Magister Scientiae Dentium - MSc(Dent) / There are both physical and emotional components which are associated with the chronic pain of TMD patients. One of the difficuhies in making an accurate assessment of each component, is the lack of objective criteria for quantitative measurement of the emotional component. This need, lead to the development of Research Diagnostic Criteria (RDC) by Dworkin and LeResche (1992). The aim of this study was to use RDC criteria to record the prevalence, and associations between Axis I (physical) and AXIS TI(emotional) factors in a sample of 100 patients attending a TMD Clinic. Patients were examined using the RDC guidelines and the diagnosis classified as either, myogenic, disc displacement or arthritis. Patients completed a self-administered personal history questiotmaire which analyzed emotional factors including, chronic graded pain, depression and nonspecific physical symptoms such as headaches, faintness and lower back pain.

Neuropathic pain is a common problem in clinical practice, affecting patients physically, emotionally, financially, and socially. Current treatment includes antidepressants, antiepileptics, and opioid analgesics. Bupropion is a specific inhibitor of neuronal noradrenaline reuptake and a weak inhibitor of dopamine reuptake, which shows some promise in the treatment of neuropathic pain.

Introduction and Background As chronic and acute pain disorders continue to be diagnosed in the clinical setting, the number of patients searching for medical care in hopes of alleviating their symptoms is on the rise. Working in both medical and psychiatric facilities as a certified nursing assistant, I saw opioids frequently prescribed as a pharmacological treatment for individuals looking to lessen the pain associated with a multitude of pain related disorders. Working in long term care facilities, I watched individuals who had never struggled with substance use disorders develop clinical dependencies on narcotic medication due to the fact that they were prescribed opioids as a means of pain reduction. I watched as individuals who had no prior history of substance abuse or addiction begin to scream in anger and frustration every four hours demanding their medication the second it was available to them after undergoing an event that caused them to experience severe pain (e.g, invasive procedures, falls, etc). Being even a few minutes late to administer their narcotic medication could mean completely destroying a therapeutic rapport with a patient. I saw patients who were previously able to carry out pleasant conversation spending all day in an opioid induced stupor, declining in neurological functioning, and so high from their medication, they were unable to complete ADLs without extensive assistance from a member of the healthcare team. While the patient is not to blame for this phenomenon, as they are just doing what is available to them as treatment for their condition, the healthcare system is doing patients a disservice by not offering alternative forms of pain management for individuals suffering with pain related symptoms. Because of this, we became interested in researching the opioid crisis, how it came to be, and ways that healthcare providers can help to reduce the amount of patients who are forced to deal with clinical dependency and opioid induced debilitation by providing alternative forms of pain management, specifically for individuals experiencing post-operative pain, as it was the most common trigger of pain I saw in the patient populations I have worked with in the clinical setting. Purpose Statement The population we will be researching includes individuals experiencing postoperative pain, who would typically undergo pharmacotherapy with opioids to alleviate their symptoms. The interventions we will be researching include ways that the registered nurse and providers can help reduce their patient’s pain using different forms of alternative pain management that do not include opioid medication. We will be comparing the effectiveness and practicality of opioid therapy to that of other forms of pain management to better understand the ways that patients can work to reduce their pain symptoms in ways that do not include narcotic medication. The way we will evaluate outcomes is by evaluating the current literature surrounding the topic and comparing the results from studies comparing the effectiveness of opioid therapy and the results from alternative forms of pain management. Literature Review In order to research this topic in greater depth, we used google scholar, PubMed, and CINAHL to ensure that each source we used was evidence-based and peer reviewed to the information we gathered was accurate, unbiased, and applicable to the clinical setting. Some databases we utilized included The National Library of Medicine, The Journal of Nursing Regulation, & Arthroscopy: The Journal of Arthroscopic & Related Surgery, all evidence-based and peer-reviewed databases. Luckily, there is an objectively large amount of data existing around the concept of pain management, as it is such a prevalent problem for individuals seeking medical care. Findings After researching forms of alternative pain management for post operative patients, we found three concepts to explore as an alternative to narcotic medication for pain management. These three concepts include: acupuncture therapy, low dose steroid use, and medical cannabis. There is strong evidence to support the effectiveness of these three treatments for managing pain symptoms. While the research on medical cannabis for post operative pain tends to be limited due to legality issues and issues regarding how to correctly dose the drug, there is large evidence to support the effectiveness of cannabis for chronic pain disorders and neuropathy that can result from undergoing surgical procedures. Conclusion After reviewing these three concepts as a form of alternative pain management, we found that there is evidence to support these forms of treatment as a viable alternative to opioid medication, or by implementing these treatments, patients may be able to reduce the amount of opioids it takes to alleviate their pain, reducing their chances of developing side effects or overdosing. There are gaps in the literature regarding cannabis as an effective treatment for acute pain due to complications of researching a schedule one substance, but there is evidence to support cannabis as a treatment for chronic pain issues that can develop from invasive surgical procedures. It is important that nurses are informed about these methods of alternative pain management in order to ensure that their clients are undergoing the best course of care possible if opioids are not a reasonable form of treatment for managing postoperative pain.

MSc Nursing, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Critically ill patients are particularly vulnerable to pain as a result of the severity of their disease conditions, diagnostic and treatment interventions but pain management is not considered a priority in the Intensive Care Unit (ICU) team (Holden, 1991: Walsh & Ford, 1992). Pain causes complications in the ICU patient, which increases their ICU stay and cost of ICU treatment (Pooler-Lunse & Price, 1992). The purpose of this study was to describe the parameters identified by ICU nurses that can be used to assess pain in the critically ill unconscious patient in the adult Intensive Care Units and whether these parameters are considered by the ICU nurses when managing the unconscious patients’ pain. The objectives of the study were to describe the parameters identified by ICU nurses that can be used for assessing pain in unconscious patients and to determine whether these parameters were considered by ICU nurses when managing the unconscious patient’s pain. A non-experimental, descriptive, prospective, comparative, two part design was used for the study. The sample comprised of ICU nurses (n = 40) in four adult ICU’s and the unconscious patients (n = 40) they nursed. Part one involved the nurses’ responses to a self administered Likert-type questionnaire about parameters that could be indicative of pain in the unconscious patient and part two involved a prospective record review of the unconscious patients ICU charts. A comparison was then done between these two parts to determine if the parameters identified by ICU nurses that could be indicative of pain in the unconscious patient, were considered in their management of the unconscious patients pain. Descriptive statistics were used to analyse data. Of the responses elicited from the questionnaire, ICU nurses agreed that raised blood pressure, pyrexia, increased respiratory rate, dilated pupils and increased heart rate could all be indicative of pain in the unconscious patient but these did not influence their management of the unconscious patient’s pain.

Objective: The objective of this study was to add to the body of knowledge about the impact of music on postoperative pain and anxiety. The specific purpose of this research study was to determine if listening to music and/or having a quiet rest period just prior to and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety, or impact mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients following a total knee arthroplasty. Methods: An experimental repeated measures design was used. Setting: A postoperative orthopedic unit in a 300-bed community hospital in the southeastern United States. Sample: Fifty-six patients having a total knee arthroplasty, randomly assigned to either a music intervention group or a quiet rest group. Measures: A visual analog scale was used to measure pain and anxiety. Physiological measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Results: A repeated measures analysis of variance between and within groups was conducted for pain and anxiety. Statistical findings between groups indicated the music group's decrease in pain or anxiety was not significantly different from the comparison rest group's decrease in pain (F = 1.120, p = .337) or anxiety (F = 1.566, p = .206) at any measurement point. However, statistical findings within groups indicated that when the groups were combined, the sample had a statistically significant decrease in pain (F = 6.699, p = .001) and anxiety (F = 4.08, p = .013) over time. Post hoc analyses showed the significant decrease in pain was from time 1 (just prior to the initiation of music or rest) to time 2 (just after 20 minutes of music or rest) (t(55) = 4.751, p = .000). Post hoc analyses showed the significant decrease in anxiety was from time 1 (just prior to the initiation of music or rest) to time 2 (just after 20 minutes of music or rest) (t(55) = 2.86, p = .006). Additionally, anxiety decreased significantly from time 3 (just after physical therapy) and time 4 (after second period of 20 minutes of music or rest period) (t(55) = 2.222, p = .030). Implications: Results of this research provides evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety when initiated just before and just after ambulation on postoperative day 1 following a total joint arthroplasty of the knee. The interventions pose no risks, and have the benefits of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with confidence, knowing there is evidence to support its efficacy.

Chronic pain is one of the most frequent reasons for a primary health care visit and people with pain identify improved function as an important goal. Self-management support provides an opportunity to improve function for people with chronic pain, but existing evidence suggests negligible changes in function. This thesis includes five manuscripts with overarching objectives of improving the understanding of reductions in function related to pain and evaluating a new self-management program aimed at improving function for people with chronic pain. The first manuscript is a cross-sectional evaluation of factors associated with reduced function in people with chronic pain referred for self-management support in primary health care. The findings suggest number of medications, depressive symptoms, cognitive factors associated with pain, mechanical hyperalgesia, and duration of symptoms explain 63% of the variance in function in people with chronic pain, multiple comorbidities, and barriers to accessing healthcare. The second manuscript is a case-series describing the participation and outcomes of six participants in Chronic pain self-management support with pain science education and exercise (COMMENCE). This study contributes to the literature by detailing the COMMENCE intervention and describing the varied responses of six participants. The third and fourth manuscripts are a protocol for a randomized controlled trial (RCT) and a completed RCT evaluating the effectiveness of COMMENCE in comparison to a wait-list control. The results suggest COMMENCE improves function for people with chronic pain (mean difference = -8.0 points on the Short Musculoskeletal Function Assessment; 95% confidence interval: -14.7 to -1.3). The fifth manuscript is a planned secondary analysis of the RCT described above. This study suggested people with a greater number of comorbidities are likely to have poorer function at the end of COMMENCE after controlling for age, gender, and baseline function. Together, these factors explained 63% of the variance in function. / Thesis / Doctor of Philosophy (PhD) / Chronic pain is associated with suffering, disability, and health care costs. This thesis includes five papers aimed at better understanding reduced function and evaluating a new self-management program for people living with chronic pain. The results of this research suggests people with more medications, longer lasting pain, negative thoughts and emotions related to their pain, and sensitivity to pressure are more likely to have poor functional abilities. A new self-management approach, Chronic pain self-management support with pain science education and exercise (COMMENCE), is described and evaluated. The results suggest people with chronic pain participating in COMMENCE experience greater improvements in function than people on a wait-list for the program. It appears people living with more chronic health conditions are likely to have poorer function at the end of the program. The findings of this thesis may help to inform management of chronic pain in primary healthcare.

Thesis advisor: Lisa Wood Magee / Background: Chronic cancer-related pain is a considerable problem in cancer survivors. The incidence of chronic pain in cancer survivors is nearly double the rate in the general population. Chronic cancer-related pain reduces quality of life and results in higher healthcare utilization. Due to a lack of alternative treatments, the management of chronic cancer-related pain relies on a biomedical model, with opioids being the cornerstone of cancer-related pain management. As concerns about the risks of long-term opioid therapy rise, there is a need to understand the factors that influence chronic cancer-related pain experience. This manuscript dissertation aims to answer the overarching question, “What are the unique factors that inform the chronic cancer-related pain experience in cancer survivors?” Methods: First, an integrative review aimed to examine the evidence of long-term opioid use in cancer-survivors. Next, a qualitative study using descriptive phenomenology was conducted to develop a deeper understanding of the daily lived experience of chronic cancer-related pain. And finally, a prospective cross-section quantitative study was completed to quantify the contribution of unique cancer-specific factors to the chronic cancer-related pain experience in cancer survivors. Results: The integrative review shed light on the biopsychosocial factors associated with the transition to long-term opioid therapy (LTOT), including the role of cancer type, medical comorbidities, mental health diagnoses, and socioeconomic factors. No studies examined pain severity, pain interference, or cancer-specific psychosocial factors in cancer survivors prescribed LTOT. Second, cancer survivors describe living with chronic cancer-related pain as the cost of survival. Yet, their suffering was often invisible to others. The role of opioids in chronic cancer-related pain leads to strained communication with clinicians and the need to self-navigate a treatment plan characterized by ‘trying everything’. And finally, select cancer-specific psychosocial factors explained relatively little variance in the pain experience compared to non-cancer specific factors of multisite pain and pain catastrophizing. Conclusions: The constellation of the finding from this body of work demonstrates unique factors that inform the chronic cancer-related pain experience in cancer survivors, and several areas of overlap with other chronic pain syndromes. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Lower back pain (LBP) is a medical condition that will affect most of us at some point in our lives. Several medical causes have been identified for LBP, yet the large majority of LBP patients do not receive a specific diagnosis. These patients use up a large majority of health care resources, and accumulate billions of dollars in medical costs in countries throughout the globe. In recent years, an increasing focus has been placed on the idea that aquatic therapy may be an effective therapy for LBP patients. Exercise therapy has already proven itself as an effective means for treating LBP. Thus, combined with the unique properties of water, experts believe that aquatic therapy is the future of LBP treatment. This thesis aims to explore the efficacy of aquatic therapy as a treatment for LBP. Through the analysis of controlled peer-reviewed studies, scholarly information databases, and historical data on LBP treatment, this thesis evaluates the relationship between aquatic therapy and LBP in its entirety. Scientific properties of water have shown its many uses in rehabilitative therapy treatments. Water, in theory, is able to manipulate the exercise environment to allow for more substantial progress to be made. In studies where aquatic therapy was tested versus no treatment, aquatic therapy proved to be a more efficient and effective option. Still, when placed against other therapies, aquatic therapy did not always prove more effective. While the analyzed studies support the idea that aquatic therapy is an effective treatment for LBP, further research is needed to determine how aquatic therapy holds up against other forms of treatment.

Chronic pain remains a prevalent problem across the United States. Chronic pain does not seem to have a function and relief of this symptom remains elusive for many sufferers. Virtual reality has been used as an adjunct therapy to decrease acute pain with promising results, but there is little research on whether virtual reality could be used as a successful intervention for those with chronic pain. Virtual reality has few side effects, so it warrants consideration for the treatment of chronic pain. There is growing evidence that there is potential for virtual reality to produce desired results with patients having chronic pain, but without more research this intervention cannot be confidently recommended (Garrett, Taverner, & McDade 2017). This thesis reviewed published research on the use of virtual reality in those with chronic pain. A total of seven studies that addressed virtual reality and chronic pain were analyzed and integrated into this literature review. All studies used virtual reality as a distraction to improve chronic pain. Three studies included patients with chronic back pain, one study included patients with chronic neck pain, and the remaining three studies addressed other types of chronic pain including chronic postoperative breast cancer pain, chronic neuropathic pain, and chronic generalized pain. All studies reviewed reported improvement of chronic pain symptoms. This literature review provides evidence to support the use of virtual reality for those with chronic pain. More rigorous research with larger sample sizes is needed to increase the generalizability of results to help people suffering with chronic pain from a variety of causes. This literature review used the search terms "chronic pain" and "virtual reality" and the following databases: EBSCOhost, Medline, CINAHL Plus with Full Text, PsycINFO, Academic Search Premiere, and Applied Science & Technology Source.

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