Michelle Briggs
Professor of Nursing
School of Health and Community Studies
Portland Building PD508A, Leeds Beckett University,
Leeds, United Kingdom
Tel: +44 (0)113 812 1924
Email: m.i.briggs@leedsbeckett.ac.uk
http://www.researchgate.net/profile/Michelle_Briggs
Co-Director Centre for Pain Research
https://www.facebook.com/pages/Leeds-BeckettPain/198981903482831
MANAGING THE SYMPTOMS OF
NEUROPATHIC PAIN
NEUROPATHIC PAIN
Neuropathic pain*
Pain caused by a lesion or disease of the somatosensory nervous system.
Note: Neuropathic pain is a clinical description (and not a diagnosis) which requires a demonstrable lesion or a
disease that satisfies established neurological diagnostic criteria. The term lesion is commonly used when
diagnostic investigations (e.g. imaging, neurophysiology, biopsies, lab tests) reveal an abnormality or when
there was obvious trauma. The term disease is commonly used when the underlying cause of the lesion is known
(e.g. stroke, vasculitis, diabetes mellitus, genetic abnormality). Somatosensory refers to information about the
body per se including visceral organs, rather than information about the external world (e.g., vision, hearing,
or olfaction). The presence of symptoms or signs (e.g., touch-evoked pain) alone does not justify the use of the
term neuropathic. Some disease entities, such as trigeminal neuralgia, are currently defined by their clinical
presentation rather than by objective diagnostic testing. Other diagnoses such as post herpetic neuralgia are
normally based upon the history. It is common when investigating neuropathic pain that diagnostic testing may
yield inconclusive or even inconsistent data. In such instances, clinical judgment is required to reduce the totality
of findings in a patient into one putative diagnosis or concise group of diagnoses.
Central neuropathic pain*
Pain caused by a lesion or disease of the central somatosensory nervous system. See neuropathic pain note.
Peripheral neuropathic pain*
Pain caused by a lesion or disease of the peripheral somatosensory nervous system. See neuropathic pain note.
PATIENTS EXPERIENCE OF NEUROPATHIC PAIN
Closs SJ Staples V, Reid I, Bennett MI, Briggs M Managing the Symptoms of Neuropathic Pain: An Exploration of Patients’ Experiences Journal of Pain and Symptom
Management Vol. 34 No. 4 October 2007
NEUROPATHIC PAIN PATIENT VOICE
http://lutube.leeds.ac.uk/hcssjc/videos/5288
DESPAIR & DISAPPOINTMENT ….WHY ?
http://www.healthtalk.org/
Lőgren M & Norrbrink C (2012) but I know what works
patient experience of spinal cord injury neuropathic pain
management Disability and Rehabilitation 34;25 21392147
Objective - To systematically review and integrate the findings of
qualitative research in order to increase our understanding of patients’
experiences of chronic non-malignant MSK pain.
Data sources–Six electronic databases up until February 2012
(Medline, Embase, Cinahl, Psychinfo, Amed and HMIC) supplemented by
hand-searching contents list of specific journals for 2001-2011 and
citation tracking.
Eligibility criteria for selecting studies - Full published reports of
qualitative studies that explored adults’ experience of chronic nonmalignant musculoskeletal pain.
Findings - We included 77 papers reporting 60 individual studies. 49
papers (37 individual studies) explored the experience of people with
chronic MSK pain, and 28 papers (23 individual studies) explored the
experience of people with Fibromyalgia (FM).
Being
Judged
CONSTR UCTION OF TIME ALTERED
Unpredictable now and futu re
Alienated &
Unrelenting body
Integrated
body
Old me is the
‘real me’
STRUGGLE TO New me is not
AFFIRM SELF
Me in
Pain
the ‘real me’
Isolated me
Connected me
Why else would I have
pain ? e.g. ‘age’,
psychosocial factors ’, lifeevents
MOVING
FORWARD
WITH PAIN
(figure 19)
CONSTRUCT AN
ACCEPTABLE EXPLANATION
STRUGGLING
TO FIND THE
‘RIGHT’
BALANCE’
(sick/well:
hide/show pain)
STRATEGIES TO
GAIN
LEGITIMACY
What is causing this and
what can I do ?
STRUGGLING TO
NEGOTIATE THE
HEALTH CARE
SYSTEM
NO DIAGNOSIS
AMBIGOUS
DIAGNOSIS
FAIL TEST
PAIN
NON-LE GITIMATE
I DON’T FEEL VALUED
AS A PERSON
I don’t think
anyone believes
me
I am not just a body
Believe me
Be alongside me
PROVING
THAT I AM
A GOOD
PERSON
INTEGRATING
MY PAINFUL BODY
REDEFINING
NORMAL
TELLING PEOPLE
ABOUT MY PAIN
MOVING
FORWARD
WITH PAIN
BEING PART OF
A COMMUNITY
REALISING THERE
IS NO CURE
BECOMING
THE EXPERT
CHANGING DIRECTION…..
THE DETECTION AND MANAGEMENT OF PAIN
IN PATIENTS WITH DEMENTIA
IN ACUTE HOSPITAL SETTINGS
SYSTEMATIC REVIEW
Nurses have been both observed and reported as not using validated tools for the
assessment of pain when caring for patients with dementia in the acute hospital,
Preference on simple questioning and observation of non-verbal cues (Coker et al.,
2010; Manias, 2012).
Coker, E., Papaioannou, A., Kaasalainen, S., Dolovich, L., Turpie, I., Taniguchi, A., 2010. Nurses’ perceived barriers to optimal pain management in older adults
on acute medical units. Appl. Nurs. Res. 23, 139–146.
Manias, E., 2012. Complexities of pain assessment and management in hospitalised older people: a qualitative observation and interview study. Int. J. Nurs.
Stud. 49 (10), 1243–1254.
REVIEW QUESTIONS
1.
Which tools are available to assess pain in adults with dementia?
2.
In which settings are they used and with what patient populations?
3.
What are their reliability, validity and clinical utility?
(e.g. do they assess pain, rather than, for example, discomfort or anxiety? do they assess pain
consistently, across time, and across patients? Are they useful in clinical practice, do they add that
extra information that is needed to make decisions? or is the information they provide redundant?)
EXAMPLES OF OBSERVATIONAL PAIN ASSESSMENT
TOOLS
RESULTS: THE TOOLS
28 tools
Each review compared a different set
of tools, and drew conclusions on
which one to recommend
Some tools were reviewed only once,
others appeared in multiple reviews
It appeared that there seemed to be
different versions of some tools
FINDINGS
Pain Tools
No one tool appeared to be more reliable and valid than the others. Little
information was available concerning clinical utility.
Our recommendation: on the basis of the available evidence none of the tools
could be recommended for use in clinical practice.
Recommendations for Research
Improve the evidence for existing tools.
Develop new tools only if on different conceptual foundations?
http://www.biomedcentral.com/content/pdf/1471-2318-14-138.pdf
EXPLORATORY STUDY - RESEARCH DESIGN
Case study approach, comparing individuals, wards and
hospitals
4 Trusts - 2 wards for each Trust (extended to 5 wards in
Manchester to improve recruitment)
Qualitative research, observations, interviews, audit of
patients’ notes
Thematic analysis
EXPLORATORY STUDY – METHODS
Site: 3 NHS Trusts in England and 1 NHS board in Scotland
Site Identifier
Wards
G (Glasgow)
Medicine for the Elderly
Continuing Care
L (Leeds)
Vascular (surgery)
Care of the Elderly
U (London)
Surgical/orthopaedic
Acute Medical Admissions
M (Manchester)
Stroke Rehabilitation
Elderly Medicine (3 wards)
Surgery
Exploratory
Study
DATA COLLECTED
30 patients
30 patients observed:
8 in Leeds, 9 in Manchester; 6 in Glasgow, 7 in London
170+ hours of observations at the bedside:
71h Leeds, 22h Manchester, 45h Glasgow and 32h London
480+ hours in the field:
161h Leeds, 73h Manchester, 167h Glasgow and 85h London
52 staff and 4 carer interviews (plus informal conversations in the
field)
25 in Leeds
16 in Glasgow
7 in Manchester
8 in London
Period of data collection: May 2013 – September 2014
PAIN IS AN EVENT TO BE RECOUNTED NOT
A THING TO BE MEASURED AND CLASSIFIED *
IT IS PRIVATELY EXPERIENCED BUT OFTEN NEEDS TO BE PUBLICALLY OBS ERVED & VALIDATED TO GAIN RELIEF
* WHAT DO I MEAN WHEN I SAY THAT PAIN IS AN EVENT ? BY DESIGNATING PAIN AS A ‘TYPE OF EVENT’ ….. I MEAN THAT IT IS
ONE OF THOSE RECURRING OCCURRENCES THAT WE REGULARLY EXPERIENCE AND WITNESS THAT PARTICIPATES IN THE
CONSTITUTION OF OUR SENSE OF SELF AND OTHER. AN EVENT IS DESIGNATED ‘PAIN’ IF IT IS IDENTIFIED AS SUCH BY THE PERSON
CLAIMING THAT KIND OF CONSCIOUSNESS. BEING-IN-PAIN REQUIRES AN INDIVIDUAL TO GIVE SIGNIFICANCE TO THIS
PARTICULAR ‘TYPE OF’ BEING. I AM USING THE WORD ‘SIGNIFICANCE’, NOT IN THE SENSE OF ‘IMPORTANCE’ (A PAIN CAN BE A
MOMENTARY PIN-PRICK) BUT IN THE SENSE OF ‘RECOGNIZED’ (IT IS A STOMACH ACHE RATHER THAN A STOMACH GURGLE
BEFORE LUNCH). PAIN IS NEVER NEUTRAL OR IMPERSONAL (EVEN PEOPLE WHO HAVE BEEN LOBOTOMIZED AND THUS LACK
EMOTIONAL ANXIETY ABOUT PAIN, STILL REGISTER THAT SOMETHING THEY CALLED PAIN IS MAKING AN IMPRESSION ON THEIR
BODIES). IN OTHER WORDS, A PAIN EVENT POSSESSES WHAT PHILOSOPHER PAUL RICOEUR CALLED (ALBEIT IN A DIFFERENT
CONTEXT), A ‘MINE-NESS’. 9 IN THIS WAY, THE PERSON BECOMES OR MAKES HERSELF INTO A PERSON -IN-PAIN THROUGH THE
PROCESS OF NAMING.
JOANNA BOURKE THE STORY OF PAIN,
NEUROPATHIC PAIN PATIENT VOICE :FINAL WORD
http://lutube.leeds.ac.uk/hcssjc/videos/5288