions frequently attended consultations, usually with a relative such as their spouse or adult child and were found to influence communicative processes in the encounter. This influence could either be negative (limiting the exchange of information, particularly relating to sensitive topics) or positive (improvement of self-care management), with study outcomes varying widely. The chronic pain subgroup has not yet been researched in the context of triadic consultations. CONCLUSION: Triadic communication can be advantageous in medical encounters; however, as differences exist depending on the individual medical setting, caution should be asserted in generalising findings.

Attitudes of Irish patients with chronic pain towards medicinal cannabis.

BACKGROUND: Medicinal cannabis use is topical in the media in Ireland. A recent Health Products Regulatory Authority review, however, has recommended against its use for patients with chronic pain. This is despite evidence for its effectiveness in this patient's cohort and the inadequate pain management of these patients. AIM: The aim of this study was to evaluate the attitudes of Irish patients with chronic pain towards medicinal cannabis. METHODS: After institutional ethics committee approval, a 12-item questionnaire (excluding demographics) was randomly assigned to patients attending a chronic pain clinic (University Hospital Limerick). The questionnaire was designed to incorporate patient's attitudes on a variety of medicinal cannabis related topics. RESULTS: Ninety-six adult patients were surveyed. 88.54% agreed that cannabis should be legalised for chronic pain medicinal purposes. 80.21% believed it would have health benefits for them and 73.96% agreed it would be socially acceptable to use cannabis for this purpose. 33.33% perceived cannabis to be addictive while 68.75% would be willing to try it if prescribed by a medical professional. CONCLUSIONS: The study highlights the attitudes of chronic pain patients in Ireland towards medicinal cannabis. It shows their desire to have medical cannabis legalised for chronic pain and that they view it as a reasonable pain management option.

Breast cancer and chronic pain: a mixed methods review.

BACKGROUND: More patients are surviving breast cancer; however, many complain of persistent pain, which significantly impacts on their lives. Studies have predominantly examined risk factors alone. This mixed methods study will systematically compare prospective and retrospective studies of chronic pain following breast cancer treatment. A wider scope than risk factors alone is included in a narrative review element. RESULTS: Common risk factors and themes were identified, and these were compared with some of the retrospective literature available. Several common themes arose in the literature such as common patient demographics, perioperative and postoperative management, treatment modalities and psychological factors. The variation in disease severity, treatment mode and symptom progression between participants in the studies made it difficult to draw conclusions from both the prospective and retrospective literature. CONCLUSION: Chronic pain is common after breast cancer. The literature has focused predominantly on risk factors for the development of chronic pain. It may be more beneficial to focus on chronic pain mechanisms and to consider the patient's narrative and experience of their illness and how this has impacted on the perception and intensity of persistent pain. A shared understanding between the patient and professional is likely to have more beneficial outcomes.

Assessment of patient concerns: a review.

BACKGROUND: Patient-centred communication is the mainstay of the medical consultation. It includes the assessment of patient concerns and is important in building the doctor-patient therapeutic relationship. Our aim was to perform a literature review to identify relevance of patient concern assessment, to identify what concerns are encountered in various clinical settings and to explore the different methodologies used to obtain them. METHODS: A narrative review was performed. RESULTS: Addressing patient concerns is associated with increased patient satisfaction. Unvoiced concerns are associated with unresolved health issues and poor doctor-patient relationships. Different specialities have focused on different aspects of concern assessment. Patient concern assessment studies are mostly qualitative in nature. Not all qualitative methods give similar results. Interviews are more reliable sources of information than questionnaires as no one questionnaire captures all patient concerns. The location where interviews take place is also relevant. CONCLUSIONS: Assessing patient concerns is associated with positive outcomes. Patient concerns are handled differently by different clinical specialties. Various methodologies have been used for concern assessment. Interviews and questionnaires can often yield different results.

Does Age Impact on Expectations and Concerns of Patients Attending a Chronic Pain Clinic?

BACKGROUND: Recognizing expectations and concerns of patients leads to more specialized management plans and greater adherence to treatment and improves outcomes. Little is known about how age impacts on expectations or concerns regarding pain in patients attending a chronic pain clinic. METHODS: We prospectively assessed the expectations and concerns of 100 adult patients at their first visit to a pain clinic. Patients reported their expectations and concerns for the clinic visit using a self-completed questionnaire. Categories of concerns and expectations were compared across age groups (≤ 65 years, > 65 years) using the chi-square test and Fisher's exact test. RESULTS: Thirty-nine patients (39%) were over 65 years of age (older patients). The most frequently stated site of pain was the lumbar spine for all patients regardless of age. Common concerns of all patients related to sleep and mobility, and the most common expectation related to analgesia. Younger patients were more concerned about employment (23% vs. 3% of older patients, P = 0.005) and social participation (21% vs. 5%, P = 0.03), whereas older patients were more likely to be concerned about mobility (46% vs. 15% of younger patients, P = 0.001). More younger patients expected education on the source of pain than did older patients (23% vs. 3%, P = 0.005), whereas older patients were more likely to be unsure or have no expectations (26% vs. 3%, P = 0.005). CONCLUSION: We found differences in patient expectations and concerns by age of those attending a chronic pain clinic. These differences can inform the communication process between physician and patient on treatment plans and outcomes.

Exploring the Facets of Empathy and Pain in Clinical Practice: A Review.

BACKGROUND: Empathy is an essential element in providing quality patient care. The significance of empathy is even more striking in pain medicine, as chronic pain is notorious for the way it can compromise an individual, leaving him or her isolated and feeling misconceived. This review examines the role of empathy in pain medicine practice. METHODS: Current and past literature focusing on empathy and pain was searched for in PubMed, Science Direct, MEDLINE (Ovid), MEDLINE (Ebsco), Research Gate, and Google Scholar in July 2015. Search dates were not limited and languages included English only. Search terms were "empathy and pain," "empathy and chronic pain," "physician empathy and pain," "neural mechanisms and empathy," "empathy in clinical practice," "empathy and stigma," and "empathy and medical students". To select relevant publications, the title and abstract of every publication were examined, and when in doubt, the rest of the publication was read. RESULTS: Four major themes were identified: (1) the neural basis for empathy and pain; (2) the value and challenges of practicing empathy pain medicine; (3) stigma and empathy for pain; and (4) empathy and physician education and training. CONCLUSION: The review reveals that empathy deserves an unchallenged place in medical care, especially in pain medicine and medical education. It highlights the need to nurture empathy at all levels of professional expertise from medical student to senior doctors.

A Comparison of Expectations of Physicians and Patients with Chronic Pain for Pain Clinic Visits.

BACKGROUND: The patient-physician encounter forms the cornerstone of every health service. However, optimal medical outcomes are often confounded by inadequate patient-physician communication. Chronic pain is estimated to affect over 25% of the population. Its effects are multifaceted with patients at increased risk of experiencing emotional and functional disturbances. Therefore, it is crucial to address all components of the patient's pain experience, including beliefs and expectations. It is our understanding that no other study to date has evaluated the expectations of physicians and compared them to those of patients for pain clinic visits. We sought to describe and compare expectations of chronic pain patients and their physicians during a clinic consultation. METHODS: We performed a retrospective review on patients attending the pain clinic for the first time who were enrolled and completed a questionnaire asking their expectations for their clinic visit as well as outcomes that would satisfy and disappoint them. Pain physicians were also included. We compared physicians' to patients' responses and evaluated relationships between patient responses and age, gender, pain location, Pain Self-Efficacy, Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale. RESULTS: One hundred chronic pain patients and 10 pain physicians were surveyed. Patients' clinical expectations for visits focused primarily on some pain relief (34%), education on the cause of pain (24%), and a definitive diagnosis (18%). Physician's expectations included formulation and communication of a management plan (70%), patient assessment for cause of pain (50%), and the education of patients on the cause of pain (40%) as important aims. Pain relief would satisfy the majority of patients (74%) and physicians (70%). No improvement would cause greatest dissatisfaction for patients (52%), but causing more harm would be disappointing to physicians (50%). Gender, age, pain location, and sleep quality all significantly influenced patients' expectations and affective pain comorbidities. CONCLUSION: We found some agreement and some discordance of clinical expectations between pain patients and physicians. Patient factors may also impact on expectations and comorbidities. Findings from this study will help doctors consider patients' expectations in planning pain clinic visits, improve patient-doctor communication and pain management, and may lead to further hypothesis-driven studies.