D.Phil. / Chronic pain is a devastating problem and one of the leading causes of disability internationally with an estimated 25-30% of people in industrialised nations suffering from it. Various approaches are available for the treatment of chronic pain with exercise therapy is often the last resort, after all else has failed. The present study was motivated by the growing prevalence of chronic pain patients and the recent progress in pain science. This study made use of a quasi-experimental design where randomization was a function of participant convenience. It made use of a Pre-Test Post-Test battery consisting both of self-report questionnaires and of a physical assessment evaluating components of chronic pain patients’ experience prior to and following a combined therapeutic intervention programme of 12 sessions. Follow- up was at 12 months. The objectives were to integrate patient reconceptualization of pain by means of an active approach combining pain education and exercise therapy, and to determine the effect of a change in pain cognition on the outcome compared to a control group receiving exercise therapy only. A heterogeneous group of chronic pain patients were randomized into 2 groups who both received exercise therapy twice per week: the experimental group (80) received exercise therapy and a specific 3 hour pain education session with the active control group (74) only receiving exercise therapy. There were no differences in pain related or demographic characteristics between groups at baseline. Both groups had a significant reduction in pain perception after 12 exercise therapy sessions (P<0.05). After a follow up period of 12 months the experimental group sustained the same level of pain reduction (P<0.05). The control group maintained only some the acquired reduction in pain perception. In the experimental group an increased participation in physical activity was also found 12 months after the intervention. Exercise therapy significantly reduces the perception of pain in chronic pain patients after 12 therapy sessions, but the combination of pain education and exercise therapy better maintain these effects after a year. Key Words: chronic pain, exercise, pain education.

This study investigated the value of headache presence during elecromyographic (EMG) feedback relaxation training and the contribution made by home relaxation practice in the elimination of tension headache. Eighteen participants, mainly coeds in their twenties, recorded headache and medication data for two baseline weeks, and were assigned to one of three training groups. Group A received EMG feedback training with headache presence during the session and home relaxation practice. Group B received EMG feedback without headache Presence and home practice. Group C received only home relaxation practice. Statistically significant treatment differences were not found, but declining trends of headache activity and medication use tend to support the efficacy of EMG training with headache presence.

Lau Suk-chu. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 85-94). / Abstracts in English and Chinese. / Abstract --- p.i / 論文摘要 --- p.iii / Acknowledgements --- p.v / Table of Contents --- p.vi / List of Tables --- p.ix / List of Figures --- p.x / Table of Abbreviations --- p.xi / CHAPTERS / Chapter 1. --- Introduction --- p.1 / Chapter 2. --- Literature Review --- p.3 / Chapter 2.1 --- The Importance of Postoperative Pain Management --- p.3 / Chapter 2.1.1 --- Humanitarian --- p.3 / Chapter 2.1.2 --- Under-management of Postoperative Pain Relief --- p.3 / Chapter 2.1.3 --- Pain Relief- A Key Strategy for Better Surgical Outcomes --- p.5 / Chapter 2.2 --- Postoperative Pain Relief and Clinical Outcomes --- p.7 / Chapter 2.3 --- Postoperative Pain Relief and QoR --- p.8 / Chapter 2.4 --- A New Concept of Service Expected for Better Surgical Pain Relief --- p.9 / Chapter 2.4.1 --- Recognition of the New Concept of Service - APS --- p.10 / Chapter 2.4.2 --- Role of an APS --- p.11 / Chapter 2.4.3 --- Organization of APS --- p.12 / Chapter 2.4.3.1 --- The Anesthesiologist-based APS --- p.12 / Chapter 2.4.3.2 --- The Nurse-based APS --- p.13 / Chapter 2.4.3.3 --- The Multidisciplinary APS --- p.14 / Chapter 2.4.4 --- Postoperative Pain Management Service in Hong Kong --- p.15 / Chapter 2.4.4.1 --- Review of postoperative pain management service in Hong Kong --- p.15 / Chapter 2.4.4.2 --- Recommending APS in Hong Kong --- p.15 / Chapter 2.4.4.3 --- The recognition of APS in Hong Kong --- p.15 / Chapter 2.4.4.4 --- The development of APS in Hong Kong --- p.16 / Chapter 2.4.4.5 --- The compliance of APS teams in Hong Kong with the recommendations made by Hospital Authority --- p.17 / Chapter 2.4.5 --- Summary of Background of APS --- p.19 / Chapter 3. --- Economic Evaluation of Acute Pain Service Programs: A Systematic Review --- p.20 / Chapter 3.1 --- Abstract --- p.20 / Chapter 3.2 --- Introduction --- p.21 / Chapter 3.3 --- Methods --- p.22 / Chapter 3.3.1 --- Study Selection Criteria --- p.22 / Chapter 3.3.2 --- Search Strategy --- p.23 / Chapter 3.3.3 --- Data Analysis --- p.23 / Chapter 3.4 --- Results --- p.24 / Chapter 3.5 --- Discussion --- p.27 / Chapter 3.6 --- Conclusion --- p.30 / Chapter 4. --- Methodology of the RCT Study --- p.41 / Chapter 4.1 --- Setting --- p.41 / Chapter 4.2 --- Eligibility Criteria for Participants --- p.42 / Chapter 4.3 --- Obtaining Informed Consent --- p.42 / Chapter 4.4 --- Study Intervention --- p.43 / Chapter 4.4.1 --- Randomization --- p.43 / Chapter 4.4.1.1 --- Randomization: Generation and Concealment --- p.43 / Chapter 4.4.1.2 --- Randomization: Implementation --- p.43 / Chapter 4.4.1.3 --- Study Intervention: APS (Intervention group) and CWPS (Control) --- p.44 / Chapter 4.5 --- Data Collection and Outcome Measures --- p.44 / Chapter 4.5.1 --- Primary Outcomes --- p.44 / Chapter 4.5.1.1 --- Data Obtained at 72 hours After Surgery --- p.44 / Chapter 4.5.1.2 --- "Data Obtained at 24, 48 and 72 hours After Surgery" --- p.46 / Chapter 4.5.2 --- Secondary Outcomes --- p.47 / Chapter 4.6 --- Sample Size --- p.47 / Chapter 4.7 --- Data Analysis --- p.48 / Chapter 4.7.1 --- Comparability Between APS and CWPS Groups --- p.48 / Chapter 4.7.2 --- Comparing Costs and Effects of Interventions --- p.48 / Chapter 5. --- Results and Analysis --- p.51 / Chapter 5.1 --- Flow of Participation --- p.51 / Chapter 5.1.1 --- Enrollment of Participation --- p.51 / Chapter 5.1.2 --- Allocation of Treatment --- p.51 / Chapter 5.1.3 --- Follow-up --- p.53 / Chapter 5.2 --- Results of Data Analysis --- p.53 / Chapter 5.2.1 --- Patient Demographics --- p.53 / Chapter 5.2.2 --- Costs of Interventions --- p.55 / Chapter 5.2.3 --- Patient Satisfaction --- p.55 / Chapter 5.2.4 --- QoR --- p.61 / Chapter 5.2.5 --- Average Pain Severity Ratings --- p.62 / Chapter 5.2.6 --- Pain at Rest Severity --- p.63 / Chapter 5.2.7 --- Pain on Movement --- p.64 / Chapter 5.2.8 --- Average Pain Interference with Daily Activities --- p.65 / Chapter 5.2.9 --- Effectiveness of Pain Relief --- p.66 / Chapter 5.2.9.1 --- Side Effects of Pain Medications --- p.66 / Chapter 5.2.9.2 --- Summary of results --- p.67 / Chapter 6. --- Discussion and Conclusion --- p.68 / Appendix A: Data Collection Form --- p.71 / Appendix B: Conference Abstract --- p.81 / Appendix C: Conference Abstract --- p.83 / REFERENCES --- p.85

Very little work has been undertaken that explores pain as a part of human existence and the inherent knowledge that accompanies it. What pain means to people and how they know their own pain is the subject of this research study.The research sought to identify ways of knowing cancer pain of six participants, each receiving palliative care at the time of this study. The themes of, balancing conflict, living with threat, always there and making sense are identified and examined to provide understanding of the ways these people know their pain. A new model of pain assessment is offered that incorporates an ontological way of knowing, and the meaning that the findings have for nursing practice is explored. Implications for nursing practice and education that are derived from the study are offered. The rigour of the study is promoted through an audit process / Doctor of Philosophy (PhD)

Pain is a common problem that affects nearly all cancer patients (Kwekkeboom, 2008). There are various factors that constitute suffering to cancer patients. Apart from physical pain, cancer patients usually experience emotional crisis and spiritual struggles (Magill, 2008). Music therapy is believed to be one of the most effective treatments for cancer patients. It provides a holistic care to patients with cancer. It will not only manage the physical sensation, but also address the psychological, social and spiritual parts of the patients (Magill, 2009). Although current studies have suggested the benefits of using music therapy in reducing pain for cancer patients, it is not a common practice in Hong Kong. As the administration rate of music therapy relies heavily on the knowledge of the nurses (Kwekkeboom, 2008). Therefore, this paper aims at providing evidence on the use of music therapy. In the hope of a clinical guideline, it can increase the administration rate of music therapy for cancer pain management in clinical setting. Apart from the clinical guideline, an implementation and evaluation plan on music therapy will also be discussed in this paper. There will be a full description from preparation to evaluation. Nurses can make use of this reference guide to provide music therapy for their cancer patients in respect to pain management. / published_or_final_version / Nursing Studies / Master / Master of Nursing

The purpose of this study is to determine the effect of childbirth preparation classes on self-efficacy in coping with labor pain in Thai primiparas. The nonprobability convenience sample consisted of sixty primiparas assigned to either a control or an experimental group (thirty in each group). In order to prevent crosscontamination, all control group data were collected before initiating enrollment of the experimental group. The control group participants received standard care and education. Participants in the experimental group attended three childbirth classes over three consecutive weeks. Data were collected at the beginning of week 1 to establish a baseline (pretest), at the end of the third class which is the end of the intervention (posttest), and at 24-48 hours after delivery (follow-up) using a demographic form, postnatal data form, and the Childbirth Self-efficacy Inventory. Overall, experimental group self-efficacy expectancy increased dramatically across three data points. In contrast, control group self-efficacy expectancy decreased dramatically across three data points. There was an interaction between time of selfefficacy expectancy measurement and group, F(1.33, 71.77) = 6.34, p < .05. Selfefficacy expectancy in the experimental group was significantly different than that of the control group, F(1, 54) = 14.66, p < .001. Outcome expectancy findings were different than self-efficacy expectancy results. Control group outcome expectancy decreased dramatically across three data points while the experimental group selfefficacy increased after the class and then decreased after the birth but was higher than baseline. There was an interaction between time of outcome expectancy measurement and group, F(1.72, 935.18) = 4.83, p < .05. Data at the follow-up or 24-48 hours after delivery revealed that only one woman from the control group received an analgesic during the birthing process. The groups did not differ in duration of labor and type of delivery. These findings indicate partial effect of childbirth preparation classes on self-efficacy in coping with labor pain. The relatively small effect size reflects the high degree of variability in issues surrounding a woman's experience of pain and measures related to self-efficacy in coping with labor pain. Additional research in this population is needed. / text

The purpose of the current study was to investigate the effects of a multidisciplinary pain management program on five measures of subjective psychosocial factors. Ninety-five participants in the comprehensive multidisciplinary treatment group and the standard medical intervention control group were surveyed about various psychosocial factors using Axis II of the West Haven - Yale Multidimensional Pain Inventory (MPI), pre- to post-treatment. It was hypothesized that post-treatment levels would be significantly lower than pre-treatment levels for all five psychosocial variables. Additionally, gender and ethnicity variables were examined. Based on preliminary analyses indicating pre-treatment differences between the experimental and control group, five 2 x 2 x 3 analyses of covariances (ANCOVAs) were used to examine the above hypotheses. Results indicated significant differences between the treatment conditions on measures of control, with the comprehensive group feeling more in control than the standard group at post-treatment. No other significant main effects for treatment condition were found on the measures of pain severity, interference with daily activities, negative mood, or social support. However, a significant gender main effect was found for social support at post-treatment, with females reporting more social support than males. A significant gender x ethnicity interaction was also found for post-treatment control, with African-American females exhibiting higher levels of control than the other groups. Finally, a significant gender x treatment condition was found for negative mood, with males in the comprehensive group reporting more affective distress than those in the standard group. In this study, control appeared to be an integral factor in the chronic pain sample and greatly improved with comprehensive multidisciplinary treatment; while other areas of relative efficacy were not confirmed in this population.

The primary objective of this study was to examine the association between the theory of planned behavior (TBP) and adherence to a multidisciplinary pain center (MPC) treatment program for chronic pain. While the results of several studies have provided support for the efficacy of MPC treatment in chronic pain, the problems of adherence and attrition are important. TPB is a cognitive/social model of behavior that has been used to predict a variety of behaviors, although it has never been used to predict adherence to a multidisciplinary chronic pain treatment program. It was predicted that Adherence would be predicted by Intentions and that Intentions would be predicted by 1) Perceived Social Norms, 2) Perceived Behavioral Control, 3) Attitudes Toward New Behavior (completing the treatment program), and 4) Attitude Toward Current Behavior (maintaining current treatment and coping strategies). It was found that the total Intentions scores did not predict the total Adherence scores. However, Intentions was predicted by 1) Perceived Behavioral Control, 2) Attitudes Toward New Behavior (completing the treatment program), and 3) Attitude Toward Current Behavior (maintaining current treatment and coping strategies). The finding that Perceived Social Norms did not predict Intentions was consistent with results of previous studies with the TBP. The secondary objective was to examine the extent to which MPC treatment affects patients' attitudes towards behaviors that are associated with successful pain management. The majority of the patients (82%) developed a more favorable attitude toward the program and their average report of the importance of the program was 6.78 on a 10-point scale. The majority of patients (74%) reported experiencing a greater decrease in pain than expected, and the average amount of pain decrease was 5.39 on a 10-point scale.

This thesis describes the synthesis of novel analogs of the unique opioid receptor modulator mitragynine along with pharmacological and behavioral studies of a subset of its novel analogs. In Chapter 1, a general overview of opioid receptors and the importance of the mu opioid receptor (MOR) for the treatment of pain is provided. The rise of the opioid epidemic is discussed which brings into attention the need to develop safer opioid therapeutics for the treatment of pain. In this regard the Mitragyna indole alkaloids, isolated from kratom leaves are of great interest as they are considered to be “atypical” opioid ligands and represent novel molecular scaffolds for the development of safer opioid receptor modulators. The introductory chapter includes a brief description of the pharmacological profile of mitragynine as a prelude to the work that follows – examining unexplored positions on the alkaloid by devising new methodology and synthetic routes to synthesize novel analogs to study its structure-activity relationship (SAR) at the opioid receptors. Chapter 2 describes the development of a new synthetic method for selective functionalization of the unexplored C11 position of the MG scaffold (C6 position in indole numbering). The method takes advantage of an indole-ethylene glycol adduct as a key intermediate which can undergo subsequent iridium-catalyzed borylation at the desired position. This late-stage C(sp2)-H functionalization approach provides a practical route to novel C11-analogs of mitragynine and related scaffolds starting from the natural product, thus allowing a systematic SAR exploration of the C11 position. Chapter 3 directly builds on Chapter 2, summarizing the neuropharmacological and behavioral studies on the C11 analogs of 7-hydroxymitragynine (7OH) and mitragynine ethylene glycol (MG-EG). Through these studies we discover that the C11 position represents a key locant for fine-tuning opioid receptor signaling efficacy. We also discuss that the parent 7-hydroxymitragynine (7OH), a low efficacy agonist, is transformed to an even lower efficacy agonist by introducing a fluorine substituent at the C11 position (11-F-7OH). This is demonstrated in vitro at both mouse and human mu opioid receptors (mMOR/hMOR) and in vivo in mouse analgesia tests. Low efficacy opioid agonists are of high interest as candidates for generating safer opioid therapeutics with mitigated side effects. Thus, this section concludes with the identification 11-F-7OH as lead compound for future investigation. Chapter 4 describes our attempts towards the functionalization of another unexplored and vital position for the activity of mitragynine at the mu opioid receptor (MOR) – the ethyl group at the C20 position. This chapter illustrates our extensive efforts towards the late-stage functionalization of the ethyl group in the C20 position of mitragynine via directed C(sp3)-H activation. Various strategies including using the mitragynine ethylene glycol (MG-EG) as a bidentate ligand or manipulating the acrylate ester group on mitragynine as a directing group are discussed in the chapter. Also described are all the screened reaction conditions using palladium catalysts and various ligands starting from pyridine-based to mono-protected amino acid-based ligands. The outcomes and hypotheses for the failures of each strategy employed are also presented in the chapter. Chapter 5 describes our efforts towards the de novo synthesis of the C20 analogs, as an alternative strategy to the failed late-stage functionalization from Chapter 4. We present a strategy to synthesize the C20 analogs through a diversification strategy from a common intermediate. We further discuss the results of our efforts towards the formal synthesis of this common intermediate. The chapter concludes with a discussion of an alternate strategy for the synthesis of the C20 analogs.

Somatization, the presentation of physical symptoms without an identifiable cause, is among the most common problems in primary medical care. Treatment approaches are typically offered within the medical consultation interview once the medical provider distinguishes between physical and emotional etiology. This dualistic strategy is especially troublesome for patients whose physical complaints cannot be validated and who are recommended for only mental health therapy. The aim of this study was to examine how medical practitioners can instead motivate patients to consider both physical and emotional treatment. An analogue intervention consisting of an enhanced consultation interview was compared to a care as usual consultation interview on the key outcome of motivation to engage in mental health treatment. A total of 129 participants with medically unexplained symptoms were randomly assigned to these two conditions. Motivation to engage in mental health treatment was evaluated with the FMP Questionnaire, Credibility and Expectancy Questionnaire, and the newly developed Motivation to Engage in Therapy questionnaire (MET). Results of ANCOVA revealed significant differences between the two analogue consultation interviews on 3 out of 5 outcome measures. The largest effect was found for the MET followed by the credibility and expectancy subscales (1.6, .9, and .8). This finding suggests that a particular type of discourse between medical provider and patient can lead to increased motivation for holistic care treatment for those with somatization.