Exploring experiences and understandings of pain in adults with intellectual disabilities

BACKGROUND

People with intellectual disabilities (ID) are at risk that their health problems, many of which cause pain, go unrecognised and untreated. Their understanding and personal experiences of pain have received little research attention.

METHOD

Information was collected from 15 adults with ID using semi-structured interviews about their experiences and understanding of pain. Transcripts were analysed using content analysis.

RESULTS

Participants described pain using negative meanings and strong imagery, with various causes of pain suggested, but said little about how they coped with pain. Participants varied in whether they reported pains to carers, some choosing to hide the experience. There seemed a general belief that others can tell when someone is in pain.

CONCLUSIONS

Conversations regarding pain with adults with ID are a real challenge; health-care staff need to think carefully about the questions they ask. Possessing verbal skills cannot be taken as an indication that pain will be communicated.

Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain

BACKGROUND

There is good evidence from studies conducted in a single-centre research setting for the efficacy of graded motor imagery (GMI) treatment, a complex physiotherapy intervention, to reduce pain in long-standing complex regional pain syndrome (CRPS). However, whether GMI is effective in clinical practice is not established.

AIM

To establish whether GMI is effective in clinical practice.

METHODS

We undertook a prospective audit of GMI treatment at two UK centres with a special interest in the management of patients with CRPS. All patients received GMI, in conjunction with a range of other 'best practice' physical and psychological interventions.

RESULTS

The patients' average pain intensities did not improve with treatment [centre 1: n = 20, pre-post numeric rating scale (NRS) difference 0.6 [confidence interval (CI) -0.3 to 1.5]; centre 2: n = 12, pre-post NRS difference 0.2 (CI: -0.9 to 1.2)]. Patients at centre 1 reported significant functional improvement. Improved performance on left/right judgement replicated in both centres seen in the clinical trials.

CONCLUSIONS

The failure of our real-world implementation of GMI suggests that better understanding of both the GMI methodology and its interaction with other treatment methods is required to ensure that GMI research results can be translated into clinical practice. Our results highlight challenges with the translation of complex interventions for chronic pain conditions into clinical practice.

Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management

Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.

Stiff upper lip: coping strategies of World War II veterans with phantom limb pain

OBJECTIVE

Study of coping with phantom pain in nonclinical war veteran amputees.

DESIGN

Semistructured interview with amputees in their home setting.

SETTING

Residential home for war veteran amputees or respondents' own homes.

PATIENTS

Amputee veterans of World War II with phantom pain.

OUTCOME MEASURES

Pain (McGill Pain Questionnaire) and pain history, coping (daily coping; Stone and Neale, J Pers Soc Psychol 1984;46:892-906), size of social network, and quality of war memories.

RESULTS

No differences in pain or coping were associated with place of residence (and prevalence of cues) or social networks; war memories appeared not to be associated with availability of cues, whether media coverage or other amputees. There was some association between the emotional tone of war memories and pain intensity. Veteran amputees were in general accepting of high levels of pain and made little use of medical resources, relating that to past experience of their pain being dismissed.

CONCLUSION

Coping with phantom pain in war veteran amputees is predominantly silent acceptance of the pain, with little use of social support however available, and rare recourse to medical help, based on past unhelpful experience. Pain and mood appeared to be unrelated to specific war cues, but higher pain scores were reported by those with unhappier war memories.