Research Poster Abstracts

Introduction/Aim: Concussions or mild traumatic brain injuries (mTBI) resulting from sports-related or whiplash injuries are a major public health issue. The extent to which neck soft tissue injuries co-occur in concussion events is not well-known nor is the extent to which the symptoms associated with these injuries contribute to post-concussion syndrome. Methods: 43 non-acute subjects were studied: concussion (16), whiplash (13) or controls (14). Subjects completed a pain scale (VAS), the Neck Disability Index (NDI) and the Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ). Three tests for cervical joint and myofascial dysfunction were conducted: joint restriction onmanual palpation; tenderness tomanual palpation and the Flexion-Rotation test (F-R test). Scores on all variables were compared by ANOVA or Chi-Squared testing with significance at p = 0.05. Results: 73% of concussion subjects had head impact; none occurred in the whiplash group. In both clinical groups, the pain VAS, NDI and RPCSQ scores were not statistically different. Significantly more upper cervical joint restrictions, tenderness and positive F-R tests were found in the concussion group vs. controls. Joint restriction and F-R test findings were similar between concussion and whiplash groups. Discussion/Conclusions: Our results provide preliminary support for similarity of symptoms and signs in both concussion and whiplash patients as well as similarly high levels of cervical joint and myofascial dysfunction in concussion subjects. Soft tissue injuries to the upper cervical spine should be assessed as early as possible in post-concussion management.

Introduction/Aim: Concussions or mild traumatic brain injuries (mTBI) resulting from sports-related or whiplash injuries are a major public health issue. The extent to which neck soft tissue injuries co-occur in concussion events is not well-known nor is the extent to which the symptoms associated with these injuries contribute to post-concussion syndrome.
Methods: 43 non-acute subjects were studied: concussion (16), whiplash (13) or controls (14). Subjects completed a pain scale (VAS), the Neck Disability Index (NDI) and the Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ). Three tests for cervical joint and myofascial dysfunction were conducted: joint restriction on manual palpation; tenderness to manual palpation and the Flexion-Rotation test (F-R test). Scores on all variables were compared by ANOVA or Chi-Squared testing with significance at p = 0.05.
Results: 73% of concussion subjects had head impact; none occurred in the whiplash group. In both clinical groups, the pain VAS, NDI and RPCSQ scores were not statistically different. Significantly more upper cervical joint restrictions, tenderness and positive F-R tests were found in the concussion group vs. controls. Joint restriction and F-R test findings were similar between concussion and whiplash groups.
Discussion/Conclusions: Our results provide preliminary support for similarity of symptoms and signs in both concussion and whiplash patients as well as similarly high levels of cervical joint and myofascial dysfunction in concussion subjects. Soft tissue injuries to the upper cervical spine should be assessed as early as possible in post-concussion management.
CONTACT Howard Vernon hvernon@cmcc.ca Introduction/Aim: Musculoskeletal chronic pain is a leading cause of healthcare utilization and disability in North America. Current clinical measures are not adequately capturing the patient's experience and perception of pain with engagement in physical activity. Increased sensitivity to physical activity (SPA) may explain low patient adherence to activity-based rehabilitation. SPA is measured through monitoring changes in pain during brief physical tasks (e.g. lifting, walking). This study aims to explore the ecological validity of a newly developed SPA measure by exploring participants' perspectives on how the lab-based task compares to daily pain experiences.
Introduction/Aim: The aim of this study was to investigate the associations between self-management perceived ability, functional status and quality of life (QOL) in patients with mid to late-stage knee osteoarthritis (OA). Methods: Patients were selected for participation in this study if 1) they rated their worst pain in the past 7 days ≥ 4 on a 0-10 pain intensity scale, 2) had a Kellgren-Lawrence (KL) OA grade ≥ 2 on radiographs. The patients' self-management perceived competency was measured with the Partners in Health Scale (PIHS) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) was also used.
Discussion/Conclusions: The more competent patients felt in their ability for self-management, the better their condition was. However, this perceived ability explained only a small proportion of the variation in their symptomatology. This suggests that there is still a lot of room for education to these patients for improving their self-care management, especially through exercise programs that target functional improvements.
Chart audit investigating high frequency emergency department users, their health demographics for chronic pain and practice patterns of opioid provision Introduction/Aim: To explore agreement between healthcare professionals adjudicating eligibility for work disability benefits.
Methods: We reviewed MEDLINE, Embase and PsycINFO up to 16 March 2016. Observational studies investigating the reproducibility between healthcare professionals performing disability evaluations using a global rating of working capacity, and reporting inter-rater reliability by a statistical measure or descriptively were eligible for review. Study conduct may occur in insurance settings where decision on work ability include normative judgements, or in research settings where decisions on work ability disregard normative considerations. Teams of paired reviewers identified eligible studies, appraised their methodological quality and generalizability, and abstracted results, using pretested forms.
Results: Of 4562 references, 16 studies conducted in an insurance setting and 7 in a research setting, performed in 12 countries, met our inclusion criteria. Applicability of findings from studies conducted in an insurance setting to real life evaluations ranged from generalizable (n = 7, 44%), probably generalizable (n = 3, 19%) to probably not generalizable (n = 6, 37%). Most studies (n = 9, 56%) found poor inter-rater reliability, and only 13% (n = 2) reported excellent agreement. This contrasts with studies conducted in a research setting where 71% (5 of 7) achieved excellent inter-rater reliability. Reliability between assessing professionals was higher when the evaluation process was guided by a standardized instrument (23 studies, p = 0.006).
Discussion/Conclusions: Despite their common use and far-reaching consequences for workers claiming disabling injury or illness, research on the reliability of medical evaluations of work disability is very limited and indicates high variation in judgements between assessing professionals.

Pharmacological treatment of neonatal abstinence syndrome: A decision model
Timothy Disher a , Louis Beaubien b , and Marsha Campbell-Yeo a a School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada; b Management, Dalhousie University, Halifax, Nova Scotia, Canada Introduction/Aim: Neonatal abstinence syndrome (NAS) defines a constellation of symptoms in neonates exposed to opiates and other drugs intrapartum. While originally relatively rare, recent publications suggest rapidly increasing incidence. Often these infants require pharmacological treatment, there are several options to choose from. Head-to-head comparisons of pharmacological agents are abundant in the literature with some including measures of cost, but a decision analysis considering all possible options is absent. The aim is To create a normative decision model to guide selection of first-line pharmacological agents for neonatal abstinence syndrome, based on the current evidence.
Methods: We used information from existing published primary trials, and publicly available estimates of costs to develop a cost-effectiveness decision model to compare the cost-effectiveness morphine, methadone, buprenorphine, morphine + clonidine, phenobarbital alone, phenobarbital + morphine, and clonidine alone as first line pharmacological treatments for NAS. The analysis took the perspective of the Canadian health payer, and effectiveness was measured in days of exposure to potentially neurotoxic drug avoided.
Results: Under the base-case scenario, morphine + clonidine has an incremental cost-effectiveness ratio (ICER) of $824.16 per day of exposure to a potentially neurotoxic drug avoided compared to buprenorphine monotherapy. All other choices were dominated (more costly and less effective). Results are sensitive to the length of home treatment with adjunct therapy and the efficacy of buprenorphine.
Discussion/Conclusions: Under the base-case scenario, morphine + clonidine has an incremental costeffectiveness ratio (ICER) of $824.16 per day of exposure to a potentially neurotoxic drug avoided compared to buprenorphine monotherapy. All other choices were dominated (more costly and less effective). Results are sensitive to the length of home treatment with adjunct therapy and the efficacy of buprenorphine.
CONTACT Timothy Disher tim.disher@dal.ca Introduction/Aim: Skin temperature asymmetry (SkTA) may assist in early identification of complex regional pain syndrome (CRPS) but previous work has been limited by methodological shortcomings, including failure to account for the cutaneous nerve distribution where temperature is measured, and reliance on laboratory equipment not clinically available. Pilot work suggested a cold pressor test (CPT) provided a consistent thermoregulatory stress and might increase sensitivity/specificity of SkTA measurements generated reliably by handheld infra-red thermometers. This study investigated the sensitivity, specificity and validity of SkTA in the upper limb to identify CRPS. Methods: Using infra-red thermometers, we evaluated SkTA over major peripheral nerve distributions in the hands before and after immersing a single foot in 5°C water for 30 seconds. Participant groups included healthy volunteers, CRPS, known nerve injury, and hand fracture.
Results: SkTA was measured in 63 persons, 16 persons with CRPS (meeting Budapest criteria). Analysis of variance for n = 378 SkTA observations supported diagnosis, CPT and nerve distribution as significant predictors (p < 0.001) explaining 94% of the variance. Sensitivity for a >1.0°C SkTA improved to 68.8% from 43.8% post CPT, while specificity dropped from 85.1% to 76.6%.
Discussion/Conclusions: This study adds further support for the accuracy of SkTA as a diagnostic indicator of CRPS. Further precision in estimates will be gained from larger studies, which should also seek to replicate our findings for SkTA in the lower limbs.
Introduction/Aim: Patients describe their sore throat using various descriptors such as difficult to swallow, or the sensation of swollen throat. Flurbiprofen has been developed as a spray and lozenge to treat the symptoms of sore throat. The aim of this study was to investigate the effect of flurbiprofen 8.75 mg, delivered as a spray or lozenge, on difficulty swallowing and swollen throat.
Methods: A randomized, double-blind study was conducted at 16 sites across Russia. Adults with acute sore throat were randomly assigned to take one dose of flurbiprofen 8.75 mg spray plus a placebo lozenge (n = 218), or flurbiprofen 8.75 mg lozenge plus placebo spray (n = 222). Patients rated difficulty swallowing and swollen throat using 100-mm visual analogue scales: Difficulty Swallowing Scale (DSS, 'not difficult' to 'very difficult') and Swollen Throat Scale (SwoTS, 'not swollen' to 'very swollen').
Discussion/Conclusions: Flurbiprofen lozenge and spray both provide an equivalent and meaningful reduction in difficulty swallowing and swollen throat, providing patients with effective treatment regardless of how they describe their symptoms.
Attitudes toward the possibility of an online pain assessment/management training program in rural long-term care facilities Natasha L. Gallant a , Thomas Hadjistavropoulos a , and Abigail Wickson-Griffiths b a Psychology, University of Regina, Regina, Saskatchewan, Canada; b Nursing, University of Regina, Regina, Saskatchewan, Canada Introduction/Aim: Underassessment of pain remains a significant issue for residents living in long-term care facilities. In rural settings, pain assessment is complicated by insufficient continuing education opportunities due to geographical isolation. The goal of this project was to evaluate, using qualitative methods, the readiness of rural facilities to address inadequacies in continuing education through online training on stateof-the-art pain assessment practices.
Methods: We conducted semi-structured interviews with 10 nurses, care aides, and administrators from two rural long-term care facilities. They were asked about the extent to which they perceived a need for specialized pain assessment training, barriers that were specific to the facility, and the extent to which they believed that online pain assessment training would address these barriers. Narrative data were analyzed using thematic content analysis.
Results: Staff perceived a need for a standardized pain assessment/management protocol to adequately address pain. Reservations about a standardized clinical approach to pain related to a perceived increase in documentation, time constraints, negative attitudes toward change, and potential for miscommunications among staff. Reactions to the possibility of online training were mixed. Negative reactions were related to unfamiliarity with online training and a preference for face-to-face training, whereas positive reactions were related to the belief that online training would address the lack of training opportunities in rural settings.
Discussion/Conclusions: Findings from this project will guide future implementation of online pain education in these two long-term care facilities to maximize probability of success through collaborative problemsolving.
CONTACT Natasha L. Gallant gallanat@uregina.ca Introduction/Aim: Cannabidiol (CBD), a nonpsychoactive cannabinoid, has recently been shown to attenuate pain and inflammation in an animal model of rheumatoid arthritis, but its effect on osteoarthritis (OA) pain is unknown. This study investigated whether local administration of CBD to a mono-arthritic knee joint is capable of altering the activity of joint nociceptors.
Methods: A chronic model of OA was induced in male Wistar rats (387-463g) by intra-articular injection of sodium monoiodoacetate (MIA, 3mg/50μl). In vivo electrophysiology experiments were conducted in with either moderate (days 14-20) and severe (days 21-27) OA. Single unit recordings of knee joint afferents that responded to mechanical rotation of the joint were carried out. Evoked firing from non-noxious and noxious rotation of the joint before and following close intraarterial injection of CBD (100, 200, and 300μg in DMSO:Cremophor:Saline, 1:1:8) were compared.
Results: Peripheral administration of CBD reduced noxious movement-evoked firing of knee afferent fibres in a dose-dependent manner (300 μg vs 100 μg, P < 0.005, n = 4-5). The desensitizing effect of CBD was more pronounced in fibres recorded from animals with severe OA. The 300 μg dose of CBD decreased afferent firing rate in response to noxious rotation by 13 and 19% in day 14-20 and 21-27 animals respectively (P < 0.0001, n = 3-5).
Discussion/Conclusions: This study demonstrates for the first time that local administration of CBD can reduce joint mechanonociception and merits further investigation into the potential use of CBD for OA pain.
CONTACT Melissa O'Brien melissa.obrien@dal.ca Introduction/Aim: The CONSORT statement is a highly-endorsed checklist that promotes a standard approach for reporting of trial findings, facilitates complete and transparent reporting, and aids critical appraisal and interpretation. We conducted a systematic review to establish the effect of the original CONSORT statement on reporting quality among randomized controlled trials assessing opioids for chronic non-cancer pain. Methods: We systematically searched several electronic databases for English-language studies that randomized patients with chronic non-cancer pain to receive an opioid or a non-opioid control. In duplicate and independently, teams of reviewers established the eligibility of each identified study, and recorded all CONSORT recommended items from trials that proved eligible. We conducted adjusted logistic regression analyses to explore the association between independent variables and reporting of CONSORT items. We fit one model per CONSORT item that showed sufficient variability in reporting; specifically, we did not consider items that were reported less than 10% of the time or greater than 90% of the time.
Results: Out of a total of 23,109 citations, 77 trials proved eligible. Data abstraction has been completed and the analysis is ongoing. Results will be available at the CPS Annual Scientific Meeting in May 2017.
Discussion/Conclusions: Our review will establish the concordance of reporting among trials of opioids for chronic non-cancer pain with the CONSORT statement, whether reporting quality improved after publication of the CONSORT statement, and factors associated with reporting of CONSORT items. ). The literature has suggested that pain, catastrophizing, depression, and disability are closely linked, but investigations on exactly how they are associated remain to be conducted. The aim of this study was to test an emotion regulation model of pain, depression, and disability in an IC/BPS sample using serial mediation. Methods: A total of 225 women diagnosed with IC/BPS recruited from tertiary care clinics in Canada and the U. S. completed questionnaires regarding demographics, pain, catastrophizing, emotion regulation, depression, and pain related disability. We ran serial mediations using Hayes' (2013) PROCESS macro testing whether difficulties in emotion regulation mediates the indirect effect of catastrophizing on the relationship between pain and depression (model 1), as well as the relationship between pain and pain related disability (model 2).
Results: A bias-corrected bootstrap confidence interval for the indirect effect of model 1 (b = .07) based on 10 000 bootstrap samples was entirely above zero (.0456 to .1058) indicating a significant indirect effect. The indirect effect of model 2 (b = .07) was also significant (CI = .0314 to .1363).
Discussion/Conclusions: The way pain influences the experience of depression and pain-related disability may operate through one's ability to regulate emotions, especially those related to pain. Understanding how emotion regulation affects a patient's experience is an important step toward informing psychological management of pain.
CONTACT Alison Crawford alison.crawford@queensu.ca Introduction/Aim: Adolescents undergoing spinal fusion surgery with instrumentation are at great risk to develop kinesiophobia (fear of movement) and consequent morbidities like disability. Identifying who is at risk of developing kinesiophobia after surgery is of paramount importance to improve recovery after such surgery.
Discussion/Conclusions: Presence of kinesiophobia after surgery was observed in the majority of patients and was associated with pain catastrophizing and functional disability. There is a clinical need to better characterize the observed fear of movement that could interfere with proper recovery after surgery.
Introduction and Aim: The Extension for Community Healthcare Outcomes Ontario Chronic Pain and Opioid Stewardship (ECHO for short) uses telehealth technology to bridge specialists in academic centres to health care providers (HCPs) in remote areas. ECHO aims to disseminate knowledge regarding chronic pain (CP) and enhance HCPs' capacity for opioid use. This study evaluated the impact of ECHO on HCPs' selfefficacy, attitudes, and satisfaction, and examined whether these outcomes are influenced by profession, presenting a case, or attendance.
Methods: A pre-post online questionnaire was administered to HCPs who attended ECHO sessions. The questionnaire assessed: 1. Self-efficacy in CP management using a 19-item validated questionnaire; 2. HCP attitudes using 7 items from the KnowPain-12 validated instrument; 3. Satisfaction using an 11-item validated questionnaire, administered only Post-ECHO.
A significant increase in self-efficacy mean scores was found between pre-and post-ECHO scores. 3 items demonstrated a significant change in attitudes from pre-to post-ECHO. As for satisfaction, participants ranged from 67.7% to 96.9% in agreement. A significant change in pre and post-ECHO attitudes scores was detected between physicians, nurses, and pharmacists but not other professions. Case presentation and attendance significantly affected satisfaction scores. Professions, case presentation or attendance influenced neither self-efficacy scores nor satisfaction ratings.
Discussion and Conclusion: ECHO demonstrated an effective and feasible strategy to build capacity and increase access to CP management and safe opioid prescribing.
Is chronic pain associated to cognitive impairments after moderate-to-severe traumatic brain injury?
Caroline Arbour a , Héjar El-Khatib b , Bérengère Houzé c , Gilles J. Lavigne d , and Nadia Gosselin b Introduction/Aim: Memory and attention disturbances are common after a traumatic brain injury (TBI), but chronic pain could accentuate cognitive impairments in these patients. This study examined whether chronic pain is associate to neuropsychological performances in moderate-to-severe TBI survivors.
Methods: Clinically meaningful chronic pain (defined as a persistent and/or recurrent pain ≥3/10 experienced over the last 3 months) was determined with the Brief Pain Inventory. The Digit span, the Color Stroop Task, the Trail-Making Test, and the Mesulam cancellation test were used to assess cognitive function. The Beck Anxiety and Depression Inventories, and the Pain Catastrophizing Scale were also used.
Results: In total (N = 39), n = 19 patients with and n = 20 patients without chronic pain were investigated 10-36 months post-TBI. Both groups were similar in terms of age (32±16 years), gender (65% male), education (14±7 years), and time elapsed since TBI (22±9 months). Participants with chronic pain reported an average pain intensity of 5±3 in the last 24-hour.
Despite presenting more extended brain injuries, no difference in cognitive performances was found between participants with and without chronic pain. Participants with chronic pain exhibited significant higher levels of anxiety (13±9 vs. 7±7) and catastrophizing (15±12 vs. 8±7), compared to those without pain. Linear regression (stepwise) showed that increased depression scores were independent predictors of chronic pain intensity after TBI (Beta = 1.190, p = 0.009).
Discussion/Conclusions: Unlike our initial hypothesis, our findings suggest that chronic pain is not associate to cognitive deficits after moderate-to-severe TBI. Chronic pain however could enhance the risk of mood disturbances in these individuals. , mediates this pathological coupling in lamina I neurons of both rodents and humans, including following chronic inflammation. Methods: We paired patch-clamp electrophysiological recordings with pharmacology, behaviour, and biochemical approaches to explore mechanisms for dysregulation of lamina I NMDARs. An ex vivo BDNF model of spinal pathology was used in both rodent and human tissue, and an in vivo injection of Freund's adjuvant into the rodent hindpaw was used to model chronic inflammatory pain.
Results: In all models, we observed a decrease in STEP 61 and an increase in pGluN2B and pFyn at lamina I synapses. Downregulation of STEP 61 was both necessary and sufficient to prime subsequent phosphorylation and potentiation of synaptic NMDARs by BDNF. Importantly, we also showed that inflammatory hyper-sensitivity was reversed by attenuating disinhibition using IP injected acetazolamide, and paired this with biochemical analysis to investigate lamina I synaptic signalling.
Discussion/Conclusions: Our results suggest that STEP 61 is the molecular brake that is lost to drive the potentiation of excitatory NMDAR responses following BDNF-mediated disinhibition at lamina I synapses of both rodents and humans. Thus, STEP 61 modulation may be a useful pharmaceutical target for treating pathological pain conditions. Introduction/Aim: Use of opioids for chronic noncancer pain may affect patients' endocrine function, including opioid induced hypogonadism. We systematically reviewed the literature for evidence regarding management of opioid-induced hypogonadism.
Methods: We searched for studies, in any language, with tailored searches of MEDLINE, CINAHL, AMED, CENTRAL, CINAHL, DARE, EMBASE, and PsycINFO, through to August 2016. Our eligibility criteria were a) randomized controlled trials or controlled/uncontrolled observational studies with ≥ 20 patients, b) enrollment of chronic noncancer pain patients with opioid-induced hypogonadism, c) assessment of any intervention to treat or manage opioid-induced hypogonadism. Pairs of reviewers worked independently to determine eligibility status of all identified citations through screening titles and abstracts, and then full text of all potentially eligible studies. Reviewers abstracted information, independently and in duplicate, using standardized forms. Only effects on patient-important outcomes were collected.
Results: Of 634 abstracts reviewed, 5 studies including one randomized controlled trial (65 patients) and four observational studies (129 patients) were eligible. Very low quality evidence found that testosterone replacement therapy was associated with improvements in pain, and depressive symptoms. Very low quality evidence found no effect of testosterone replacement therapy on sexual function or physical functioning.
Discussion/Conclusions: There is limited evidence, of very low quality, regarding management of opioidinduced hypogonadism. The available evidence suggests that testosterone replacement therapy be helpful; however, large, rigorously conducted, randomized controlled trials, are needed to establish the role of testosterone replacement therapy in the management of opioid-induced hypogonadism.  Results: Fifteen people participated in this study aged 20 to 34, 4 female. There was a significant increase in post-intervention WHCP score compared to the preintervention score (p < 0.05), with a median effect size.
There was no significant increase in the COS (p = 0.081).
Discussion/Conclusions: The results from the study indicate that by inhibiting a virtual body that had some of the limitations CP patients might have and engaging in tasks in the simulation game, players achieved a significant increase in WHCP. The game failed to significantly increase empathy for CP patients, possibly because of flaws in game design, the age demographic, the short duration and insufficient repeated exposure. Further modifications may provide a useful interactive storytelling tool to help foster awareness of CP.
Introduction/Aim: Disability insurance protects workers from total loss of income in case of a disabling injury or illness by providing wage-replacement benefits. To better inform early identification of claims at risk of prolonged recovery, we explored predictors of disability benefits claim duration.
Methods: Using administrative data from SSQ Financial, a private Canadian disability insurer, we evaluated the association between nine variables and short-term disability and long-term disability benefits duration using Cox proportional hazards regression analyses.
Results: We analyzed 70,776 short-term disability and 22,205 long-term disability claims. For both shortterm disability and long-term disability claims, and across all disorders, older age, female gender, heavy job demands, presence of comorbidity, attending an independent medical evaluation, receipt of rehabilitation therapy, and longer time to claim approval were associated with longer claim duration. Higher predisability salary was associated with longer short-term disability claim duration. Quebec residency was associated with longer short-term disability claim duration among workers with psychological disorders, but shorter short-term disability claim duration among those with musculoskeletal diseases and other illnesses. For long-term disability claims, however, residing in Quebec was associated with shorter claim duration, although the magnitude of the association differed across clinical conditions. Discussion/Conclusions: The factors we found to be associated with short-term and long-term disability claim duration may be helpful to identify claims at risk of prolonged recovery. Our study has limitations, however, and well-designed prospective studies are needed to confirm our findings and identify other promising predictors.
CONTACT Sohail M. Mulla mullasm@mcmaster.ca Introduction/Aim: Chronic pain is often disabling and can be associated with reduced participation in physical activity. Sensitivity to physical activity (SPA) is emerging as an important predictor of poor outcomes in painrelated conditions, but it is currently not clear whether SPA is associated with reduced participation in physical activity. The aim of this study is to identify if high levels of SPA are associated with low levels of self-reported physical activity among adults with chronic musculoskeletal pain (>3 months) at 9-day follow-up. Methods: Preliminary analysis was conducted on 47 participants from a longitudinal study on a cohort of people with chronic musculoskeletal pain (>3months). SPA was measured by calculating the mean difference in self-reported numerical pain rating scale scores (0-100) and the mean difference in pressure pain thresholds (kPa) from before to after a standardized walking (6-minute walk test) and lifting (18 weighted canisters) tasks. Physical activity levels were obtained via the International Physical Activity Questionnaire (IPAQ, long version, telephone format) nine days after the in-person testing session. For data analysis, a median split was used to divide participants into two groups: high or low SPA.
Results: Participants with high SPA were found to have lower total daily physical activity than participants with low SPA. This difference was statistically significant.
Discussion/Conclusions: This study suggests that a patient's level of sensitivity physical activity is an important indicator of their level of physical activity in daily life. Methods: Thirty adult participants (17 Males, aged 23-68) were recruited in a pain clinic. The research study was a within-subject study comparing Cardboard VR with OR. The participants experienced both conditions, and filled out the same Pre-VR and Post-VR questionnaires before and after each VR condition. The questionnaires asked them to rate their Introduction/Aim: The facial expression of pain is a reliable non-verbal signal, but may be interpreted differently from different viewing angles. Fine-grained observational approaches (e.g., Facial Action Coding System; FACS), used in the evaluation of pain responses, are based on a full view of the face. The contribution of certain viewing angles to facial coding accuracy is unknown. We compared inter-rater reliability from side view and full view coding of pain responses.
Methods: Videos of older adults (with and without dementia) undergoing a series of physiotherapy movements were coded for facial pain responses based on FACS (incorporating action intensity), and gross pain behaviors using a clinical observation method. Separate coding was done for full (incorporating left, right, and front views), and left side views of the face. A second coder independently coded videos for reliability calculation.
Discussion/Conclusions: Similar levels of inter-rater agreement can be achieved in coding the full view and the side view of the face during pain. Side and full coding do not provide the same assessment of facial expression, as evidenced by weaker inter-rater reliability between the two. Potential implications for pain sufferers will be discussed. Introduction/Aim: To explore registered nurses (RNs) experiences in providing pain care to children in the rural hospital setting and understand the challenges and facilitators. Methods: An exploratory descriptive qualitative study using semi-structured interviews by Skype or telephone with RNs who work at one of the nine eligible sites in rural Northern Ontario. Eligible sites were those in Northern Ontario with dedicated inpatient pediatric beds. Purposeful and snowball sampling was used. Recruitment was done via a mail out strategy, social media campaign, and community advertisement. Data were analyzed using inductive content analysis. A coding sheet was developed and categories were mapped, and collapsed into main categories.
Results: There were 5 main categories identified. RNs needed to practice as generalists, which threaded across all categories. Resource challenges included a lack of specialist expertise and educational opportunities. Distance education strategies did not consider the context challenges or preference of learning of the nurses. Pediatric pain was not formally identified as a priority within their practice or institution. Most participants stated there were no explicit standards for pain.
However, topical anaesthetics for skin breaking procedures were commonly used but sucrose for infants was not, illustrating that the adoption of evidenced informed pain strategies may be random. Moving forward adoption of preprinted orders was suggested as a possible facilitator for use of evidenced-based pain management.
Discussion/Conclusions: There is opportunity to improve pediatric pain management in rural Northern Ontario. However, strategies above and beyond distance education are needed that consider the challenges of the rural context. Methods: 3T-MR data were acquired from 32 TN patients (20F, age 68.8±13.5), 6 months post-GKRS. Tissue microstructure measures of fractional anisotropy (FA), axial, radial, and mean diffusivities (AD, RD, and MD, respectively) were extracted from the radiosurgical target area of the affected trigeminal nerve. The contralateral, asymptomatic nerve served as the control. Early, 6-month trigeminal nerve microstructure was compared with long-term clinical results. Patients were classified as responders if they achieved at least 75% reduction in preoperative pain for 12 months or longer following treatment.

ORCID
Results: Based on clinical follow-up data, we identified 17 long-term responders and 15 non-responders. Radiosurgical target FA value at 6 months was predictive of long-term clinical results, demonstrating significant lower FA in responders versus non-responders. There was no significant change in FA of the asymptomatic nerve between the two groups.
Discussion/Conclusions: Early trigeminal nerve microstructural alterations as a result of radiosurgery successfully prognosticate long-term treatment response. Specifically, the lower FA of responders, which is indicative of disrupted nerve organization, prognosticates better long-term pain relief. DTI serves as a promising tool to assess the effects and prognosis of radiosurgery on the trigeminal nerve.
CONTACT Sarasa Tohyama sarasa.tohyama@mail.utoronto.ca Introduction/Aim: Individuals suffering from chronic pain are at an increased risk for suicidality. The aim of this study was to evaluate predictors of suicidal ideation in a sample of OHIP patients in an interdisciplinary chronic pain management program.
Methods: Patients referred to psychological services in an interdisciplinary chronic pain program completed self-report questionnaires as part of the assessment process including demographic information and measures for pain, bothersome symptoms (PHQ-15), depression (PHQ-9) including the item for suicidal ideation, anxiety (GAD-7), disability (PDI), paincatastrophizing (PCS) and coping (B-CPCI). Data were analyzed using descriptive statistics, and linear regressions were employed to evaluate the predictors of suicidal ideation.
Discussion/Conclusions: Suicidal ideation was best predicted by passive coping (guarding and resting) deactivation (increased disability) and maladaptive pain appraisals (catastrophizing). Sedentary behaviours and anxiety-related to pain appear to be predictive of suicidal ideation, and as such treatment of patients referred to psychology within the OHIPfunded interdisciplinary chronic pain program should focus on activation and active-coping skills as well as cognitive therapy to improve pain catastrophizing. Introduction/Aim: Functional ability represents a core dimension of outcome assessment in chronic pain, both for documenting patient progress and for evaluating program effectiveness. In 1995, the International Association for the Study of Pain (IASP) circulated a self-report measure of functional ability. Although the measure has sometimes been used in research studies, it has never been subjected to a thorough investigation of its psychometric properties. Methods: In this study, 950 patients with chronic pain completed the 16-item Limitations in Daily Activities Scale (LIDAS) at two pre-treatment and one post-treatment assessment. Individual item analysis was conducted and the results favoured a 13-item scale.
Results: Exploratory Factor Analyses suggest that the LIDAS has a 3-factor structure consisting of Daily Tasks, Global Participation, and Personal Care. Reliability analyses for the total scale (α = 0.90) as well as for each factor (αs = 0.82 to 0.84) indicated excellent internal consistency, good-excellent test-retest reliability across factors (rs = 0.66 to 0.88), and sensitivity to change with treatment. LIDAS scores correlated with measures of pain intensity, pain cognitions, and depression, as well as with other self-report and clinician-administered measures of functional performance. A minimal clinically important difference of 5 points was established for assessing meaningful individual improvement after treatment.
Discussion/Conclusions: In conclusion, the LIDAS is a reliable, valid, and clinically relevant option for assessing functional ability in patients with chronic pain. Aims: Hydrotherapy is a painful procedure associated with treatment of burn injuries. Very few studies have used virtual reality (VR) for procedural pain and anxiety in young children with burn injuries. The aim of this study was to assess the feasibility and acceptability of a VR prototype for procedural pain and anxiety in children with burn injuries.
Methods: This prospective pilot study recruited children from 3 months to 10 y.o. with burn injuries requiring hydrotherapy sessions for wound burn care. Pain was assessed using the FLACC (min 0, max10) and anxiety using the PBCL (Pain Behavioral Check List) (min 8, max 40). Satisfaction of healthcare professionals was also documented using a pretested questionnaire (min 8, max 32).
Results: Fifteen participants were included in the analyses. Mean age was 2.2 ± 2.1 years, and the mean TBSA 5 % (±4%). Pain did not significantly vary before, during and after the procedure with mean FLACC scores respectively at: 2.1 (±2.7), 2.9 (±3), 2.6 (±3). Mean PBCL score was 11.4 (±5.2) during the procedure and the mean score for satisfaction of healthcare professionals was 26.3 (±4.2). VR prototype did not interfere with the procedure and was considered very useful by most healthcare professionals for reducing children's pain and anxiety.
Conclusion: The VR prototype is a feasible and acceptable method of distraction for procedural pain and anxiety in young children with burn injuries. A larger trial with a control group would be required to assess its efficacy. Aim of investigation: Sex differences in pain processing mechanisms are increasingly recognized. In our previous study, we observed that female mice, unlike males, do not require microglia to produce pain hypersensitivity after neuropathic or inflammatory injury.
Using T-cell deficient mice, we found that female mutant mice "switch" to the "male" microglial system. Important open question included whether T cells are important for female pain. Methods: Mechanical allodynia was assessed after spared nerve injury (SNI) and post complete Freund's adjuvant (CFA) injection using von Frey fibers. After allodynia was confirmed, CD8, CD4 and CD3 Ab or minocycline were injected, and withdrawal thresholds measured. mRNA was from spleen immune cells were analyzed for Granzyme B, TNF-α and IL-4 by qPCR. Also, immune cells extracted from lumbar spinal cord were immunostained with CD45, CD11b, CD4, CD8, and analyzed using flow cytometry.
Results: In contrast to male mice, female mice showed: 1) inhibition of CD8 + T cells and CD3 + T cells reversed allodynia in female mice, 2) CD8+T cells from female spleen showed increased IFNγ production by 4-fold after SNI, and 3) spinal CD8 + T cell level did not decrease after SNI. Interestingly, IFNγRKO female mice showed the same pain behavioural response as wild-type males wherein minocycline reversed allodynia. Consistent with this, IFNγR KO female, like wild-type male, mice did show downregulation of CD8 + T cells.
Conclusion: Our current data further suggest that female mice, unlike males, are using CD8 + T cells to induce neuropathic pain, and that this mechanism appears to be dependent on IFNγRs.
Toll-like receptor 4 (TLR4) involvement in nociceptive processes within rat medullary dorsal horn in dental inflammatory pain model increased electromyographic (EMG) activities. Central sensitization has been shown to depend on MDH microglia activation, and TLR4 is involved in microglial activation in pain states. However, the role of TLR4 in CNS mechanisms of dental pain is unclear. Therefore, the aims of this study were to test if TLR-4 expression occurs in MDH, and if bilateral EMG activities in the anterior digastric (AD) muscles evoked by MO application (0.2 μL/95%) to the pulp are dependent on TLR4 processes in MDH Methods: The first maxillary molar pulp was exposed in adult male Sprague-Dawley rats, and TLR4 antagonist (LPS-RS, 25 μg/10 μl) or isotonic saline (as vehicle control; 8-13 rats/group) was applied to MDH 10 min before pulpal MO application. AD EMG activities were recorded from 15 min prior to LPS-RS or vehicle application, until 15 min after MO application. The ipsi-and contralateral MDH regions were removed after euthanasia for western blot analysis of TLR4 expression in MDH.
Results: TLR4 expression was apparent in MDH, and MO application increased EMG activities in the AD muscles that were significantly reduced following MDH administration of LPS-RS (2-way ANOVA, posthoc Bonferroni, p=0.0004).
Discussion/Conclusions: TLR4 activation in the MDH may be a mechanism mediating dental inflammatory pain. Aim: Fast-track surgery programs reduce length of stay by identifying and addressing factors that cause patients to remain in hospital, including pain (Kehlet, 2013). The assessment and management of acute pain is an important component of quality care for patients after total knee arthroplasty. The aim of this focused ethnography was to explore the factors influencing orthopedic surgery nurses' decisions to administer prn opioid analgesia for acute postoperative pain. Methods: Semi-structured interviews began with a vignette of a patient who received a nerve block for analgesia following total knee arthroplasty, and proceeded to examine factors that influence participants' pain management. Interviews were transcribed and analyzed using thematic analysis and constant comparison.
Results: The ten nurses who participated described a complex clinical environment where the interplay of several factors informed their decision to administer prn opioid analgesia. The unit's culture and physical space influenced nurses' assessment of pain and their decision whether to treat the pain with prn opioids. Each nurse's self-concept affected pain management decisions because of the perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient's expression of pain from within the milieu of the unit culture and their unique self-concept.
Conclusions: Understanding the complexity of factors that influence nurses' postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the setting of fast-track surgeries. Results: Sixty-three articles were included in the analysis. Significant overlap exists between FM and MPS for both clinical presentation and diagnostic criteria. Two-thirds of pain patients are misdiagnosed as having FM (Fitzcharles & Boulos, 2003), however the proportion of those patients who exhibit MPS is unknown.
Discussion/Conclusions: The development of a clinical decision rule for the diagnosis of MPS will enable practitioners to reliably and consistently distinguish between MPS vs FM. This is urgently needed given that the treatment protocols for MPS and FM differ significantly.
CONTACT Sheryl Bourgaize sbourgai@uoguelph.ca Introduction/Aim: Opioid analgesic use is limited by development of tolerance and increasing the dose exacerbates side effects. Spinal glial activation contributes to tolerance as astrocytes and microglia shift to a pro-inflammatory phenotype. Spinal administration of ultra-low dose (ULD) G-protein-coupled receptor (GPCR) antagonists including opioid and α 2adrenergic receptor (AR) antagonists paradoxically enhance morphine effectiveness and attenuate loss of potency. Here, we determined whether systemic ULD α 2 -AR antagonists atipamezole or efaroxan attenuate tolerance development, whether these paradoxical effects extend to another GPCR family: the cannabinoid (CB 1 ) receptor, and if changes in spinal gliosis explain their mechanism of action. Methods: Male rats were treated daily with morphine (5mg/kg) alone or in combination with ULD α 2 -AR (atipamezole, efaroxan) or CB 1 (rimonabant) antagonists (5ng/kg); control groups received ULD injections only. Thermal tail flick latencies were assessed across seven days, before and 30 minutes postinjection. On day eight, spinal cords were isolated and changes in spinal gliosis were assessed through fluorescent immunohistochemistry.
Results: Both ULD α 2 -AR antagonists attenuated morphine tolerance, whereas the ULD CB 1 antagonist did not. In contrast, both ULD atipamezole and ULD rimonabant attenuated morphine-induced micro-and astrogliosis in deep and superficial spinal dorsal horn.
Discussion/Conclusions: While both ULD atipamezole and ULD rimonabant attenuated chronic mor-phine-induced spinal gliosis, only the α 2 -AR antagonists attenuated tolerance. While the paradoxical effects of ULD GPCR antagonists are common to several receptor systems associated with pain and reward, their mechanisms may differ and effects on spinal glia alone may not be the main mechanism through which tolerance is modulated.
CONTACT Patrick Grenier 8pg3@queensu.ca Introduction/Aim: Somatic symptoms aside from pain are elevated in chronic pain patients relative to painfree controls. We identified SNP rs11575542 associated with frequency of somatic symptoms assessed with the Pennebaker Inventory of Limbic Languidness (PILL) questionnaire in a community-based cohort of temporomandidular disorder (Orofacial Pain Prospective Evaluation and Risk Assessment, OPPERA). This polymorphism is a non-synonymous missense variant (1385G>A, arginine to glutamine) located in the dopadecarboxylase (DDC) gene. The current study was designed to identify the molecular functional effect of variant allele on the enzymatic activity of DDC. Methods: DDC variants (DDCwt=allele G/arginine; DDCmut=allele A/glutamine) were cloned into pcDNA3.1-vectors and transfected to HEK293-cells. Lysates were prepared for western immunoblotting and enzymatic activity assays. 5-HTP and L-DOPA were used as substrates and the decarboxylation products were determined with UHPLC with a coulometric array detector. Michaelis-Menten parameters (Km, Vmax) were obtained from full kinetic curves.
Results: Expression levels of DDCwt and DDCmut were consistently similar. We observed a significant 20-23% reduction in the Vmax of the DDCmut for both 5-HTP and L-DOPA, but Km values did not differ significantly.
Discussion/Conclusions: Our results show that the functional effect of rs11575542 is reflected in the DDC enzymatic activity such that the mutant enzyme has a lower maximum kinetic velocity. This finding is likely very relevant to somatic symptoms as this mutation, associated with higher somatic scores, also reduces enzymatic efficacy.  Introduction/Aim: In 2010, the tertiary-care center involved in this study adjusted the treatment guidelines for neonatal abstinence syndrome (NAS) to include concomitant clonidine and morphine administration as first-line therapy. This study is the first evaluation of this practice change and aimed to compare treatment outcomes between the morphine alone and morphine + clonidine regimen for NAS in a neonatal intensive care unit from 2006-2015.
Methods: Using a retrospective population-based cohort design, infants treated pharmacologically for NAS delivered between 2006-2015, were identified using the Nova Scotia Atlee Perinatal Database. Treatment information was collected using chart review.
Results: The incidence of NAS increased from 0.79 per 1000 live births in 2007 to 4.00 per 1000 live births in 2015. The expected change over time due to adjusted guidelines was observed with 91% of infants from 2010-2015 being treated with morphine + clonidine. Of the 188 infants identified, a significantly longer length of treatment (p=0.004) and higher peak morphine dose (p=0.045) was observed in the morphine + clonidine group. Higher cumulative morphine exposure was also observed with combination therapy (p=0.228). The clinical factors of gestational age, weight, sex, and maternal smoking did not control for the differences seen between groups.
Discussion/Conclusions: The increase in length of treatment and morphine dose seen in the morphine + clonidine group was unexpected, as our findings contrasted with previous work on this treatment combination. Further exploration examining the impact of additional clinical characteristics is warranted such as maternal methadone and antidepressant exposure.  polymorphisms (SNPs) in TRPV1 for association with acute and chronic pain conditions in a discovery cohort and two replication cohorts. Methods: We genotyped five common nonsynonymous TRPV1 SNPs in a prospective cohort of 3200 participants as part of the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study. Participants underwent a clinical exam and quantitative sensory testing (QST), and incident TMD cases were identified. We attempted replication of initial association results in (1) a TMD case-control cohort of 400 genotyped Caucasian females and (2) 250,000 participants of the U.K. BioBank (UKBB) cohort. TRPV1 SNPs were analysed for association with TMD and QST measures in the OPPERA and TMD cohorts and with chronic pain phenotypes in OPPERA and UKBB.
Results: Allele G of SNP rs55916885 (Q85R) is associated with increased sensitivity to heat in both OPPERA and TMD cohorts. By contrast, it is not associated with any tested chronic pain phenotype in OPPERA or UKBB.
Discussion/Conclusions: The minor allele of rs55916885 appears to increase the risk of heat sensitivity in TRPV1 but not modulate the risk of chronic pain conditions in the tested cohorts. Reducing the number of staircases within MPT assessments would improve clinical feasibility of the technique. Our purpose was to determine the fewest number of staircases in a MPT assessment necessary to reproduce the MPT reading from the 5-staircase method. We hypothesized that fewer than 5 staircases were needed to provide an accurate and reproducible MPT.
Methods: Thirty-nine young healthy participants (21.82±2.27years) were exposed to one MPT assessment during one session. Five staircases were used in all MPT assessments. Nineteen participants completed a second MPT assessment following a 30-minute break and a third MPT assessment one week later to assess within and between day repeatability respectively. MPT was calculated using 5, 4, 3, 2, and 1 set(s) of ascending/ descending pinprick staircases. Differences were compared using a one-way ANOVA. Within and between day intra-class correlation coefficients (ICC) assessed repeatability for MPTs calculated from respective staircase numbers.
Results Our goal was to directly compare the utility of a FACS-based fine grained system to the PACSLAC-II in differentiating painful from non-painful states in older adults with and without dementia. Methods: We video-recorded 52 older adults with dementia (residing in long-term care) and 48 older adult outpatients without dementia, attending a physiotherapy clinic, during baseline conditions and while they took part in a standardized physiotherapy examination designed to identify painful areas. Videos were reliably coded using well established pain-related facial responses based on the FACS. They were also coded using the pain behaviours of the PACSLAC-II.
Results: Both tools reliably differentiated between painful and non-painful states, but the PACSLAC-II accounted for a greater portion of the variance than the fine-grained FACS-based approach. Participants with dementia obtained higher scores on the PACSLAC-II than participants without dementia.
Discussion/Conclusions: The results suggest that easy-to-use observational approaches for clinical settings are valid and that there may not be any clinically important advantages to using more resource intensive coding approaches based on FACS.
CONTACT Thomas Hadjistavropoulos hadjistt@uregina.ca Introduction/Aim: This is an experimental study of pain communication in couples. Despite evidence that chronic pain in one partner impacts both members of the dyad, dyadic influences on pain communication have not been sufficiently examined and are typically based on retrospective report. Our goal was to directly study contextual influences (i.e., presence of chronic pain, relationship quality, and pain catastrophizing) on self-reported and non-verbal (i.e., facial expressions) pain responses.
Methods: Couples with (n = 66) and without (n = 65) an individual with chronic pain (ICP) completed relationship and pain catastrophizing questionnaires. Subsequently, one partner underwent a pain task (pain target, PT), while the other partner observed (pain observer, PO). In couples with an ICP, the ICP was assigned to be the PT. Pain intensity and perceived pain intensity ratings were recorded at multiple intervals and facial expressions were video-recorded throughout the pain task. Pain-related facial expression was quantified using the Facial Action Coding System. Facial expressions of emotions were measured using specialized computer vision software.
Results: Relationship variables in POs and catastrophizing in PTs interacted with the presence/absence of chronic pain to influence pain-related facial expressions, but not self-reported pain. PTs provided higher pain ratings than POs and female PTs reported and showed more pain, regardless of chronic pain status. Facial expressions of emotions occurring between partners differed by group.
Discussion/Conclusions: Contextual variables influence pain communication in couples, and PTs and POs are influenced by distinct variables. Self-report and non-verbal responses are not displayed in parallel manners.
CONTACT Michelle M. Gagnon michelle.gagnon@usask.ca Introduction/Aim: Being diagnosed with a chronic disease can cause significant distress. Such an event can disrupt an individual's understanding of their 'meaning in life'; their purpose. This can initiate an active search for new purpose in order to reduce the distress, and improve adjustment to medical disease. This paper reviews the literature to describe the multiple life changes associated with the diagnosis of a chronic medical disease and to create a framework for understanding the relationship between Meaning in Life and these changes. Methods: A database search using keywords and subject headings was performed in 5 databases. After sorting according to predetermined criteria, 46 papers were included in the present review.
Results: Adjustment consists of the psychological, physical and social changes that occur after the diagnosis of a chronic medical condition or trauma. This causes an active search for meaning in an attempt to restore the patient's sense of purpose. The act of searching and finding new meaning in life is associated with positive adjustment outcomes. However, searching without success can have a negative impact on adjustment and quality of life.
Discussion/Conclusions: A diagnosis of a chronic medical condition causes psychological, physical and/ or social distress, which can have a negative impact on an individual's sense of purpose, or Meaning in Life. This preliminary review of the literature describes the process of searching for Meaning in Life, and explores its consequences on adjustment to chronic medical condition after diagnosis. Future recommendations for the direction of research in this area will be provided. Introduction/Aim: Children's memories for pain are a powerful mechanism underlying pain trajectories. Parentchild interactions have been posited to play an important role in shaping pain memory biases, particularly among young children. Parent-child reminiscing about past negative events creates a powerful sociolinguistic context that shapes children's memory. Previous studies have identified adaptive ways to reminisce with children: using elaborative questions and emotion-laden words is associated with more accurate recall. However, no studies have yet examined how parents and children reminisce about postsurgical pain and how it may influence subsequent pain memories. Using a longitudinal design, we investigated the reminiscing style of parent-child surgery-related narratives and their influence on children's post-surgical pain recall. Methods: To date, 45, 4-to 7-year old children (20 girls, mean age = 5.31) and their parents reported pain (the Faces Pain Scale-Revised, FPS-R) after tonsillectomy, a common outpatient pediatric surgery associated with high levels of post-surgical pain. Two weeks post-surgery, children and parents came to the lab and engaged in a narrative elicita-tion task wherein they reminisced about the surgery experience. Narratives were coded using an established coding scheme drawn from the developmental literature. One month post-surgery, children recalled their post-surgical pain using the FPS-R.
Results: Findings revealed that more elaborative parental reminiscing (r = -.30) and more frequent use of explanations (r = -.26) and emotion-laden words (r = -.34) were associated with less distressing children's pain memories.
Discussion/Conclusions: Reminiscing with children about post-surgical pain using elaborations and emotion-rich language might help them to develop less distressing pain memories, thus positively altering pain trajectories. Results: 7047 articles were identified, 100 underwent full text screening and 27 studies were included in the final review (25 from the search and two from reference lists). Sixteen articles (59%) were non-experimental studies, and 11 (41%) were experimental, of which 8 were randomized controlled trials (RCTs). Interventions were categorized into: Pharmacological, physical, psychological, and others. The majority of the articles solely focused on pharmacological interventions (n= 21, 78%), one on physical, and one on psychological interventions. Four studies included more than one category of interventions. The majority of the studies focused on post-operative pain management (n=18, 67%), two (7%) on analgesia and sedation management, and seven (26%) on other pain management for different conditions. Discussion/Conclusions: The majority were non clinical trials focusing on medications and postoperative pain management. More research, especially clinical trials, is warranted to determine the most effective non-pharmacological (physical and psychological) interventions. Introduction/Aim: In contrast to burgeoning literature on risk factors and negative outcomes associated with pediatric chronic pain, there is a paucity of research examining resilience factors implicated in adaptive functioning and positive outcomes 1,2 . Resilience factors that have been examined include self-efficacy 3,4 , acceptance 5,6 , and optimism 7 . Benefit finding (BF) is characterized by positive changes or gains in the face of significant adversity 7,8 and has been identified as a potential resilience outcome in risk-resilience conceptual models of chronic pain 9,10 . Much of the existing research examining the role of BF in pediatric health conditions has assessed children diagnosed with cancer, revealing positive relationships with adaptive outcomes 11 . This is the first study to examine associations between BF and pain-related variables in a sample of adolescents with chronic pain. Methods: Youth (n = 118, 65% = girls, M age = 13.43) were assessed at the point of entry into a tertiary, interdisciplinary pediatric chronic pain program and completed psychometrically sound measures assessing pain characteristics, pain catastrophizing, and BF (adapted for the chronic pain context) as part of a multi-wave outcome initiative.
Discussion/Conclusions: In contrast to other chronic illness populations, BF was related to worse outcomes, suggesting that while benefit is perceived among youth who are severely affected by pain, this construct operates differently in this population. Future research is needed to examine BF as a predictor of treatment response and longterm outcomes. Introduction/Aim: Memory for pain is a robust predictor of worse pain and distress during subsequent pain experiences. Parent anxiety has been linked to child pain memory, and parent emotional availability (EA) is the strongest predictor of child anticipatory distress for future painful procedures. Parental involvement has been hypothesized as being important to pain memories, however, the extent to which parent-child EA contributes to child pain memory is unknown. We examined whether parent-child EA is associated with child memories for pain 1-month post-surgery.
Methods: To-date, we recruited 27 children aged 4-7 years (mean=5.5), undergoing a tonsillectomy procedure. Parents filled out the State-Trait Anxiety Questionnaire to assess their own anxiety. Children reported their post-surgical pain using the Faces Pain Scale-Revised (FPS-R). Two weeks following the surgery, parent-child dyads came to the lab and reminisced about the surgical experience using a structured elicitation task. EA was assessed during this reminiscing task using the EA Scale. One-month post-surgery, children recalled their pain using the FPS-R.
Results: Children of dyads who had greater ratings of parent-child EA (p=0.02) developed less distressing pain memories 1-month post-surgery (adjusted R 2 =0.22) compared to children of dyads with lower parent-child EA, after accounting for child age and sex, post-surgical pain, socio-economic status, and parent state-trait anxiety (all n.s.).
Discussion/Conclusions: Parents who are EA to their child, may have the opportunity to reframe their child's memory for pain, so that they remember it more accurately/positively; thereby, potentially decreasing the likelihood that their child will be distressed and avoidant of future painful procedures. administrators, and clinicians were responsible for initial curriculum development. In addition to instruction by a pain expert, a recorded lecture format has been used to include leaders in pain research, management, and education.
Results: The certificate consists of three courses offered in a distance based format. Courses consist of asynchronous and synchronous learning activities. Graduate level credit earned may be used as elective credit for clinicians pursuing graduate studies.
Physician participants may obtain MAINPRO Cert+ credits through the College of Family Physicians of Canada (CFPC) and courses may be used towards credentialing through the Canadian Academy of Pain Management (CAPM). Pain certificate program registrants represent a diverse mix of clinicians including physicians, pharmacists, physical therapists, occupational therapists, psychologists, nurses, social workers, and others. Since May 2010, over 150 clinicians have registered for this certificate program.
Discussion/Conclusions: Post-course quantitative and qualitative participant surveys reveal high levels of satisfaction and applicability to practice. To date post-course evaluation has consisted of student evaluations and a post (1.5 years) program completion evaluation. Data collected has helped determine level of knowledge translation in the clinical setting.
CONTACT Shawn Drefs sdrefs@ualberta.ca Introduction/Aim: The objective of this survey was to collect information regarding patient experience with using medical cannabis for chronic pain under the expanded program for medical cannabis which allowed patients to purchase varying strains of cannabis from a variety of producers (launched in June 2013).
Methods: This was a pragmatic survey study of a consecutive group of patients who were using cannabis as a part of their pain management in the context of a tertiary care pain clinic. The survey was given to patients known to be using medical cannabis who presented for follow-up between April and September of 2015.
Patients were asked to complete the survey and return it to the clinic. Information regarding type of pain or other symptoms as well as dose, route of administration, side effects and products used was collected Results: Fifty percent (N = 12) of surveys were returned completed. 10 participants reported pain to be slightly or much improved with additional improvements in sleep and other symptoms. All reported side effects, the most common were dry mouth and drowsiness. Most were using a smoked or vaporized route of delivery, the majority a dose of 3-4 puffs and an average daily dose of 1.75 grams.
Discussion/Conclusions: This survey supports that some patients using marihuana for chronic pain conditions report benefit in pain, sleep and other symptoms side effects were similar to those reported with other types of analgesic medications. There was not enough information to report on strain specific differences for specific pain diagnoses. Further research is needed. . Dispersion time 1.28 ± 0.71s was significantly longer than injecting into a saline bag 0.05 ± 0.006s (p = 0.0001).
Discussion/Conclusions: This technique of studying dynamic epidural biomechanics proved acceptable in this small pilot study, maintaining sterility while interfering minimally with epidural insertion. There is high inter-individual variability in LOR biomechanics, while demographic variability was small. Health quality experts reason that highly variable methods cannot all be best practice.. Pressure dispersion time (the time that pressure is elevated above baseline after injection) is a function of epidural tissue properties. Dispersion times suggest that the epidural space behaves as a poroelastic tissue. Further dynamic biomechanic research may suggest an optimal LOR volume and force that may lead to safer epidural insertion. Introduction/Aim: The aim of the present study was to examine the factor structure and psychometric properties of the 12-item Sensitivity to Pain Traumatization Scale (SPTS), a measure of the anxiety-related cognitive, emotional, and behavioral responses to pain that resemble a traumatic stress response. Methods: A sample of 134 adults (50% female; M age = 50.06, SD age = 14.05) completed a questionnaire assessing symptoms of pain, anxiety, depression, and trauma at their first outpatient visit to the Transitional Pain Service after surgery. Confirmatory factor analysis was used to estimate a non-hierarchical, one-factor model of the SPTS.
Discussion/Conclusions: The findings support the one-factor model and validity of the SPTS in postsurgical patients seen by the Transitional Pain Service. Introduction/Aim: We examined whether patterns of uterine innervation were related to pain specifically in women with endometriosis or more generally in women with menstrual pain. Methods: Full thickness uterine samples were collected (n = 10) from women undergoing hysterectomy and classified based on presence/absence of selfreported endometriosis and pelvic pain severity. Tissues were fixed (4% paraformaldehyde), cryoprotected and frozen. Fluorescent immunostaining (16μm sections) was undertaken using CD31 (pan-endothelial) and either PGP9.5 (pan-neuronal) or tyrosine hydroxylase (TH, sympathetic axons) antibodies. Axon density was determined in different uterine regions by counting axon crossing points from an overlying grid (researcher blinded to patient details).
Discussion/Conclusions: Using optimised protocols, we demonstrate that axon density is increased in sub-serosal myometrium of women with endometriosis; future studies should consider how these patterns relate to pain symptoms. Unlike previous studies that suggested using endometrial biopsies for endometriosis diagnosis, we rarely observed endometrial axons.
CONTACT Jane E. Girling jgirling@unimelb.edu.au Speaking up about painful sex: Goals for disclosing pain are associated with women's sexual functioning, relationship satisfaction, and depressive symptoms . We examined whether disclosure (vs. nondisclosure) of painful sexual intercourse, as well as the goals for disclosure, were associated with women's psychological, sexual, and relationship well-being. Methods: Women (N = 272) completed standardized online measures assessing sexual problems, relationship satisfaction, sexual functioning, depressive symptoms, and goals for disclosing sexual problems.
Results: Women reporting pain during intercourse who had disclosed this problem to their current partner reported fewer depressive symptoms, and greater sexual functioning and relationship satisfaction compared to non-disclosers. When women endorsed stronger approach goals for disclosure, they also reported greater sexual functioning and relationship satisfaction, and fewer depressive symptoms, whereas when women had stronger avoidance goals they reported poorer sexual functioning and relationship satisfaction, and more depressive symptoms.
Discussion/Conclusions: Findings may inform clinical interventions by suggesting that disclosing painful sex, particularly when motivated by approach goals, may benefit women's well-being by enhancing intimacy or allowing couples to adapt sexual activities to accommodate the pain. Taking care of complex regional pain syndrome: Overview of clinical reality in a tertiary pain clinic Demographic data, medical history, medication tried and interventional therapies (IT) received were assessed. Using bivariate logistic regression, these data were compared with outcome referring to pain reduction, hand function improvement and return to work.
Results: 92% suffered of type 1 CRPS. 26% were classified Not Otherwise Specified (NOS), but had similar evolution then the rest of the group. Patients had an average of 10 IT, most often intravenous regional anesthesia (IVRA) with passive mobilization given by occupational therapist (OT) (97% Introduction/Aim: Research has shown that health anxiety (HA) significantly contributes to disability in chronic pain populations. The aim of the current study was to examine if metacognitive beliefs may account for the relationship between chronic pain and HA. Methods: University students who reported experiencing (n = 157), or not experiencing (n = 128), chronic or recurring pain completed the Chronic Pain Grade Scale (CPGS), Short Health Anxiety Inventory (SHAI), and Metacognitions about Health Questionnaire (MCQ-HA). Bivariate correlations were conducted to determine whether CPGS intensity and disability subscale scores correlated with SHAI scores. Partial correlations were conducted to examine whether these correlations remained significant when controlling for MCQ-HA scores.
Results: In the pain sample, bivariate correlations revealed that HA significantly correlated with disability, r = .20, but not with intensity, r = .13. Partial correlations controlling for metacognitive beliefs revealed that the relationship between HA and disability was no longer significant, r = .04. In the non-pain sample, bivariate correlations revealed that HA significantly correlated with both disability, r = .19, and intensity, r = .26. Partial correlations revealed that the relationship between HA and both intensity, r = .16, and disability, r = .02, were no longer significant when controlling for metacognitions.
Discussion/Conclusions: Metacognitions appear to contribute to the relationship between chronic pain and HA. These results have implications for the treatment of HA in chronic pain populations. Future research should examine the contributions of metacognitive beliefs in delineating the relationship between chronic pain and HA. Results: Participants' responses indicate identity reformation (a two-component process) is an overarching theme influencing how relationship barriers (e.g., CP stereotypes) are experienced. Dating barriers forced participants to recognize their inability to be the person they were before CP or who they 'should' be (realizing I can't be me). Participants subsequently began formulating a with-CP identity and assessing its value against prior identities (evaluating with-CP me). Some participants equated having CP to being shamefully flawed and unworthy of love and acceptance. These participants struggled to maintain their pre-CP selves or adopted a pain-focused identity. Alternatively, those who held neutral/positive beliefs about persons with CP were more willing and able to integrate pain as a part of their identity without shame, and described more success pursuing romantic relationships.
Discussion/Conclusions: When people view their with-CP identity as shameful, they are less willing and able to work towards initiating/developing a loving romantic relationship -a cherished life goal for many. These findings suggest positive with-CP identity development may be an important clinical target for helping-professionals. Competitiveness in facebook peer support groups for Fibromyalgia week per month for three consecutive months and analyzed according to the six steps of thematic analysis.
Results: Preliminary analyses identified competitiveness as a key response to support-seeking posts. It had two main components: (1) "I'm sicker than you" where participants describe experiencing more symptoms than previous posters which they equate with greater suffering; and (2) "I'm the Expert" where participants used the length of time they had experienced symptoms to invalidate differing opinions. A secondary theme, responder usurping, where participants attempted to redirect the groups' focus from the original supportseeking post to themselves, was noted in our latent analysis of competitive excerpts.
Discussion/Conclusions: The results of this analysis suggest patients, in trying to prove the severity of their own suffering, further isolate themselves and potentially miss opportunities to experience emotional support, a sense of belonging, and to offer support for others. These results also suggest that even in a safe space, participants continue struggling to legitimize their suffering. Introduction/Aim: High rates of post-traumatic stress disorder (PTSD) symptoms have recently been found among parents of youth with chronic pain. Moreover, higher parental PTSD symptoms have been linked to worse child pain outcomes. Children's and parents' catastrophic thinking about child pain are robust predictors of child pain symptoms and have been proposed as potential mechanisms through which parental PTSD influences children's pain. This study is the first to examine whether child and parent pain catastrophizing mediates the relationship between parental PTSD symptoms and child pain among a cohort of youth with chronic pain. Methods: Eighty-nine children diagnosed with chronic pain (65% female, M age = 13.43, Range = 8-17 years) in a tertiary level chronic pain program and their parents (92.5% mothers) completed data collection. Parents completed self-report measures of PTSD symptoms and catastrophizing about child pain. Children completed self-report measures of pain catastrophizing and pain interference.
Results: Analyses using the Preacher and Hayes bootstrapping macro showed that the relationship between parental PTSD symptoms and child pain interference was mediated by higher levels of parent pain catastrophizing (95% CI Lower to Upper = .023-.234) and child pain catastrophizing (95% CI Lower to Upper = .074-.240). Parent and child pain catastrophizing accounted for 11% and 14% of the variance in the relationship between parental PTSD symptoms and child pain interference, respectively. Discussion/Conclusions: Parent and child catastrophic thinking about pain play important roles in understanding how parental PTSD symptoms influence children's chronic pain experience and may inform the refinement of family-based interventions to reduce children's pain.
Is sex worth the pain? Willingness to engage in sexual activity among partnered women with Fibromyalgia Kirsten M. Gullickson a , Lyndsay Crump a , Diane L. LaChapelle a , Pablo Santos-Iglesias b , and E. Sandra Byers a a Psychology, University of New Brunswick, Fredericton, New Brunswick, Canada; b Oncology, University of Calgary, Calgary, Alberta, Canada Aim: Fibromyalgia (FM) negatively impacts sexual functioning although little is known about the nature of its impact, therefore we qualitatively explored how and why FM impacts sexual well-being among women in committed relationships.
Methods: Seventeen women with FM, who reported being in a relationship for at least 12 months, provided demographic/health information then participated in a semi-structured interview. Participants were asked to describe the impact of FM on various aspects of their sexual functioning (e.g., frequency, desire, arousal, satisfaction). Interview audio recordings were transcribed verbatim and the content was coded using Thematic Analysis.
Results: The most commonly reported impacts of FM on sexual well-being were decreased sexual frequency and reduced sexual satisfaction. Participants identified numerous barriers to sex, including muscle pain/soreness, fatigue, depression, decreased arousal, and negative body image. The majority of participants described making few attempts to engage in sexual activity, but a minority prioritized their sexual relation-ship and described efforts to adjust their sexual scripts to accommodate FM (e.g., changing the timing, duration, location, or nature of their sexual encounters). Participants reported varying levels of emotional distress and relationship conflict as a result of the sexual impacts of FM.
Conclusions: In women with FM, willingness to work toward a positive sexual relationship and degree of associated emotional distress may depend on whether the individual and their partner consider sex to be a valued activity to be prioritized. Encouraging clarification of sexual and relationship values may facilitate chronic pain acceptance and aid individual and dyadic adjustment to FM. Results: None of the 10 participants interviewed could name specific low back pain clinical practice guidelines. However, they correctly described what the guidelines generally recommend. We identified six themes related to barriers and facilitators for chiropractors screening and managing psychosocial factors. The themes revolved around the participants' desire to fulfill patients' anatomy-focused treatment expectations and a perceived lack of training on managing psychosocial factors. This was compounded by concerns about going beyond the chiropractic scope of practice and a perceived lack of practical psychosocial screening and management resources. Furthermore, social factors, such as the influence of other healthcare practitioners, were reported to act as barriers or facilitators to screening and managing psychosocial factors.
Discussion/Conclusions: Most chiropractors in our study treated with a biomedical approach and reported that they do not always address psychosocial factors identified in their patients with low back pain. Many of the barriers identified appeared to be modifiable with relatively low-cost interventions, such as continuing education using evidence-informed behaviour change techniques.
CONTACT Peter Stilwell peterstilwell@dal.ca Introduction/Aim: The aim of this study was to examine the contribution of neutrophil elastase and proteinase-activated receptor-2 (PAR2) to the development of joint pain associated with monoiodoacetate (MIA)induced osteoarthritis (OA). Methods: Experimental OA was induced in male C57BL/6 mice (22-36g) by injecting MIA (0.3mg/10µl) into the right knee joint. One cohort of animals received a synthetic inhibitor of neutrophil elastase (Sivelestat: 50 mg/kg i.p.) 10 min before and 240 min after MIA injection, and once on days 1 to 3. A second cohort received an endogenous inhibitor of neutrophil elastase (alpha-1 antitrypsin: 10 µg i.p.) 15 min before and 12 hours after MIA injection. The role of PAR2 receptors was investigated by comparing the development of MIAinduced OA in wild-type and PAR2-knockout mice. Pain was measured using von Frey hair algesiometry at several time points over two weeks. Joint nerve damage was also assessed on day 14 by measurement of saphenous nerve fibre myelin thickness using G-ratio values.
Results: Joint pain appeared on day 1 and persisted to day 14 post-MIA (P<0.0001). Early blockade of neutrophil elastase using Sivelestat or alpha-1 antitrypsin produced significant improvement in joint pain throughout the time course (P<0.0001). PAR2 knockout animals injected with MIA showed reduced joint pain (P<0.0001) over the two week time course and less saphenous nerve demyelination (P<0.05).
Discussion/Conclusions: Early inhibition of neutrophil elastase improves later pain responses in MIA-induced OA. Knock out of PAR2 prevents the development of MIA-induced tactile allodynia and demyelination, suggesting these effects are mediated by a PAR2 mechanism.
Outcome domains to evaluate paediatric chronic pain rehabiliation program success: What is meaningful to youth, parents, and other important stakeholders? Introduction/Aim: Paediatric chronic pain rehabilitation programs for youth with high levels of pain-related disability require the collaboration of multiple stakeholders, thus creating challenges in establishing common outcomes upon which to evaluate these interventions. Previous outcome recommendations (PedIMMPACT) have not formally integrated the perspectives of youth with chronic pain, their parents, and other important stakeholders (e.g., teachers). This study aimed to identify outcome domains sensitive to the perspectives and needs of these various stakeholders.
Methods: An exploratory qualitative design guided this study. Data was gathered from a 12-member advisory group, composed of youth with chronic pain, their parents, clinicians, healthcare managers, and teachers, using a combination of electronic questionnaires and audio-recorded focus groups. A thematic content analysis process was used to analyse the data.
Results: All participants described the intervention goal as improving function despite the pain. Four primary outcome domains emerged: 1) independence in self-management of pain condition, daily activities, and health needs; 2) participation in meaningful activities with family, school, friends, and in the community; 3) quality of life of the youth and their family members, including sleep, mood and affect, and selfefficacy; and 4) costs to the family and the healthcare system. Pain intensity and frequency were seen as secondary outcome domains.
Discussion / Conclusions: Stakeholderidentified domains provide valuable information about the expectations of various stakeholders involved in the complex rehabilitation interventions for youth with pain-related disability and can create a foundation upon which effectiveness evaluation studies of these programs can be based.
CONTACT Karen Hurtubise karen.hurtubise@usherbrooke.ca Introduction/Aim: The study explored the relationship between siblings' behaviours and children's pain outcomes during cold-pressor pain. Methods: 92 sibling dyads between the ages of 8-12 took turns participating in the cold pressor task (CPT) in a counterbalanced order with their sibling present. The behaviour of the observing sibling was coded as attending (e.g., symptom talk), non-attending (e.g., distraction) and coping/encouragement behaviour. Pain tolerance, as assessed by immersion duration, was recorded. Following the CPT, children rated their pain intensity and pain-related fear.
Results: A series of actor-partner interdependence models using structural equation modelling was conducted. The child who participated in the CPT first was considered Sibling 1, and the child who participated second was considered Sibling 2. Greater levels of coping behaviours by Sibling 2 was related to higher pain intensity (b* = .27, p < .01) and fear (b* = .17, p < .05) reported by their participating sibling. Further, greater coping behaviours by Sibling 1 was related to their own greater fear (b* = .22, p < .05), and greater levels of coping behaviours by Sibling 2 was related to their own greater pain intensity ratings (b* = .19, p < .05). Greater attending behaviours by Siblings 1 (b* = −.15, p < .05) and 2 (b* = −.26, p < .01) was related to lower pain tolerance for their participating siblings. Greater non-attending behaviours by Sibling 2 was related to higher fear ratings by their participating sibling (b* = .25, p < .05).
Discussion/Conclusions: The findings suggest that the behaviours of a present sibling related to children's pain experiences, with behaviours that drew attention to the pain/experience generally being associated with poorer outcomes.
CONTACT Meghan Schinkel meghan.schinkel@dal.ca Introduction/Aim: Inguinal hernia repair is one of the most common surgical procedures in the world. Chronic pain following herniorraphy is now recognized as the most significant complication of this procedure and is due to primary or secondary injuries to nerve tissue. Multiple pharmacologic, non-pharmacologic and surgical treatment modalities have been used, and have varied success rates. Pulsed radiofrequency (PRF) is fairly new in the treatment of chronic pain, and has been used successfully in the treatment of groin pain. It is safe, non-neurodestructive and is less painful than continuous radiofrequency. The purpose of our study is to examine a case series of three patients with chronic ilioinguinal neuropathy following herniorraphy that were treated with PRF at our institution. Methods: Three patients diagnosed with chronic ilioinguinal neuropathy secondary to herniorraphy were treated with ultrasound-guided ilioinguinal PRF at 42°C between 4 to 10 minutes, with a 20G 100mm needle (10mm active tip). All patients treated with PRF have had initial positive responses to ilioinguinal nerve blocks. All techniques were executed by the same algologist (JFC).
Results: After the PRF, 2/3 patients reported almost complete pain relief for at least 1 month. Past 1 month, all patients experienced chronic pain, but at a decreased level compared to the period before the PRF. No complications were observed.
Discussion/Conclusions: In the three patients studied, PRF was successful in diminishing chronic ilioinguinal pain following herniorraphy without complications. Further studies are needed to confirm our results. Methods: We interviewed 13 low back pain patients in our local ED before and after seeing a physician. Transcripts were analyzed using a theoretical framework ("a typology of reasons") developed based on existing qualitative literature on the topic. Thematic results are presented.
Results: We confirmed many themes motivating patients' decisions to visit the ED that have been suggested from previous literature, including intensity/ change in pain, and access to diagnostics tools. Counter to previous research, patients did not report issues accessing their family physician, and overall expressed satisfaction with their family physician. While many voiced their reluctance to present to the ED, they also conveyed satisfaction with the care they received.
Discussion/Conclusions: Patients' motivations were highly varied, though many fell within the typology of reasons developed through our comprehensive search of the literature. Furthermore, most patients did not receive any specialized interventions, such as diagnostic imaging, even if that had motivated them to present to the ED. Despite this, the majority of patients reported being satisfied with the care they received and felt they had made the right decision in visiting the ED for their low back pain.
CONTACT Alexander Stathakis a.stathakis@dal.ca Introduction/Aim: Chronic post-surgical pain (CPSP) leads to significant disability. Research is needed on psychological processes that support people with CPSP in improving pain-related disability. One proposed process is pain acceptance, characterized as the experience of ongoing pain without attempts to avoid, reduce, or control it. For people with CPSP, pain acceptance may reduce disability by fostering greater re-engagement with valued life activities. The purpose of this study was to test the mediating role of pain acceptance in the relationship between pain intensity and disability in patients who had undergone coronary artery bypass graft surgery (CABGS) at least 6 months earlier.
Methods: N = 133 patients (Age M = 62.67 years, SD = 11.74; 72% Male) reported CPSP. Pain intensity was measured using a 0-10 scale. Disability was measured using the Pain Disability Index. Pain acceptance was measured using the Chronic Pain Acceptance Questionnaire. Mediation with pain acceptance (mediator), pain intensity (predictor), and disability (outcome) was tested according to Hayes (2016) specifications.
Results: Pain intensity was positively correlated with disability (r = .44, p < .001) and inversely correlated with pain acceptance (r = -.45, p < .001). The mediation model revealed pain acceptance was a significant inverse predictor of disability (β = -.73, p < .001), while the direct effect of pain intensity on disability was not significant (β = .11, p = .22), supporting a full mediation.
Discussion/Conclusions: Results demonstrate that pain acceptance mediates the relationship between pain and disability in CPSP patients. Acceptancebased chronic pain interventions may assist sufferers in engaging in flexible and persistent patterns of valued activities.
CONTACT Muhammad Abid Azam abidazam@yorku.ca Quantitative sensory testing indicates differential pain thresholds and pain after-effects in patients with chronic pain after cardiac surgery Introduction/Aim: Chronic pain occurs in~10% of patients following cardiac surgery. Little is known about sensory processing changes related to chronic post-surgical pain (CPSP). Quantitative sensory testing (QST) is comprised of methods to assess differential responses to noxious/non-noxious stimulation. This cross-sectional study examined QST measures in patients who had undergone coronary artery bypass graft surgery (CABGS) at least 6 months earlier.
Methods: 367 patients (Age M = 66.05 years, SD = 11.58; 75% Male) underwent CPSP assessment and were grouped for presence of chronic pain at CABGS sites (CPSP; n = 133), other chronic pain (OCP; n = 97), or no pain (NP; n = 137). Pain detection thermal (cold/heat pain) thresholds (TPT) were measured at the chest and right forearm. Cold pressor task (CPT) was conducted with one arm submerged in cold water (M = 1.47°C, SD = .77) until pain was intolerable. Pain intensity and unpleasantness ratings were obtained using a 0-10 numeric rating scale 30 seconds after CPT arm withdrawal. One-way ANOVAs were conducted followed by Bonferroni post-hoc comparisons (α<.017).
Discussion/Conclusions: Results suggest CPSP alters pain-modulatory processing leading to lower heat and higher cold pain thresholds, and prolonged cold pain effects after CPT arm withdrawal.
CONTACT Muhammad Abid Azam abidazam@yorku.ca Aim: Current treatments for corneal pain are frequently ineffective. Cannabinoid receptor 1 (CB1R) orthosteric activation has antinociceptive effects, however, therapeutic applications are limited due to behavioral sideeffects. Allosteric modulators bind to distinct sites at CB1R, and may offer an alternative approach to reduce pain with reduced side-effects. Therefore, the purpose of this research was to investigate the antinociceptive properties of the CB1R allosteric modulators GAT229 and GAT228 in a mouse model of corneal injury. Methods: Corneal hyperalgesia was generated using chemical cauterization of the cornea in wildtype (WT) and CB2R knockout (CB2R-/-) mice. Cauterized eyes were treated topically with GAT229 and GAT228 (0.5-2%, w/v) alone or in combination with orthosteric CB1R agonist, Δ 8 -tetrahydrocannabinol (Δ 8 THC), in the presence/ absence of the CB1R antagonist AM251 (2mg/kg, ip). Increased number of eye blinks, squints and wipes, recorded 6 hours post-injury using capsaicinstimulation were collectively termed as corneal hyperalgesia.
Conclusion: The CB 1 R allosteric modulators GAT 229 and GAT 228 reduce corneal hyperalgesia either through potentiating the orthosteric activity or independently through allosteric activation. Allosteric modulation of CB1R could offer a novel approach for treating corneal pain while reducing the sideeffects produced from CB1R orthosteric activation.
Introduction/Aim: Low back pain remains a condition with relatively high incidence and prevalence, affecting 70-85% of people at some point in their lives. Low back pain management may be best suited for primary care, yet it is one of the most common reasons for presentation to emergency departments.
Methods: The objective of this study was to provide a summary of the evidence on effectiveness of treatments relevant to the emergency department for adults with low back pain. We conducted an overview of systematic reviews following robust methods advocated by Cochrane. We searched the Cochrane Library (including Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews), and included systematic reviews of randomized controlled trials for treatments for low back pain appropriate for delivery in the emergency department setting.
Results: Salicylate-containing rubefacients and superficial heat provide a statistically significant reduction in pain compared to placebo for acute low back pain. For chronic low back pain, buprenorphine (opioid) provided both a statistically significant and clinically important improvement in pain. We will provide results on other key outcome measures: function/ disability and adverse events.
Discussion/Conclusions: Majority of the interventions included in this study provided a small but statistically significant reduction in pain for both acute and chronic low back pain. Buprenorphine (opioid) produced a clinically important improvement in pain for chronic low back pain. Our study is the first overview of reviews to summarize the evidence on the effectiveness of treatments in emergency department settings for reducing pain and disability in patients with low back pain. Results: The search yielded 61 pieces mentioning the IDHTH campaign, of which all but one focused specifically on the campaign. Online media comprised 73.7% of coverage and traditional media accounted for 26%. Of total coverage, 55.7% of pieces included campaignproduced multimedia, most notably hyperlinks (37%), videos (31%) and social media images (18%). Fifty-nine per cent of coverage generated social media engagement (4,523 social media 'hits'), notably general shares where the platform was not specified (67.8%) and Facebook shares (11.5%) and likes (10.1%). The online pieces where audience commentary was enabled generated 138 comments. Earned media coverage and audience commentary are being analyzed for content themes.
Conclusions: The findings indicate that earned media extended the reach and impact of the IDHTH campaign and offers a window into audience reception of and engagement with public communication about children's pain. This study serves as one measure of the effectiveness of a science-media partnership in promoting knowledge-translation efforts to bridge the critical knowledge-to-action gap in children's pain.
Acute and prophylactic treatment with cannabidiol attenuates pain in a rat model of osteoarthritis Methods: OA was induced in male Wistar rats (232-309g) by intra-articular (i.artic.) injection of sodium monoiodoacetate (MIA 3mg/50µl). On day 14 after OA induction, joint pain was measured by hindlimb weight bearing and hindpaw tactile allodynia. CBD (300µg/50µl, n = 8) or vehicle (50µl DMSO:cremophor:0.9% NaCl, 1:1:8, n = 8) was locally administered (i.artic.) and joint pain was assessed over 4 hours. Prophylactic use of CBD was assessed in a separate cohort of rats, where CBD (300µg/50µl, n = 8) or vehicle (50µl, n = 8) was administered subcutaneously (s.c.) over the ipsilateral knee joint 30 min prior to the induction of OA and every 24 hours for the first three days thereafter. Joint pain was then measured over the course of MIA development on days 0, 1, 2, 3, 7, 10, and 14.
Results: Acute administration of CBD on day 14 significantly improved hindpaw withdrawal threshold (p < 0.0001) and hindlimb weight bearing (p = 0.0013). Prophylactic administration of CBD attenuated hindpaw withdrawal threshold (p < 0.0001) over the course of 14 days, but did not significantly improve hindlimb weight bearing (p > 0.05).
Discussion/Conclusions: This study suggests for the first time that local CBD administration attenuates pain in established OA, and early prophylactic CBD treatment prevented the later development of pain in OA. Introduction/Aim: Instruction in activity pacing is frequently included in the treatment of individuals with chronic pain. Research suggests, however, that individuals with chronic pain experience difficulty employing this strategy and that several factors limit their ability to do so. This study examined the effectiveness of an interdisciplinary group program addressing these issues, and examined the relationship between changes in beliefs about pacing and changes in psychosocial functioning. Methods: Fifteen individuals with chronic pain with ongoing difficulties employing activity pacing completed a five-week interdisciplinary group program. The group incorporated discussion and homework to provide opportunities to challenge beliefs that limit activity pacing (e.g., concerns about maintaining productivity, completing activities once started, and concerns about the responses of others). At the beginning and end of group, individuals completed the Pacing Obstacles Questionnaire (POQ) which measures beliefs about pacing, and measures of affect, activity, pain acceptance, and perceived disability. Correlations between changes in beliefs and changes in the outcome measures were examined to explore the relationship between beliefs and functioning, and to evaluate the effectiveness of treatment.
Results: A significant decrease in perceived obstacles to activity pacing was observed. Decreased concerns about pacing were related to increased use of pacing, improved affect, and greater acceptance of pain.
Conclusions: Most respondents endorsed chewing, snorting, smoking or injecting a prescription opioid tablet/capsule in the month prior to entering treatment. The most endorsed route of administration varied within each active pharmaceutical ingredient.

CONTACT Colleen M. Haynes
Colleen.Haynes@rmpdc.org Introduction/Aim: To identify the availability of institutional resources (e.g. policies, continuing education) to support nurses' pediatric pain management practices in rural northern Ontario hospitals. Methods: An exploratory descriptive online survey was conducted using a pilot tested study specific questionnaire. A purposeful sampling method was used to recruit nurse administrators from eligible northern rural hospitals with dedicated inpatient pediatric beds. Descriptive statistics were used to quantify the types of institutional resources.
Results: Representatives from eight of nine eligible sites responded to the survey. On average hospitals admitted 50 (SD = 48) pediatric patients per year and had an average of 3392 (SD = 3625) pediatric visits (i.e. emergency and outpatient clinics) per year. Most respondents reported that nurses used pain assessment tools, but not all sites had a range of tools to meet the developmental differences across the pediatric population. Most sites (n = 6, 75%) had several policies or procedures to support pediatric pain care. Sucrose and kangaroo care were not commonly used for infants, despite their effectiveness, low cost and ease of use, yet all sites identified consistent use of topical anesthetic for needle pokes. Not all sites offered introductory or continuing education on pediatric pain. Selfidentified scarcity of resources (i.e. no dedicated funding for education) was identified as a challenge. Guidelines or order sets were suggested as potential strategies to improve pain care in the rural context.
Discussion/Conclusions: The findings from this study provide insights into how best to improve tailored strategies to improve pediatric pain care in the rural Northern Ontario. Introduction/Aim: 20-60% of women experience chronic postoperative pain after breast cancer surgery (BCS). They may also undergo several other potentially painful treatments in the year following BCS. It is unclear whether they receive adequate pain management and the factors associated with analgesic adequacy are unknown. This study aimed to describe analgesic adequacy in women reporting cancer treatment-related pain (CTP) 1 year after BCS and identify its correlates. Methods: 161 women who underwent unilateral or bilateral lumpectomy or mastectomy completed measures of pain and physical and psychosocial wellbeing 1 year after BCS. Sociodemographic and clinical data were collected. Analgesic adequacy was measured with the Pain Management Index (PMI). Descriptive statistics characterized women reporting CTP daily or most days of the week. Backwards linear regression identified correlates of CTP analgesic adequacy.
Discussion/Conclusions: Most women with CTP 1 year after BCS received inadequate analgesia. Inadequate analgesia was associated with pain, impact, and psychological factors, highlighting the multifactorial nature of analgesic adequacy. Future research is needed to further elucidate CTP management. Introduction/Aim: To model the prediction of preschooler coping responses during vaccinations. Both caregiver and child variables from the 12-month and preschool vaccinations were included. Methods: The data is part of an ongoing longitudinal study that followed caregivers and children from infancy to preschool. Two separate path models (Minute 1 and Minute 2 post-needle) were estimated using data from the 12-month vaccination (n = 548), the preschool vaccination (n = 302), and a preschool psychological assessment (n = 172). Predictors of a preschooler coping response composite were examined as well as the interrelationships between predictors.
Discussion/Conclusions: For the first time in the literature, longitudinal dynamic infant-caregiver pathways predicting preschooler coping responses have been elucidated. Caregiver behaviors during vaccinations are not only critical to both child pain coping responses in the short and long-term but also relate to child cognitive abilities outside the vaccination context.
Poor internal consistency and item redundancy on the modified beahviour pain scale and face, legs, activity, cry, and consolability scale Introduction/Aim: A major barrier to providing adequate pain relief to infants and young children is accurately measuring how much pain they are feeling. A number of observational pain instruments have been developed to provide objective measures of pain. However, to move the field further, construct validation and refinement of these tools is warranted. The objective of this study was to evaluate basic psychometric properties of two behavioral pain scales, MBPS (Taddio et al., 1995) and FLACC (Merkel et al., 1997), used to assess acute pain in infants and young children.
Methods: Caregivers and their children were videotaped during routine immunization appointments. The videotapes were coded for pain-related distress behaviours. Polychoric correlations between pain behaviours were examined immediately after the needle and 1-minute post-needle at 2-month (MBPS; n = 499), 12-month (MBPS; n = 548) and preschool immunizations (FLACC; n = 302).
Results: Very weak inter-item correlations were revealed on MBPS (e.g. face and movement at 2-months immediately after needle; r = .12), and FLACC (e.g. cry and activity at preschool immediately after needle, r = .04). Very high correlations were also found between items on both scales (e.g. cry and consolability on FLACC immediately after needle, r = .96).
Discussion/Conclusions: Weakly correlated items suggest poor internal consistency on both FLACC and MBPS. Very high correlations suggest redundancy that will bias internal consistency estimates. Given strong content validity of these measures, redefinition of core items appears warranted. It is unknown whether physicians are using these criteria. The objective of this study was to investigate physician knowledge and use of the FM diagnostic criteria and treatment modalities. Methods: A questionnaire was distributed to a convenience sample of Canadian physicians who diagnose chronic pain conditions. We divided participant data into three groups based on their FM education and the proportion of FM patients encountered in their field of practice to accurately determine knowledge and experience differences. Physician responses were scored and analyzed for their association with education and experience in FM.
Results: Physician knowledge of the 1990 and 2010 criteria was associated with their education and experience with FM. Physicians with the most FM education and experience did not indicate comprehensive knowledge of the criteria, scoring a mean of 91.5 from 133. Physicians had adequate knowledge of the FM treatments. Fifty-one percent of physicians used a set of criteria in their practice and only 38% used the 2010 criteria.
Discussion/Conclusions: Many physicians lack adequate knowledge of the FM diagnostic criteria and did not adhere to them. This is concerning since it is not congruent with evidence based medicine. Poor knowledge of criteria may increase time for diagnosis and chances of misdiagnosis. Knowledge translation strategies should be implemented to address this problem. Future studies should aim to develop reliable biomarkers diagnostic of FM, rather that relying on solely symptom-based criteria.
CONTACT Dinesh Kumbhare dinesh.kumbhare@uhn.ca Introduction/Aim: Tender points are muscle regions of increased pain sensitivity and occur at muscle-tendon junctions and around joints. We investigated whether mechano-nociceptors are localized to these areas in the masticatory muscles. Methods: Electrophysiology: Female rats were anesthetized and placed in stereotaxic frame. A recording electrode was lowered into the trigeminal ganglion. Temporalis and masseter muscle mechano-nociceptors were identified (n = 64). Their receptive fields (RFs) were mapped and their mechanical thresholds (MTs) were measured with an electronic von Frey hair (EVF).

Localization of rat masticatory muscle mechano-nociceptors to tender points
Behavior: MTs were measured with an EVF in 6 female rats Results: Electrophysiology: The RFs of mechanonociceptors were found primarily near the muscle attachment areas to the jaw bone and the zygomatic arch. Localization was greatest near the three muscle insertion sites of the temporalis, anterior and posterior masseter muscles. The MTs of the mechanonociceptors at these spots were 39.6 ± 8.0g (n = 10), 47.9 ± 12.2g (n = 11) and 41.1 ± 8.8g (n = 9) respec-tively. MTs of the other mechano-nociceptors was 36.7 ± 4.5g (n = 34). Conduction velocities (CV) of fibers from the three sites combined was 8.2 ± 0.7m/s, compared to 9.8 ± 0.8m/s from the rest of the fibers.
Behavior: Compared to the belly of the masseter muscle (MT = 32.6 ± 2.4g), muscle insertion sites of the temporalis, anterior and posterior masseter muscles were more sensitive with MTs of 23.1 ± 1.7g, 19.2 ± 1.3g and 25.4 ± 1.4g, respectively.
Discussion/Conclusions: Masticatory muscle mechano-nociceptor innervation appears to be increased at muscle insertion sites. This may explain the increased sensitivity of female rats to mechanical stimulation in these areas. This finding may be useful in investigating the physiological characteristics of tender points. Establishing the psychometric properties of the OUCHI tool during two-month vaccinations Methods: Using archival footage (OUCH Cohort: 760 infants followed over vaccinations between 2 months and 5 years), 81 two-month infant-parent dyads were coded that had also been coded at 6-and 12-month vaccination appointments. Divergent and convergent validity relationships were assessed using EAS (Biringen, 2008), and NFCS (Grunau & Craig, 1987) and MBPS (Taddio et al., 1995), respectively. Test-retest reliability with the 6-and 12-month OUCHI scores was also assessed.
Results: The OUCHI Tool coded on parents during the 2-month vaccination showed interrater reliability (r's = 0.73 to 0.98), test-retest reliability with parent OUCHI scores at 6-month (r = 0.24) and 12month Introduction/Aim: There is a growing interest in discovering plant-based anti-inflammatory compounds as potential alternatives to conventional drugs. The aim of this study was to evaluate anti-inflammatory activity of phytochemical-rich extracts prepared from 12 herbal plants, often cited in Canadian traditional medicine for the treatment of pain associated with streptococcal pharyngitis, using human tonsil epithelial cells (HTonEpiC) in vitro.
Methods: Twenty-seven phytochemical-rich extracts were evaluated for the anti-inflammatory effects using HTonEpiC model. The HTonEpiC were triggered by a mixture of lipoteichoic acid (LTA) and peptidoglycan (PGN) (10 µg/mL) for 4 h and then were incubated with ethanol extracts (EE) or aqueous extracts (AE) for 20 h. The secretion of four pro-inflammatory cytokines in cell-free supernatants were measured using enzymelinked immunosorbent assays (ELISA). Total phenolic and total flavonoid contents of the extracts were determined using spectrophotometric methods.
Results: The herbal plant extracts (≤ 5 μg/mL) were not cytotoxic to HTonEpiC. The extracts exhibited a broad range of reduction (1.2% to 92.6%) of secretion of interleukin-8 (IL-8), human beta defensin-2 (hBD-2), epithelial-derived neutrophil activating protein-78 (ENA-78) and granulocyte chemotactic protein-2 (GCP-2). The danshen root EE and both EE and AE of clove, ginger and echinacea flower exhibited the greatest anti-inflammatory activity in vitro where they were significantly suppressed the secretion of all tested pro-inflammatory cytokines.
Discussion/Conclusions: The most efficacious, danshen root, clove, ginger and echinacea flowers extracts exhibits therapeutic potential for developing natural health products in the management of painful inflammation due to streptococcal pharyngitis.   Discussion/Conclusions: For the first time in the literature, correlation data are provided on infant physiological response to immunization pain and temperamental measures at 12 months of age. Additionally, this study provides preliminary evidence that physiological response to vaccination pain may be reflective of parental report of infant temperament outside of the pain context.

CONTACT Jordana A. Waxman waxmanja@yorku.ca
Introduction/Aim: To determine the use of verbal behaviors during pain between teen friendship dyads when a member has chronic pain compared to healthy friendship dyads.
Methods: An observational multisite study using the cold pressor task was conducted with 61 dyads (30 with a chronic pain teen). Data consisted of self-report friendship features (e.g. satisfaction), pain (e.g. intensity, duration), and observed behaviors. Measure and task completion order were controlled. Videos were coded for attending (e.g. symptom related talk, reassurance) and non-attending (e.g. distraction) verbal behaviors for both dyad members as cold pressor participant and observing friend.
Results: Friendship satisfaction significantly correlated with the friends' use of attending behaviors (−.217) and non-attending (.218). Regression 1: controlling for age and sex 12.5% of the variance in pain intensity was predicted by participants' use of attending behaviors. Regression 2: controlling for age and sex 16.9% of the variance in pain duration was predicted by the participants' use of nonattending behaviors. Analysis of variance revealed teens in the chronic pain dyad used significantly fewer nonattending behaviors during the cold pressor compared healthy teen dyads.
Discussion/Conclusions: Teens with chronic pain and their friends use fewer non-attending behaviors when experiencing pain compared to healthy teens. Perhaps friends of teens with chronic pain are influenced by their friend's reaction to pain over time, which may change their natural behaviors from more non-attending to attending. Determining ways to help teens with chronic pain use more non-attending behaviors when spending time with their friends may increase their friends' use of non-attending behaviors. Introduction/Aim: There has been a growth in the proportion of emerging adults vulnerable to painrelated sequelae of chronic health conditions (CHCs). Given the lack of research during this important developmental period, this study investigated the association between CHCs and chronic disruptive pain (CDP) among emerging adults and the extent to which psychiatric disorders moderate this association. Methods: The data come from the 2012 Canadian Community Health Survey -Mental Health. Respondents were 15-30 years of age (n = 5987). Odds ratios (OR) and 95% confidence intervals (CI) were computed from ordinal logistic regression models adjusting for sociodemographic covariates. Product-term interactions between CHCs and psychiatric disorders were included in the models to explore the moderating effects.

ORCID
Results: Compared to controls, participants with CHCs had greater odds of reporting CDP (OR = 4.94, 95% CI = 4.08-5.99). Alcohol (β = −0.66; p = 0.025) and drug abuse/dependence disorders (β = −1.24; p = 0.012) were found to moderate the association between CHCs and CDP. Specifically, the probability of CDP was higher for emerging adults without CHCs and with alcohol or drug disorders; however, among participants with CHCs, risk was higher for respondents without these disorders.
Discussion/Conclusions: Conclusively, there is a robust association between CHCs and CDP. The moderating effects suggest that alcohol or drug disorders are especially harmful for young adults without CHCs and contribute to higher levels of CDP; however, among those with CHCs, alcohol and illicit drugs may be used as a numbing agent to blunt CDP. Therefore, healthcare providers should be proactive in screening for psychiatric disorders and should support young people with CHCs to minimize painrelated impact. Introduction/Aim: Extant research indicates that perceived injustice is a risk factor for complicated trajectories of recovery and lower rates of return to work in individuals with whiplash injuries. The mechanisms by which perceived injustice contributes to poor outcomes however are not well understood. Couched within the model of perceived unfairness discussed in psychological and epidemiological research, is the assumption that the experience of unfairness might impact on poor health outcomes via compromised beliefs in the ability to cope with adversity.
No empirical research to date tested the relation between these variables in the context of chronic pain. The aim of the present study was to investigate whether reduced perception of pain self-efficacy mediated the relation between perceived injustice, pain, disability, depressive symptoms, and work related outcomes in individuals with whiplash injuries. Methods: The study sample consisted of 104 individuals enrolled in a multidisciplinary treatment program designed to promote functional recovery following whiplash injury. They completed questionnaires prior to treatment, and provided information pertaining to pain and occupational outcomes at one year follow-up.
Results: The results of regression analyses revealed that reduced self-efficacy mediated the relation between perceived injustice, disability and depressive symptomatology before treatment. Reduced self-efficacy also mediated the relation between perceived injustice, pain and hours spent at work at one year follow-up.
Discussion/Conclusions: The results of the present study suggest that reduced self-efficacy might be one pathway by which perceived injustice contributes to poor health and employment outcomes in individuals with pain conditions. Clinical and theoretical implications are discussed. Introduction/Aim: Pain catastrophizing has been conceptualized as a negative cognitive-affective response to anticipated or actual pain. Pain catastrophizing emerged as the most robust predictor of pain outcomes in clinical and experimental research. One well researched pathway by which catastrophizing is thought to augment pain intensity is excessive focus to pain symptoms, and impaired ability to divert attention from painful sensation. Attentional mechanisms have also been implicated in the construction of time during a painful experience. The relation between catastrophic cognitions and perceived duration of a painful event remains unexplored. Methods: The aim of the present study was to explore the relation between pain catastrophizing, other pain coping strategies and perceived duration of time when in pain.
The study sample consisted of 135 undergraduate students. They completed questionnaires before and after painful stimulation and a neutral task of equal duration.
Results: The results revealed that participants perceived the duration of painful exposure to be shorter than the duration of a neutral task. Compared to low catastrophizers high catastrophizers perceived the duration of a painful procedure to be significantly longer. However, high catastrophizers were more accurate than low catastrophizers when estimating the duration of the painful procedure. During exposure to pain, high catastrophizers focused more on their pain, and were less able to suppress pain related thoughts.
Discussion/Conclusions: The results of the present study support the involvement of attentional mechanisms in perception of duration of painful experience, and suggest that high catastrophizers are more accurate in estimating time when in pain. CONTACT Esther Yakobov estheryakob@gmail.com The relationship between rate of algometer application and pain pressure threshold in the assessment of latent myofascial trigger points ). The effect of rate of application (RoA) of the pressure algometer on the raw PPT score is poorly understood. The purpose of this study was to investigate the relationship between RoA and raw PPT. We tested the hypothesis that a positive linear relationship exists between RoA and raw PPT. Methods: Thirty-three young healthy individuals (21.90 ± 1.77 years, 171.33 ± 11.07 cm, 68.71 ± 12.31 kg) with an identified latent trigger point in the right infraspinatus muscle were recruited from the University of Guelph student population. Participants received three PPT assessments at a baseline rate (30N/s), followed by two assessment trials at each of three target rates: low (15N/s), medium (35N/s), and fast (55N/s). Real-time data were collected using a custom designed program in Labview (National Instruments, version 2013) and saved for post-hoc analysis. Pearson's correlation coefficients and linear regression analysis were performed for each individual participant's rate variable trials.
Results: The mean Pearson's correlation coefficient between RoA and PPT demonstrated a strong, positive relationship (Pearson's R Mean ± SD: 0.77 ± 0.19). The average slope of the linear regression between RoA and PPT was low (slope Mean ± SD: 0.13 ± 0.09).
Discussion/Conclusions: The RoA during PPT assessment is strongly correlated to the raw PPT score. Although our data demonstrates a robust relationship between RoA and PPT, the observed effect of rate on PPT (slope) was small. Further research should investigate the clinical relevance of changes in rate on the raw PPT score in a clinical population. Introduction/Aim: Endometriosis, a complex gynaecological disease causing pelvic pain, is influenced by environmental and genetic factors. Genome-wide association studies have identified single-nucleotide polymorphisms associated with endometriosis. Pain perception also has a genetic component; however, studies have yet to consider pain genetics relative to endometrium and/or endometriosis. We aim to elucidate the interaction between endometriosis and pain genetics and associated effects on gene expression (expression quantitative trait loci [eQTL]). Methods: We developed an extensive database of genetic, molecular and clinical information from women with/without endometriosis (Royal Women's Hospital; n = 648). Blood samples were genotyped using Human CoreExome chips. Endometrial gene expression was generated using Illumina Human HT12v4.0 Beadchips. eQTL analysis was performed using recoded and imputed SNP genotypes (n = 123, minor allele dosage, linear regression models, covariate: menstrual phase). We then identified endometrial eQTLs previously associated with pain/pain conditions. Results Ongoing studies will explore mechanisms causing endometriosis pain; we will examine functions of eQTLs in endometriosis pathophysiology and utilize our extensive database to examine factors contributing to heterogeneous pain symptoms. Ultimately, we hope to provide tailored therapy to women based on pain phenotypes. references of included studies. Studies were included for the review if they met the following criteria: 1) inclusion of children and adolescents (0-18 years) undergoing any type of surgery; 2) assessment of pain at least 2 months after surgery; and 3) assessment of one or more potential risk factors for development of CPSP.
Results: The search strategy generated a total of 1777 unique references. Twelve studies met the inclusion criteria and were reviewed in greater detail for analysis. Assessed risk factors associated with CPSP included child age, preoperative and acute postoperative pain, anxiety, pain catastrophizing, and parental catastrophizing.
Discussion/Conclusions: Early identification of patients at risk for CPSP and awareness of the impact of psychological factors will allow for earlier intervention and potentially better pain outcomes. Due to the small number of current studies, there is a need for further larger scale well designed studies to investigate this topic. Methods: an observational study at UTHK. Consenting adult patients undergoing major abdominal, thoracic, or orthopedic surgery were recruited. On post-operative day 2, participants were administered the International Pain Outcomes (IPO) and a brief questionnaire to assess attitudes towards postoperative pain.
Results: 91 patients were recruited; 83 (91%) completed the questionnaire. Practice: 54% received preemptive analgesia; 8% received no POA. On average, the worst pain was 6/10 (±2) and the least 3/10 (±1). 44% (±22%) of the time patients were in severe pain, with an interference score of 5/10 (±2) in ability to do activities in bed. Perceptions: 54% (±21%) of patients felt they received adequate pain relief, and 71% felt more pain treatment was not necessary. 57% of patients felt pain should not be taken away completely, and 76% felt they should put up with some pain rather than complain.
Discussion/Conclusions: With 8% of patients receiving no POA, POA at UTHK would not meet generally accepted practice in Canada. That 71% of patients felt that POA was adequate despite an activity interference score of 5/10 may be due to cultural perceptions that pain is necessary and patients should not complain. These results can be used as a baseline to evaluate future interventions in pain management in Kigali. Methods: 3T T1 anatomical, 60-directions diffusionweighted, and FIESTA images were acquired and aligned to diffusion space via ANTs for 27 surgicallynaïve TN patients. NVCs were graded (I to III) with FIESTA images. Multi-tensor tractography was used to identify bilateral trigeminal nerves at the pontine segment, root entry zone, and cisternal point of maximal compression. From these regions, DTI-derived microstructural metrics-axial, radial, mean diffusivities, and fractional anisotropy (FA)-were extracted for linear mixed effects statistics between nerve types with significance set at p < 0.05.

Untangling trigeminal neuralgia from neurovascular compression: The role of multimodal magnetic resonance imaging and microstructural diffusivity analysis
Results: Across all NVC grades, asymptomatic nerves did not demonstrate diffusivity changes. Symptomatic nerves, however, displayed significant, grade-dependent variations in diffusivities. Compared to contralateral nerves, Grade I symptomatic nerves had higher FA (p < 0.01) at the point of maximal compression while Grade III symptomatic nerves had lower FA (p < 0.05) at the root entry zone.
Discussion/Conclusions: Microstructural diffusivities can be of significant value for distinguishing nerves with pain from those without pain and provide valuable insights into the pathophysiology of TN.
CONTACT Peter Shih-Ping Hung peter.hung@mail.utoronto.ca Introduction/Aim: To explore patient attitudes towards screening to assess suitability for low back surgery by non-physician healthcare providers. Methods: We administered a 19-item cross-sectional survey to adults with low back and/or low back-related leg pain who were referred for elective surgical assessment at one of five spine surgeons' clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician healthcare providers.
Results: 80 low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a non-physician healthcare provider to establish if they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician healthcare provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons' and nonphysicians' determination of surgical candidates.
Discussion/Conclusions: Patients referred for surgical consultation for low back or low back-related leg pain are largely willing to accept screening by nonphysician healthcare providers. Future research should explore the concordance of screening results between surgeon and non-physician healthcare providers.
CONTACT Joshua Rempel rempeljt@mcmaster.ca Introduction/Aim: Health care providers (HCPs) must concern themselves with their chronic pain patients' possible abuse or misuse of psychoactive medications. Urine drug testing (UDT) offers 'objective', though fallible, evidence of substance consumption that may bolster or counter patients' narratives. Mandating UDT as part of clinical care can stress the therapeutic alliance. Participants in Ontario's ProjectECHO-Chronic Pain ('ECHO'), a telementoring intervention, described using UDT in their practices. This qualitative investigation explores these dialogues. Methods: Data from six focus group discussions, twelve in-depth interviews, and two group discussions were read by two or more researchers, using a qualitative-descriptive analytic approach. These authors compared their analyses and discussed divergent interpretations until achieving consensus regarding meaningful, relevant themes.
Results: ECHO participants repeatedly voiced the challenges of ordering UDT for their pain patients on opioids. Some HCPs described discomfort or 'feeling conflicted' when requesting UDTs while others avoided doing them altogether. Others spoke about their attempts to negotiate a mutually acceptable 'middle ground'. Doctors described patients who 'fired' them after 'failing' a UDT or after being asked to submit to one. Team-based pharmacists expressed concern over poorly defined roles and lack of clear communication between pharmacist and HCP.
Discussion/Conclusions: Requesting UDT for patients on prescription opioids is a sensible bestpractice policy that assumes a mutual desire for patients' well-being and longevity. The everyday practice of health care, however, implicitly constructs cultural definitions of well-being and appropriateness that may not be shared. Promoting trust and compliance within the therapeutic relationship requires effective communication to accompany testing. Introduction/Aim: Children's memories of pain are a robust predictor of increased pain and distress at subsequent painful experiences and future health behaviours. Research suggests that parent catastrophizing leads to adolescents developing negatively biased memories for post-surgical pain. This study is the first to examine the relationship between parent and child anxiety prior to surgery and young children's subsequent memories for pain. Methods: Thirty children aged 4-7 undergoing tonsillectomies, and their parents were recruited. Two hours prior to surgery, parents completed the State-Trait Anxiety Inventory, and reported their children's anxiety levels on a numerical rating scale. The Modified Yale Preoperative Anxiety Scale was used to assess children's behavioural anxiety. Post-surgery and again one month later, parents and children reported on child pain using the Faces Pain Scale-Revised.
Results: Hierarchical regression analyses revealed that children of parents with higher state anxiety had more negatively estimated pain memories than children of less anxious parents, after controlling for child age and sex, and initial pain ratings. Parent anxiety accounted for 22.7% of the variance in child pain memories above and beyond the controlled variables (R 2 Δ = 0.227, p < .01), while the overall model accounted for 38.3% of the variance. Child anxiety was not significantly related to pain memory biases.
Discussion/Conclusions: Parental, but not child, anxiety was found to lead to negative biases in young children's pain memories which parallels findings linking parent catastrophizing to adolescents' post-surgical pain memories. Findings suggest parental anxiety may be a fruitful target for intervention to minimize children's pain memory biases. Introduction/Aim: Children with cancer often cite needle insertions into a subcutaneous port (SCP) as painful and frightening, even with topical anesthetic. We developed an evidence-based program employed on a humanoid robot that uses interactive movements and vocalizations to coach children through SCP access.
Research objectives were to determine the feasibility and obtain preliminary estimates of effectiveness of the robot on pain and anxiety in children undergoing SCP access. Methods: 40 children with cancer (4-9 years) who reported pain during previous SCP access, were randomized to receive either: intervention (robot using pre-programmed series of coaching behaviours before, during, and after procedure; N = 16) or active control (robot moving only; N = 24) during needle insertion by a nurse.
Results: Mean age was 6.15 years and 40% were female. Study accrual rate was 98%. Parents reported high satisfaction: 62% thought that MEDi was "very helpful" in reducing their child's pain. Across both control and intervention groups, 81% reported decreased pain in the presence of MEDi. In addition, 67% of children enjoyed the presence of MEDi "very much." There was a trend that children in intervention group reported less pain from previous SCP access (p-value = 0.08) compared to those in the control group. The technical difficulties that occurred which caused a disturbance during the intervention was 82% compared to the control group at 18%. Discussion/Conclusions: Implementation of this study protocol is feasible but the robot's SCP program would need to be refined in the intervention group before a future definitive RCT is conducted. Introduction/Aim: Mentorship is important for professional and academic growth; however, the role of mentorship in anesthesia is still being defined. We surveyed Canadian anesthesia residents to explore their perceptions of mentorship relationships. Methods: We administered a 20-item cross-sectional survey to program directors and anesthesia residents in all Canadian departments of anesthesia. Program directors were asked about their mentorship programs, and residents were asked about their perceptions of benefits and barriers to effective mentoring.
Results: Sixteen of 17 (94%) program directors and 189 of 585 (32%) anesthesia residents responded to our survey. While 143 of 180 (79%) residents agreed that mentorship was beneficial to overall success as an anesthesiologist, only 11 of 16 (69%) program directors reported formal mentorship as part of their residency program, and only 119 of 189 (63%) residents reported access to a mentor. Barriers reported by residents included insufficient time with mentors, lack of formalized meeting times and objectives, mentor-mentee incompatibility (personal or professional), and lack of resident choice in mentor selection.
Discussion/Conclusions: Our study confirms that, despite positive perceptions among residents, mentorship remains underutilized in anesthesia programs. We identify barriers to effective mentorship, including the need to consider resident choice as a means to improve formal anesthesia mentorship programs.

School functioning in children with chronic pain: A review and preliminary model
Kailyn Jones a and Melanie Noel b a Werklund School of Education, University of Calgary, Calgary, Alberta, Canada; b Department of Psychology, University of Calgary, Calgary, Alberta, Canada Introduction/Aim: School is often cited as the "work" of childhood, and serves not only as an imperative site for the development of academic and cognitive skills but also for the development of identity, independence and social relationships. Elevated school absences in children with chronic pain are well documented; however, little about how pain effects school success beyond poor attendance is known. The developmental consequences and financial costs of school impairment are extensive with these children often achieving poorer grades, requiring costly special education services, and sometimes requiring full time homebound instruction. The aim of this study was to review what is known about school functioning in this population and propose a preliminary model to explain the phenomenon.
Methods: Using a set of predetermined inclusion criteria, key databases were searched for articles in peer-reviewed journals published since 2000. Articles were then reviewed and synthesized into the model.
Results: Studies were revealed to include measurement across variables from four key domains of functioning: (1) psychological factors (i.e., depressive and anxious symptoms); (2) social factors (i.e., peer relationships, child perceptions of teacher support and parent responses); (3) physiological factors (i.e., sleep disturbances), and (4) cognitive factors (i.e., perceived and actual disruption in divided attention and working memory).
Discussion/Conclusions: This review and preliminary model may serve as a tool to summarize factors that explain poor school functioning in children with chronic pain. The model also highlights a number of factors beyond pain intensity that should be considered when supporting this population in their schooling.
CONTACT Kailyn Jones kailyn.jones@ucalgary.ca Introduction/Aim: Inadequately controlled sternotomy pain after cardiac surgery can lead to delayed recovery. Preoperative intravenous methadone is effective for reducing postoperative pain and opioid consumption. This initial pilot study investigated the effect of oral preoperative methadone on analgesia requirements, pain scores, and side effects.
Methods: Patients undergoing isolated coronary artery bypass graft (CABG) (n = 21) were randomized to receive methadone (0.3 mg/kg) or placebo prior to entering the operating room. Morphine requirements using patientcontrolled analgesia (PCA) and Visual Analogue Scale (VAS) pain scores Q12H were recorded for 72 hours.
Time to extubating, level of sedation, nausea, vomiting, pruritus, hypoventilation and hypoxia were also measured.
Results: Postoperative morphine during the first 24 hours was reduced by a mean of 23mg in the methadone group (mean difference [99%CI], -23 [37 to 13] mg; P < 0.005). Reduction in pain scores were not significant (P = 0.08). No reduction in PCA morphine or pain scores was observed beyond 24 hours postoperatively. The incidence of opioid related side effects was not increased throughout the postoperative period.
Discussion/Conclusion: Preoperative oral methadone reduced morphine requirements in the first 24 hours post CABG with no difference in opioid-related side effects. It could be conveniently given prior to starting an intravenous line as an effective, low cost, preoperative medication for cardiac surgery patients. A larger multi-centre study is planned.
CONTACT Timothy Bolton tim.bolton@usask.ca Introduction/Aim: We conducted a systematic review of randomized controlled trials to establish the benefits and harms of opioids for chronic non-cancer pain (CNCP). Methods: Studies eligible for our review randomly allocated patients presenting with CNCP to an opioid analgesic or a non-opioid control, and reported outcomes at ≥4 weeks' follow-up. We identified relevant randomized controlled trials by a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, PsycINFO, and CENTRAL through to September 2016.
Results: Of 23,040 identified citations, 96 proved eligible. We found evidence of a subgroup effect based on duration of treatment. We found evidence of publication bias for reporting effects on pain and physical function. When restricted to 27 trials that treated patients for ≥3 months and were not at risk of publication bias (13,876 patients), high quality evidence showed that, compared to placebo, opioids reduced pain among patients with CNCP by 0.64cm on a 10cm VAS for pain (95% CI = −0.76 to −0.53, I 2 = 51%; minimally important difference [MID] is 1cm). When restricted to 33 trials (12,058 patients) that were not at risk of publication bias, high quality evidence showed that, compared to placebo, opioids improved functional outcomes among patients with CNCP by 2.16 points on a 100-point SF-36 physical component summary score (95% CI 1.56 to 2.76, I 2 =55%; MID is 5-points). Low to moderate quality evidence showed no difference in pain relief between opioids and nonsteroidal anti-inflammatory drugs (NSAIDs), nabilone, or antidepressants.
Discussion/Conclusions: On average, opioids produce small improvements in pain and function compared to placebo, and are similarly effective for pain relief compared to NSAIDS, nabilone, or anti-depressants.
CONTACT Jason W. Busse bussejw@mcmaster.ca Introduction/Aim: To investigate the role of blood monoamines as biomarkers of conditioned pain modulation (CPM) efficacy. Methods: 105 pediatric patients with chronic back pain were enrolled in the study. The protocol involved: dosage of plasma monoamines (dopamine, DOPA; serotonin, 5-HT; epinephrine, Epi; norepinephrine, NE; metanephrine, ME; and normetanephrine, NME), quantitative sensory testing and conditioned pain modulation (CPM), as well as clinical assessment (functional disability index, FDI; adolescent pediatric pain tool, APPT; revised children's anxiety and depression scale, RCADS; Pittsburgh sleep quality index, PSQI).
Discussion/Conclusions: Plasma monoamines are associated with CPM efficacy. DOPA, 5-HT, NE, NME, and ME can be used as biomarkers of CPM efficacy in pediatrics. Their use as CPM biomarkers is especially important in pediatric patients with neurologic disorders that preclude adequate pain assessment. Future studies are needed to assess the efficacy of tailored treatments for pain according to plasma monoamines.
CONTACT Alisson R. Teles alisson.r.teles@gmail.com Introduction/Aim: Children whose parents have chronic pain are at greater risk for pain and mental health problems than other children (Higgins et al., 2015). Children's catastrophizing about their pain predicts negative outcomes (Vervoort et al., 2006); catastrophizing about parents' pain may confer risk through similar mechanisms and be increased in this population due to increased exposure to parental pain. This project examines relationships between child catastrophizing about parents' pain, child outcomes, and parent pain. Methods: In an ongoing study, children (8-15 years) of parents with chronic pain (duration at least 6 months) completed a modified Pain Catastrophizing Scale for Parents (PCS-P; Goubert et al., 2006) regarding parents' pain. Children and parents reported on their pain and catastrophizing about their own pain, and children reported on their internalizing symptoms.
Discussion/Conclusions: Results should be interpreted cautiously given the small sample to date; data from the final sample (estimated N = 70) will be reported. Preliminary results suggest that children's catastrophizing about parents' chronic pain may be a risk factor for children's outcomes warranting further study. Introduction/Aim: Opioids are commonly used for acute pain management after traumatic injury and corrective surgeries. Few studies have prospectively followed patients and their pain management in the months following injury. The aim of this study was to examine the incidence and predictors of persistent prescription opioid use 4-months after traumatic injury. Methods: Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4-months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information. We used multivariate logistic regression models to progressively add significant T1 and T2 variables in order to assess their relative contributions to explaining T2 opioid use.
Conclusions: Over a third of adults were using opioids 4 months after traumatic musculoskeletal injury. Their use is related to pain severity and how well patients cope specifically with their pain, over and above other psychological factors, such as depression and anxiety.
Introduction/Aim: The purpose of this study was to describe healthcare use (HCU) in the first 3 days following ambulatory surgery in Ontario. The objectives were to measure emergency service utilization (ED) and admission (AD) rates, identify the primary reasons for accessing services, and identify groups at high risk for HCU.
Methods: A prospective cohort study using administrative data from the Institute for Clinical Evaluative Sciences was conducted in adults who underwent ambulatory surgery between 2009-2014. Introduction/Aim: A significant proportion of adolescent idiopathic scoliosis (AIS) patients have chronic back pain. It was demonstrated that a suboptimal conditioned pain modulation (CPM) efficacy is associated with chronic pain. The objective was to investigate if chronic pain patients with an optimal CPM efficacy display different alterations in their ascending sensory pain processes compared to chronic pain patients with a suboptimal CPM efficacy.
Methods: Sixty patients with painful AIS performed mechanical and thermal quantitative sensory testing (QST). Patients were stratified into 2 groups based on the efficacy of their inhibitory pain response (optimal and suboptimal groups, n = 30 each). Differences in the mechanical detection, pressure pain, heat pain and tolerance thresholds and thermal temporal pain summation) between the 2 groups were evaluated using Mann-Whitney tests. Pain, functional and emotional profiles were assessed with questionnaires.
Results: Great variability in the CPM response was observed among the cohort (mean of -32.44%, 95%CI -45.16 to -18.71). A significant difference was observed in the heat pain threshold between the 2 groups (mean of 40.20°C ±3.25 and 38.56°C ±3.30 respectively, (p = 0.0276)), but not in the other QST parameters (p > 0.05). More patients had functional disability in the optimal CPM group (30% versus 10% in the suboptimal group), although the 2 groups displayed similar pain and emotional profiles.
Discussion/Conclusions: Our results suggest that AIS patients with a suboptimal endogenous inhibitory pain response develop an increased peripheral sensitivity to heat. Further work is needed to understand the underlying cause of chronic back pain associated to scoliosis. Methods: Fifty fibromyalgia patients were randomly assigned to two groups: 1) continuous sine wave singlefrequency stimulation (40 Hz) and 2) random intermittent complex wave gamma range stimulation with peaks at 45 and 95 Hz. The intervention was selfadministered with a portable vibroacoustic therapy device 30 minutes daily, 5 days per week, over 5 weeks, concomitant with standard care. Fibromyalgia symptoms (Fibromyalgia Impact Questionnaire Revised -FIQR), pain severity (Brief Pain Inventory), depression severity (Patient Health Questionnaire -9), quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire), and sleep quality (Pittsburg Sleep Quality Index) were assessed at baseline and postintervention. Data were analyzed by intention to treat.
Results: Results revealed statistically significant improvements between baseline and postintervention assessments in all outcome measures, including fibromyalgia symptoms, pain severity and interference, depression severity, quality of life, and sleep quality. No significant group differences were detected. Of those who completed all study assessments (n = 38), clinical significant changes in the FIQR post-intervention scores were observed for 20 patients, with an average improvement of 40% (range: 14.16% to 90%).
Discussion/Conclusions: These findings suggest that rhythmic sensory stimulation with gamma frequency vibrotactile and auditory stimuli can potentially decrease pain severity and fibromyalgia symptoms, ease associated comorbidities such as sleep disturbances and depression, and improve patients' quality of life. Further research is needed to understand the mechanisms underlying these effects.
CONTACT Thenille Braun Janzen thenille.braunjanzen@utoronto.ca four-week intensive interdisciplinary program in reducing this co-morbidity. Methods: Differences between admission and discharge from a four-week program on several measures of pain-related variables such as depression, anxiety, pain intensity, pain-related disability, catastrophizing and other pain-related variables were examined in 602 consecutively admitted patients with chronic pain (52% women). A MANOVA also examined these differences in males and females.
Results: Highly significant differences were obtained between admission and discharge on all variables examined (p < 0.001). Gender effects were not obtained in terms of the co-morbidity variables. No interaction effects were found. Of particular interest here are the reductions in depression, catastrophizing (both at 25%) and anxiety (13%) scores at discharge, all clinically significant results. Discussion/Conclusions: These results supported the hypothesis that co-morbidity of pain and psychological distress in individuals with chronic pain can be reduced after four weeks of interdisciplinary pain management. Introduction/Aim: To establish the current state of research related to the self-management of cardiac pain in women using the process and methodology of evidence mapping. Methods: The main purpose of evidence mapping is to provide an overview of a broad range of research and identify evidence gaps and future research needs. Six steps were used to construct an evidence map of cardiac pain in women: 1) Identify the scope of the evidence map, 2) Define the key variables, 3) Establish a comprehensive search strategy, 4) Identify study inclusion and exclusion criteria, 5) Systematically retrieve, screen and classify the evidence, and 6) Report the findings in an evidence map. Twenty-one databases and grey literature sources were systematically searched using keywords and Medical Subject Headings (MeSH).
Discussion/Conclusions: Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research has focused on young and old women, non-obstructive cardiac pain, or self-management interventions to assist women to manage cardiac pain.
Preliminary acceptability and feasibility of virtual reality distraction for subcutaneous port access in youth with cancer Introduction/Aim: Children with cancer cite needle procedures, such as subcutaneous port access (SCP), as the most painful and distressing experiences during treatment. Distraction via virtual reality (VR) offers promise for reducing needle-related pain and distress given its highly immersive and interactive virtual environment. Prior to assessing efficacy, the VR intervention must be deemed acceptable and safe for youth with cancer during SCP. Specific aims were to assess (1) acceptability of VR (hardware and software) in youth with cancer, (2) any adverse events with VR use, and (3) capacity to communicate with youth during VR.
Methods: A mixed-methods, child-centered approach with three iterative cycles of VR intervention testing. Testing cycles included observation and interviews with youth with cancer 8-18 years old using VR hardware and software equipment to identify acceptability and safety issues requiring intervention refinement.
Results: Eight youth with cancer tested the VR interactive underwater distraction intervention (5 prior to and 3 during SCP). Youth reported the VR easy to navigate. They desired more interactive intervention components, a greater variety of games and music, and optional notifications of steps during needle procedure. Limitations to engaging fully with the VR equipment (e.g., turning head left/right) were identified due to requirements to remain still during the procedure. No adverse events occurred.
Discussion/Conclusions: Next steps include completing iterative testing during SCP procedures with modifications based on user feedback, and a pilot randomized controlled trial to evaluate preliminary effectiveness of VR distraction on pain intensity and distress during SCP needle insertion in this population. Pain as a key dimension of complexity: Physician narratives of patients with chronic pain

Fiona Webster and Kathleen Rice
Background: While there has been a great deal of attention paid to identifying the epidemiology of multimorbidity and patient complexity using administrative data, comparatively little attention has been paid to the processes of care that treating complex patients entails, and to identifying what high-quality, patient-centered care for these patients should look like. Consequently, the concept of patient complexity itself does not necessarily speak to how challenging or straightforward it may be to provide high-quality patient-centered care. Further, the phenomenon of multi-morbidity is not well understood and currently includes 16 common medical conditions, not including pain. Methods: Our team undertook a critical ethnographic approach known as institutional ethnography in the province of Ontario, Canada. Results: We interviewed over 40 participants, including primary care providers (physicians, nurses, nurse practitioners, and allied health professionals). Discussion: Our findings suggest that a definition of patient complexity based solely on presence and number of multi-morbidities is far too narrow. Indeed, from the perspective of primary care physicians, patients they consider complex are challenging not so much due their medical problems alone, but rather to their social and living conditions. In virtually every example that we were offered, chronic pain was raised by physicians as representing the greatest challenge to care provision.
They also described that pain was frequently bound up with poverty, trauma, and mental health concerns. Such patients were challenging and frustrating for health care providers in part because the interventions needed are far beyond the scope of expertise, even as their social issues rendered the treatment of potentiallystraightforward medical problems complicated.
Introduction/Aim: Chronic pelvic pain (CPP) is a common condition observed in primary health care yet no research has surveyed the experience of these individuals within the health system. In order to address this gap, the current study explored patients' experiences when consulting for the first time with a health care provider (HCP) to communicate symptoms of CPP.
Methods: Thirty individuals (M age = 40, SD = 12; 27 females) with CPP completed a 10-15 minute anonymous survey while awaiting their medical appointment at the Wasser Pain Management Centre. Participants were asked to provide demographic information, pain duration, pain onset, the medical specialty of their initial HCP, and to report their feelings associated with expressing their symptoms as well as their overall satisfaction.
Results: The average pain duration was 5 years and 70% of patients were unsure how their pain began. The majority of patients indicated their first HCP was a family physician or gynecologist. Sixty percent reported a negative experience while expressing their symptoms such as feeling uncomfortable and hesitant and 67% reported feeling disappointed with the quality of health care obtained from their initial HCP. Patients were most disappointed with the level of dismissiveness and the lack of knowledge and personalized care received. The average overall satisfaction reported was 3.93 out of 10.
Discussion/Conclusions: These findings highlight the urgent need to provide early education regarding adequate diagnostic approaches for HCPs. Adopting a supportive and empathic therapeutic environment is critical for facilitating optimal health care for individuals with CPP. Results: Almost all parents (88%) reported administering at least one intervention within the past 2 weeks. An exploratory factor analysis on parents' responses revealed a 2-factor structure characterizing the strategies as either physical (α = 0.57) or psychological (α = 0.79). Heat, cold, and massage/rubbing were characterized as physical while talking, deep breathing, relaxation, rest/sleep, distraction, prayer/ meditation and imagery were characterized as psychological. Responses for both factors were positively associated with parent-reported child worst, least, and average pain intensity.
Discussion/Conclusions: Parents reported frequent pain intervention use and their responses categorized strategies as either physical or psychological. Future research will examine parental use of multimodal interventions and decision making surrounding selection of pain interventions. Introduction/Aim: Prevention of harm is an important concern when prescribing opioids for chronic non-cancer pain (CNCP). We conducted a systematic review on risk mitigation strategies for opioid prescribing in CNCP patients.
Methods: We searched MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO through July 2016 for randomized controlled trials (RCTs) and observational studies investigating the effect of risk mitigation strategies (e.g. urine drug screening, treatment agreements, take-home naloxone, abuse-deterrent formulations, patch exchange, structured opioid therapy, specialist review, screening for aberrant drug-related behaviours) for CNCP patients prescribed opioids. Screening, data abstraction and risk of bias assessment were performed independently and in duplicate. When possible, we pooled relative measures of association as pooled odds ratios (OR).
Results: We identified 8 observational studies that were eligible for our review, all of which provided low quality evidence. Four articles (2,624 patients) suggested no association between treatment agreements and opioid misuse (pooled OR 1.28, 95% CI 0.80 to 2.05), one study (179,385 patients) found no association between baseline urine drug screening and risk of opioid overdose (HR 1.36, 95% CI 0.79-2.34), one study (1,985 patients) reported no association between take-home naloxone and the odds of fatal overdose (OR 1.08, 95%CI 0.18-6.46) and two industry-funded, single-arm observational studies reported a lower incidence of addiction, overdose, and death after tamper-resistant OxyContin was introduced.
Discussion/Conclusions: Although guidelines and professional organizations often recommend risk mitigation strategies to reduce harm when prescribing opioids for CNCP, the available evidence provides very little support for any approach.
CONTACT Raad Yameen raad.yameen@mail.utoronto.ca Introduction/Aim: Rates of pain conditions are disproportionately high amongst Indigenous populations in Canada. Research has shown that healthcare provider pain assessments in non-Caucasian populations are lower than those conducted for non-Hispanic Caucasians, leading to disparities in effective pain treatment. As few studies examine this relationship between healthcare providers and Canadian Indigenous groups, the aim of this study is to develop text-based vignettes to further the study of pain assessments for Aboriginal patients by healthcare providers.
Methods: Evidence-based, patient-related variables (sex, pain type, age, and ethnic saliency) were included in text-based vignettes with the objective of measuring responder assessment of race sensitive pain expression or beliefs. The vignettes were provided to 7 content experts in pain management to score content validity on three dimensions: usability, comprehensibility, and scenario validity. The results of the CVI (Lynn, 1986), including revisions and content expert suggestions for improvements, will be presented. The revised tool will be piloted in a survey-based, quantitative study with medical students.
Discussion/Conclusions: The tool was rated to be comprehensible and relevant, with clear semantics.
Recommendations included increasing the amount of clinically relevant details to aid in uncovering provider attitudes. The revised vignettes, containing expert feedback, will proceed to the pilot stage and begin to contribute to this understudied area of clinical research.
Introduction/Aim: In order to make optimal decisions between goods of different nature, instrumental decision-making systems must base their choices on an abstract quantity: value (equivalent to the concept of utility in economy). In the present study, we aimed at determining the monetary value of pain in order to gain insight on how it influences reward seeking.
Methods: 30 healthy volunteers were recruited. Painful stimuli consisted of electrical shocks (Digitimer) delivered on the ankle. We first determined the psychometric function of their pain sensitivity. Thereafter, participants underwent a decisionmaking task during which they had to accept or decline offers that included pairs of varying levels of pain (threshold to tolerance) and monetary compensations (0 to 5 $).
Results: Our data show that the monetary value of pain increases as a function of stimulus intensity (t = 2.63, p = 0.001), with steeper increments in pain value when approaching pain tolerance.
Discussion/Conclusions: Our findings indicate that similar increases in perceived pain intensity yield greater gains in value when approaching pain tolerance than near-threshold levels.
Aim: To provide an updated synthesis of the current state of evidence for the effectiveness of breastfeeding and expressed breast milk feeding in reducing procedural pain in full term and preterm infants.
Methods: A systematic search of key electronic databases (PubMed, CINAHL, EMBASE) was completed from January 1, 2011 to December 22, 2016. The search strategy included key terms for infant, breastfeeding, breast milk, and pain. Inclusion criteria required that studies be 1) an empirical investigation examining the use of breastfeeding or expressed breast milk as a pain relieving intervention, 2) include a sample of full term or preterm born infants, and 3) be published in English in a peer-reviewed journal. Risk of bias was scored using using Cochrane tools.
Results: Of the 1,032 abstracts screened, 21 were found eligible for inclusion. Fifteen studies reported on the use of breastfeeding or expressed breast milk in full term infants (n = 1,908) and six reported on preterm infants (n = 428). Direct breastfeeding was more effective than maternal holding, maternal skinto-skin contact, topical anesthetics, and music therapy; and was as or more effective than sweet tasting solutions in full term infants. Expressed breast milk was not consistently found to reduce pain responding in full term or preterm infants. Studies generally had moderate to high risk of bias.
Conclusion: There is sufficient evidence to recommend direct breastfeeding for procedural pain management in full term infants. Based on current evidence, expressed breast milk alone should not be considered an adequate intervention.
Introduction/Aim: The purpose of this study was to predict outcomes of interdisciplinary chronic pain management. Outcomes were defined in terms of goal attainment and patient satisfaction after a four-week program. Patients had heterogeneous pain and were referred by insurance companies, worker's compensation and veterans affairs. They completed a variety of psychometric instruments on pain-related measures at admission and discharge. At discharge, they also provided ratings of goal attainment and program satisfaction.
Methods: Stepwise regression analyses were performed on a large data set of 882 patients who provided complete data at both admission and discharge with goal attainment and program satisfaction scores as the criterion variables. Difference scores between admission and discharge on pain intensity, depression, anxiety, catastrophizing, recent bothersome symptoms, acceptance and readiness to change measures served as the predictors.
Results: Goal attainment was best predicted by the difference scores on readiness to change subscales (precontemplation, contemplation and maintenance), recent bothersome symptoms, catastrophizing, and activities engagement subscale of the acceptance measure. Patient satisfaction with treatment was best predicted by the difference scores on pre-contemplation and maintenance, recent bothersome symptoms, and the activities engagement subscale of the acceptance measure.
Discussion/Conclusions: Results show that patients are more likely to evaluate their goal attainment and satisfaction more positively when they also make changes in their readiness to change, they adopt self-management strategies for pain, reduce their symptoms in the past month and are more accepting of their chronic pain problem. These results are discussed in the context of the literature on pain management outcomes. Introduction/Aim: Chronic post surgical pain (CPSP) occurs in 10-50% of patients after common surgical procedures, in 2-10% this is severe. A key predictor of CPSP is severity of initial postoperative pain. It is critical to maximize strategies to improve the management of postoperative pain. The current study examined whether continuous neural blockade would improve outcomes following major ankle surgery.
Methods: This was a pragmatic trial where a program of continuous neural blockade at home was available. It was hypothesized that some patients would not receive continuous neural blockade (eg. patient preference or ineligible block) and that groups may differ in pain control and CPSP. Outcome measures consisted of the Brief Pain Inventory (BPI) pain and interference scales. Patients were followed to 6 months.
Results: Thirty-nine patients were recruited, 34 received continuous neural blockade, 5 inpatient multimodal analgesia. There were large decreases in mean pain severity, F(2.37, 90.68) = 27.23, p < .001, η p 2 = .42 and pain interference over time, F(2.54, 96.39) = 20.08, p < .001, η p 2 = .35. Group size was too small to compare difference in CPSP between groups. Pain scores indicated both groups did well. Four patients had CPSP at 3 months and 2 patients (5%) at 6 months, 12 patients were taking an opioid before surgery this was down to 4 patients using an opioid at 6 months.
Discussion/Conclusions: Even with best evidence postsurgical analgesic approaches the rate of CPSP is 5%, to improve beyond this may require a transitional pain service that also addresses psychosocial aspects.
CONTACT Matthew Foss matthew.foss@dal.ca Introduction/Aim: Repeated opioid use can lead to physical dependence, which manifests as a withdrawal syndrome upon cessation of drug use. Converging evidence suggests that opioid withdrawal is critically mediated by cellular changes in the spinal dorsal horn. In the present study, we examined the role of microglial pannexin-1 (Panx1) channels in morphine withdrawal.
Methods: Rats and mice were treated with escalating doses of morphine for 5 days. On day 5, the opioid receptor antagonist naloxone was injected to rapidly precipitate withdrawal behaviours. To assess the role of spinal microglia in withdrawal, Mac1-Saporin was intrathecally injected into morphine dependent animals prior to withdrawal. Mixed adult cell cultures were isolated from the spinal cords of morphine dependent and control animals and analyzed for co-expression of Panx1 and CD11b (a microglial marker) using flow cytometry, and for functional changes in microglial Panx1 using a YO-PRO dye-uptake assay.
Results: Depletion of spinal microglia significantly attenuated the physical signs of morphine withdrawal. Using flow cytometry, we found that morphine treatment increased Panx1 expression exclusively within the microglial population. In acutely isolated spinal micro-glia, BzATP-evoked YO-PRO dye uptake was potentiated in microglia isolated from morphine dependent animals compared to control animals. To test the role of microglial Panx1 in vivo, we genetically deleted Panx1 from Cx3cr1 expressing cells (microglial population) in mice and found that these animals exhibited a robust reduction in withdrawal symptoms.
Discussion/Conclusions: Collectively, our findings reveal a novel and critical role for microglial Panx1 in morphine withdrawal. Results: Bonferroni-corrected bivariate correlations revealed no significant relationships between measures of executive function and FLACC scores at 1, 2, or 3 minutes post-needle.
Discussion/Conclusions: Our results suggest that teacher-reported, parent-reported and objective measures (both behavioural and cognitive) of executive functioning are not associated with painrelated distress signalling among preschoolers. This may be due to the fact that preschoolers' selfregulatory strategies have not yet been consolidated, and thus there are still a number of influential situational (e.g., caregiver behaviour) and dispositional (e.g., temperament) factors that work together to predict post-needle distress while broader self-regulatory abilities (such as those tapped into during psychoeducational assessments) are still being developed. Introduction/Aim: To study the prevalence of unexpected tandem mass spectrometry (TMS) urinary drug screening (UDS) results for all new patients presenting at a hospital-based chronic pain center and to assess which drugs are most likely to contribute to an unexpected result. Also, to assess the clinical utilization of unexpected results by pain physicians.
Methods: From June 2014 to June 2016, a total of 664 chronic non-cancer pain (CNCP) patients were seen for initial consult at a hospital-based chronic pain center. Charts were reviewed and used to create a database containing sex, age, UDS result, and medication/illicit drug history. For all unexpected results, an interview was conducted with the treating physician to determine the clinical implications of the UDS.
Results: The overall percentage of patients with an unexpected UDS result was 16.67% for the general pain specialists and 50% for the pain/addictions specialist, with opioids and benzodiazepines contributing the most. Although eight out of nine physicians found UDS helpful in general, only 29.58% of unexpected UDS were helpful in the management of their patients and had a direct influence on their care.
Discussion/Conclusions: The prevalence of unexpected results in UDS in CNCP patients is significant. Most physicians agree that UDS is helpful but in only a limited number of cases did the unexpected result provide helpful information that significantly influenced patient care. When UDS impacted patient care, it provided information to improve collaborative practices and patient-physician communication. It was also used as a method to guide further testing and prescribing. Introduction/Aim: Despite strong evidence that repeated pain exposure in neonates is associated with adverse outcomes, inadequate pain assessment and management has been reported with less than half receiving pain relief. Given the past decade's emphasis on optimizing care in neonatal settings, there is a need to evaluate the current status of pain assessment and use of pain relieving interventions in this population. The aim of this study is thus to evaluate the level of pain assessment and management in a cohort of hospitalized Canadian preterm neonates.
Methods: A secondary analysis of study data collected from premature neonates enrolled in a clinical trial (Campbell-Yeo et al., 2013) and supplemental chart review.
Results: The 242 neonates included in the study underwent a total of 10468 painful procedures (4801 tissue breaking and 5667 non tissue breaking with only 56.6% and 12.2% having a documented pain score using the Premature Infant Pain Profile (PIPP) respectively). Of those with a documented pain score the most likely procedures to receive a pain score were heel sticks Introduction/Aim: Little research exists on suicide completion rates in chronic pain. We aimed to describe attempts and completions in a population-based matched sample with and without chronic pain using administrative data. Methods: Ontarians ≥18 years were identified from the Canadian Community Health Survey. Individuals with and without chronic pain were matched on age, sex, rurality and income using propensity methods and linked administrative data. They were followed from survey response to death or December 31, 2013. Suicide attempts and completions were identified using ICD-10 codes from emergency department records and Ontario death records, respectively. We also employed an accepted broader definition of suicide, which included accidental poisoning and death of undetermined intent. Suicide rates were expressed as number per 100,000 person years.
Results: There were 18,430 pairs of adults with (cases) and without (controls) chronic pain. Average age was 56 years and 61% were female. Mean (SD) follow-up was 6.9 (3.6) years. 133 people attempted suicide at least once among cases versus 66 among controls (P < 0.01). There were 19 suicides among cases compared to 12 among controls (p > 0.05), translating to 15 and 9 suicides per 100,000 person years. For the broad suicide definition, there were 38 and 17 suicides (p < 0.01) with rates of 30 and 13 per 100,000.
Discussion/Conclusions: Suicide attempts and completions (broad definition) occurred twice as frequently in people with chronic pain versus matched controls. There was no statistical difference in completions using the narrow definition. Our results suggest that chronic pain is associated with suicidal behavior. . We conducted a systematic review to explore the association between the intensity of acute postoperative pain and the development of CPSP following cardiac surgery. Methods: We searched CINAHL, EBSCOhost, Cochrane Library, Clinical Evidence, Medline PubMed, ProQuest and Ovid from 1997-2017. Eligible studies enrolled patients undergoing cardiac surgery and, in an adjusted model, reported the association between acute post-surgical pain intensity and the development of CPSP. We appraised the quality of studies using Critical Appraisal Skills Programme Checklist and risk for bias using Quality in Prognostic Studies tool. We used inverse-variance, random-effects meta-analysis to summarize standardized mean differences (SMD) (associated 95% CI) to examine the strength of association between acute postop pain and CPSP.
Results: Six studies, involving 1,812 patients, were eligible. Methodological quality ranged from high to low; key methodological issues included heterogeneity and reliability of measurement approaches, chart auditing strategies and attrition. Acute post-operative pain showed a small association with the development of CPSP (SMD 0.28; 95%CI 0.12 to 0.44).
Discussion/Conclusion: Our review suggests there is a small association between greater intensity of acute post-operative pain and the development of CPSP after Introduction/Aim: To examine if caregiver sensitivity mediates the relationship between caregiver culture and preschool pain at 1 and 2 minutes post-needle.
Methods: A subsample (N = 154) of preschoolercaregiver dyads was examined from a longitudinal cohort following routine immunization appointments from infancy through preschool. Preschooler pain behaviors were coded at 1 and 2 minutes post-needle (FLACC). 1 Caregiver sensitivity was coded using The Maternal Behavior Q-Set Short Form (MBQS-SF). 2 Caregiver culture was operationalized according to an objectively derived individualism rating of caregivers' self-reported heritage culture. 3 Results: Two mediation models showed that the indirect effect of caregiver culture on preschooler pain, through caregiver sensitivity, was non-significant at 1 minute (AB = −.017; 95% CI [−.167, .065]) and 2 minutes post-needle (AB = −.011; 95% CI [−.151, .079]).
Discussion/Conclusions: Caregiver sensitivity did not mediate the relationship between caregiver culture and preschool pain expression at 1 and 2 minutes post-needle. The present findings differ from analyses during infancy wherein caregiver emotional availability mediated the relationship between the level of individualism of caregivers' self-reported heritage culture and infant pain. 4 While preliminary, the discrepancy between the infant and preschool relationships suggests that caregiver culture may have less influence on caregiver sensitivity and in turn pain expression during the preschool vaccination. Preschoolers are more mature in their pain self-regulatory strategies and thus parental factors (such as culture and sensitivity) may have different impacts than during infancy.
Introduction/Aims: The ECHO Ontario Chronic Pain Program is a telementoring (telehealth) platform, which supports health care providers (HCPs; spokes) in managing their own patients with chronic pain in their home communities, using the expertise of subspecialists (hub). Aims: Potentially harmful patient outcomes, including mild worsening of pain severity, are common patient safety incidents reported in massage and manual therapies research. There is, however, a common complaint that uniformity and consensus regarding what constitutes an adverse event is lacking. A scoping review was conducted to explore definitions and taxonomies used to operationalize potentially harmful outcomes across disciplines that use 'hands-on' manual therapy. Methods: Based on the methodology of Arksey and O'Malley a six stage scoping review was conducted. Eight electronic databases were searched. Inclusion and exclusion criteria were applied for screening then data was extracted and charted to collate and synthesize material ending in a stakeholder consultation to support knowledge translation.
Results: A total of 967 records were identified and 14 were relevant to our study objectives and included in our final sample. Reporting of mild, minor and transient worsening of pain is common in the manual therapy research from massage therapy, acupuncture, chiropractic, physiotherapy, osteopathy and naprapathy. The duration, intensity and impact on function are the common elements used in taxonomies and numeric rating scales are common Introduction/Aim: Approximately 10% of sore throats are caused by a bacterial infection (Worrall. Can Fam Physician 2007;53:1961-2); therefore, antibiotics are not usually warranted. The NSAID, flurbiprofen, has been developed as both a lozenge and spray to relieve sore throat symptoms. This analysis investigated the effect of flurbiprofen 8.75 mg spray and lozenge on sore throat pain intensity in patients positive or negative for betahaemolytic haemolytic group A or C.
Methods: A randomised, double-blind study was conducted across 16 centres in Russia in adult patients with acute sore throat. At baseline, beta-haemolytic streptococci were identified by throat swab culture. Patients were randomly assigned to take one dose of flurbiprofen 8.75 mg spray plus placebo lozenge (n=218), or flurbiprofen 8.75 mg lozenge plus placebo spray (n=222), and were asked to rate sore throat pain on the Sore Throat Pain Intensity Scale (STPIS; 100mm visual analogue scale, 'no pain' to 'severe pain').
Results: Similar proportions of patients in the spray (6.5%, 13/201) and lozenge (4.3%, 9/210) groups were positive for beta-haemolytic streptococci (group A or C). Mean±standard deviation change from baseline in STPIS at 2 hours post-dose was similar between patients positive for beta-haemolytic streptococci (-36.5±20.89 mm for spray and -44.2±24.83 mm for lozenge) and negative (-41.1±21.84 mm for spray and -40.1±22.28 mm for lozenge). Swab testing results were not known until after clinical evaluations were completed and patients did not take antibiotics during the study.
Discussion/Conclusions: Both flurbiprofen 8.75 mg spray and lozenge provide relief from sore throat pain in patients positive or negative for beta-haemolytic streptococci (group A or C).
A pilot focus group study of Farmooo, a virtual reality pain distraction game designed for 14-to 18-year-old patients undergoing chemotherapy Janice Ng, Henry Lo, Xin Tong, Weina Jin, Diane Gromala, and Caron Strahlendorf Introduction/Aim: Farmooo is an immersive Virtual Reality (VR) farm simulation game designed to help distract teenage cancer patients from pain during their chemotherapy treatments. The research is collaboration between BC Children's Hospital and Simon Fraser University's Pain Studies Lab.
Methods: A 2.25-hour Focus Group was conducted with 6 outpatients (for their comparatively risk-free potential). The study session comprised: a presentation about the design of Farmooo, game testing, a post-test questionnaire and a discussion circle.
Results: Participants expressed deep appreciation that a VR game was built specifically for them. Some concerns were raised about interaction with an attached IV, warm hands necessary for accurate gesture detection and desire for more challenging gameplay. Most participants enjoyed the game, particularly the experience of feeling immersed in the 3D interactive VR environment (M = 75.33, SD = 26.83). All showed high interest in and positive attitudes about using a more robust VR game if they were still undergoing chemotherapy (M = 87.17, SD = 11.41). Nausea associated with VR was much less concerning than expected. Background: Preterm neonates at risk of developing retinopathy of prematurity (RoP) undergo frequent and painful eye exams. Currently, no consensus regarding the optimal way to manage this pain has been reached. A lack of head-to-head randomized clinical trials (RCT) comparing possible pain relieving treatment options has contributed to this problem. Aim: To estimate the relative efficacy and safety of all available interventions intended to reduce pain from RoP exams.
Methods: We searched MEDLINE, Embase, Cochrane CENTRAL, and Web of Science for randomized controlled trials comparing at least two pain-relieving interventions. Two reviewers performed study selection, data extraction, and quality appraisal. We performed a network meta-analysis using a random-effect model.
Results: Fifteen trials (n = 915 infants), evaluating nine treatments reported results from a validated pain assessment tool. Sweet taste + topical anesthetic, and multisensory (engagement of multiple senses e.g. gustatory + non nutritive sucking (NNS)) interventions + topical anesthetic showed statistically significant improvement over topical anesthetic alone (MD: -1.78; -3.03), although absolute scores still indicated moderate pain. Neither acetaminophen, digital retina imaging, sweet taste alone, or NNS combined with anesthetic showed significant improvement over anesthetic alone. Four studies reported adverse events with no differences in rates of events between anesthetic drops alone or in combination with sweet taste, Tylenol, multi-sensory interventions, or NNS.
Conclusions: Combining topical anesthetic with sweet taste or multisensory interventions is likely to provide the most effective pain relief for RoP exams, although no treatment reduces overall scores to ranges considered to indicate low or no pain. Verreault, Dean Tripp, and Mala Joneja. Published with license by Taylor & Francis. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The moral rights of the named author(s) have been asserted.
The potential use of a serious game to help patients learn about post-operative pain management -an evaluation study Introduction/Aim: To describe the evaluation of a serious game designed for patients to learn about postoperative pain management.
Methods: The game was developed by an interdisciplinary team. In the game, the player controls the actions of a virtual human character who has recently been discharged home from hospital after surgery. By making different decisions about the character's daily activities (including pain management) players can observe how their decisions influence the character's recovery. The usability and efficacy of the game were evaluated in one session with questionnaires measuring usability, attitudes towards pain management and knowledge acquisition; semi-structured interviews; and direct observation while participants played the game. Results: Participants (N = 20, mean age 48 ± 14, 11 women), recruited from the public, described the usability of the game as high and expressed satisfaction with this novel method of learning, despite some technological challenges. Ease of use was confirmed by observation. Knowledge of pain medication and strategies such as taking pain medication regularly, improved after playing the game. Correct answers increased from 54% (before playing) to 71% (p = 0.001).
Discussion/Conclusions: A serious computer game has the potential to improve knowledge about post-operative pain management. The game was well received by participants and can be a useful tool to initiate and facilitate discussions between healthcare providers and patients.
CONTACT Brynja Ingadottir brynjain@landspitali.is Aims: Migraines are common. Cognitive Behavioral Therapy (CBT) is advocated as the first-line treatment although rarely available. Internet-based interventions can help gain access. There is limited evidence that Internet-based CBT, with no human support, are well used, accepted and effective. Our purpose was to assess acceptability and adherence to two self-guided CBT: SPHERE, a comprehensive program aimed to teach a variety of skills, and PRISM, a targeted program aimed to identify headache triggers and provide recommendations to cope with them. Method: A pilot randomized controlled trial was performed. Sixty participants were stratified into two age groups (14-21, 22-35) and randomly allocated to SPHERE, PRISM or usual care. The Client Satisfaction Questionnaire (CSQ-8) and interviews were conducted 4-month post-randomization.
Conclusions: Low adherence to internet interventions is common. The nascent field of research on internet interventions could benefit from taking into account participant views. Based on participants' feedback we are introducing changes (e.g., add instructions, simplify programs) and we will test adherence to new versions. Introduction/Aim: The anterior cingulate cortex (ACC) in the medial prefrontal cortex (mPFC) has long been associated with the affective components of pain perception. Pyramidal neurons in layer 2/3 of the ACC display hyperexcitable characteristics in chronic pain. Reversal/ inhibition of these hyperexcitable characteristics by optogenetics has proven to provide analgesic benefits. cAMP-activated HCN channels, highly expressed in the mPFC, have been reported to modulate neuronal excitability via their control of input resistance. Previous studies have shown that Gs-coupled D1 dopamine receptors (D1R), responsible for upregulated cAMP, are colocalized around HCN channels. Our goal is to trigger analgesic effects through a decrease in cellular excitability by activating prefrontal D1R receptors.

ORCID
Methods: To determine if dopamine modulates pyramidal cell activity in the ACC, we used whole-cell patch clamp electrophysiology to measure changes in excitability of layer 2/3 pyramidal cells in acute brain slices of six-week-old C57BL/6 mice following 10 uM DA and 10 uM D1R agonist application.
Results: Our whole cell patch clamp recordings indicate that D1R activation is inhibitory in layer 2/3 pyramidal cells in the ACC, hinting at a dopaminergic control on prefrontal activity.
Discussion/Conclusions: In further studies, we will investigate the molecular basis of dopaminergic inhibition in the ACC, and the impact on cognitive functions in chronic pain conditions. Using an established mouse model for chronic neuropathic pain (SNI surgery), we will measure the effects of dopamine and dopamine receptor subtype-selective agonists on both cell excitability and nocifensive behaviors in vitro and in vivo.  Introduction/Aim: The analgesic effect of morphine and its derivatives relies on the presence of the mu opioid receptors (MOR) in pain pathways. Interestingly, MORs are expressed in the anterior cingulate cortex (ACC), a prefrontal area involved in generating the affective and emotional components of the pain experience. Recent rodent studies suggest that the endogenous opioid system in the ACC is important for pain processing and pain relief. Our aim is to determine both the function and localization of MORs in the ACC. Methods: We perform whole-cell patch clamp recordings of layer 2/3 pyramidal cells in the ACC in acute slices from wild type C57Bl/6 mice. We bath apply DAMGO, a selective mu opioid receptor agonist, to observe the effect of MOR activation on cellular excitability. We induce persistent firing in these cells with 3,5-DHPG, a metabotropic glutamate receptor agonist. For the immunohistochemistry experiments, we utilize the Oprm1-mCherry transgenic mouse line.
Results: We found that roughly 50% of the pyramidal cells respond to DAMGO with a decrease in cellular excitability. In addition, we found that DAMGO inhibits DHPG-induced persistent firing. Lastly, we show evidence of Oprm1-mCherry expression in the ACC.
Discussion/Conclusions: We demonstrate that MOR activation modulates a population of layer 2/3 ACC pyramidal cells. In future experiments, we plan to determine whether prefrontal MORs are localized to presynaptic and/or postsynaptic elements. Finally, our future aim is to see how MOR expression and function in the ACC are affected under chronic pain conditions. Strengthening system services and supports to promote stay-at-work and return-to-work for persons living with persistent pain: A qualitative study Introduction/Aim: Tapping into the expertise of a broad spectrum of experts that interact with injured workers with chronic pain was identified as an imperative by the steering committee of the Creating a Way Forward Project initiated by the Canadian Pain Coalition and Canadian Injured Workers' Alliance. The aim was to provide evidence and knowledge to inform social change in the opportunities for injured workers to live and work with chronic pain.
Methods: A focus group study comprised of N=15 experts participated in a group interview/discussion process exploring barriers, facilitators and opportunities to work with persistent pain. A template analysis (King 2004) was conducted by two qualitative researchers to identify the preliminary codes from dialogue with a heterogeneous group of experts and stakeholders. Deeper reflection on the discussion from a constructivist standpoint led to core themes and insights that were confirmed with experts.
Results: Insights included: Purposeful capacity building through knowledge and education; enabling interconnectivity of services and providers; establishing collaborative planning processes among people, services and stakeholders; and strengthening the interdependence of the stakeholders through a focus on shared benefits related to achieving positive outcomes for injured workers with chronic pain.
Discussion/Conclusions: Social change at the systems level must consider the functionality, integrity, and stabilization of services and supports in the context in which persons with persistent pain live and work. In the poster we will present opportunities informed by this research to help injured workers with persistent pain engage in orchestrating a healthy way of living, stay at work and return to work.
CONTACT Lynn Cooper lkcooperbes@rogers.com; office@canadianpaincoalition.ca The psychophysical phenomenon currently known as conditioned pain modulation (CPM) or heterotopic noxious conditioning stimulation (HNCS) is the human correlate of the diffuse noxious inhibitory control (DNIC) phenomenon first demonstrated in rats in 1979 by Le Bars. The observation that pain inhibits pain, of course, is quite old, but the laboratory demonstration of such counterirritation has become increasingly popular as an experimental measure of the "capacity" of endogenous pain inhibitory mechanisms. Evidence has been amassed suggesting that CPM/HNCS is both a risk factor for the development of chronic pain and a predictor of treatment response. The magnitude and even direction of the phenomenon in healthy volunteers is, in fact, highly variable and dependent on various parameters of both the conditioning and the test stimuli. In a study performed in outbred CD-1 mice, we observed to our surprise that following intraperitoneal injection of acetic acid mice displayed increased sensitivity to noxious thermal heat on the plantar hind paw. This apparent thermal hyperalgesia-the exact opposite of what DNIC should produce-was quite robust, representing a ≈4-5s decrease in paw-withdrawal latencies (from an ≈20 s baseline) sustained over the 30 min duration of acetic acid-induced abdominal constriction behavior. Given the surprising direction of this effect, and the increasingly prominent role of mice in pain research we performed a parametric analysis of DNIC in the laboratory mouse.
Introduction/Aim: The psychophysical phenomenon currently known as conditioned pain modulation (CPM) or heterotopic noxious conditioning stimulation (HNCS) is the human correlate of the diffuse noxious inhibitory control (DNIC) phenomenon first demonstrated in rats in 1979 by Le Bars. The observation that pain inhibits pain, of course, is quite old, but the laboratory demonstration of such counter-irritation has become increasingly popular as an experimental measure of the "capacity" of endogenous pain inhibitory mechanisms. Evidence has been amassed suggesting that CPM/HNCS is both a risk factor for the development of chronic pain and a predictor of treatment response. The magnitude and even direction of the phenomenon in healthy volunteers is, in fact, highly variable and dependent on various parameters of both the conditioning and the test stimuli. In a study performed in outbred CD-1 mice, we observed to our surprise that following intraperitoneal injection of acetic acid mice displayed increased sensitivity to noxious thermal heat on the plantar hind paw. This apparent thermal hyperalgesia-the exact opposite of what DNIC should produce -was quite robust, representing an ≈4-5 s decrease in paw-withdrawal latencies (from an ≈20 s baseline) sustained over the 30 min duration of acetic acid-induced abdominal constriction behavior. Given the surprising direction of this effect, and the increasingly prominent role of mice in pain research we performed a parametric analysis of DNIC in the laboratory mouse.
Methods: Naïve, young adult CD-1 (7-12 weeks of age) mice of both sexes were used. In one study, inbred DBA/2J and C57BL/6J mice, bred in our laboratory from breeders obtained from The Jackson Laboratory (Bar Harbor, ME), were used. All mice were housed with their same-sex littermates (two to four animals per cage) in standard shoebox cages, maintained in a temperature-controlled (20 ± 1°C) environment (14:10 h light/dark cycle), and fed (Harlan Teklad 8604) and watered ad libitum. Nociceptive assays were performed as previously described in more detail (Mogil et al., 2015). Brief tests are as follows: radiant heat paw-withdrawl test, hot water tail-withdrawl test, hot-plate test, Von Frey test, and Orofacial formalin test.
Results: 3.1. Long-lasting thermal hyperalgesia during and after acetic acid injection Mice of both sexes were tested for baseline thermal nociception five times at 5-min intervals on the radiant heat paw-withdrawal test. Female mice trended towards higher pain sensitivity, but no sex differences were evinced (F 1,38 = 1.0, p=0.32) and latencies were fairly stable (repeated measures: F 4,152 = 2.1, p=0.08). Following intraperitoneal injection of 0.9% acetic acid, mice were tested at 5-min intervals for 30 min, and all post-injection latencies were robustly hyperalgesic. Overall, a highly significant thermal hyperalgesia was demonstrated, equally in both sexes (repeated measure: F 1,40 = 174.5, p<0.001; sex x repeated measure: F 1,40 = 0.8, p=0.36). The presence of paw-withdrawal testing did not in turn affect abdominal constriction behavior caused by acetic acid.
To replicate the finding and establish its duration, a separate group of mice were tested at 10-min intervals before and for 80 min following acetic acid injection. Although abdominal constriction behavior ceased in all mice by 40 min post-injection, significant hyperalgesia (repeated measures: F 13,143 = 3.9, p<0.001) persisted until 70 min post-injection.

Hyperalgesia is dependent on the conditioning stimulus intensity
To establish the influence of the intensity of the conditioning stimulus on the magnitude of hyperalgesia, we conducted experiments varying the concentration of acetic acid, acetic acid concentration strongly affected hyperalgesic magnitude and statistical significance (concentration x repeated measures: F 4,24 = 7.8, p<0.001), with increasing concentrations producing increasing hyperalgesia. Furthermore, post-injection withdrawal responses were much more likely to be judged as "exaggerated", and this likelihood was also highly dependent on acetic acid concentration (concentration x repeated measures: F 4,24 = 17.8, p<0.001).

Hyperalgesia is observed using different test stimuli and conditioning stimuli
To test whether the presence of hyperalgesia instead of analgesia was simply due to the particular pairing of acetic acid as a conditioning stimulus and the radiant heat pawwithdrawal test as the test stimulus, we conducted new experiments using different assays. As shown in Figure 3, hyperalgesia was observed when nociception was assessed before and after acetic acid injection on the 49°C hot water tail-withdrawal test (repeated measure: F 1,16 = 12.8, p=0.003) the 53°C hot-plate test (repeated measure: F 1,25 = 17.4, p=0.01) and the von Frey test. Furthermore, if acetic acid was replaced by orofacial formalin as the conditioning stimulus, hyperalgesia was also observed using the radiant heat paw-withdrawal test (repeated measure: F 1,20 = 25.8, p=0.003).
Discussion/Conclusions: Mice become hyperalgesic after injection of acetic acid paired with a thermal assay. This thermal hyperalgesia is long lastinglasting up to 30 minutes after injection. Hyperalgesia is dependent on both testing and conditioning stimuli. Hyperalgesia is also dependent on the test stimulus intensity itselfshowing that the magnitude of the observed hyperalgesia becomes larger as the test stimulus intensity increases. However, at a certain threshold, thermal hyperalgesia switches to analgesia, suggesting that this effect is completely dependent upon the test stimulus intensity. These results show that conditioned pain modulation is dependent on test and conditioning stimuli.
CONTACT Shannon Tansley shannon.tansley@mcgill.ca specific, non-invasive pain model in rodents for the investigation of nociceptive signalling pathways based on designer receptors exclusively activated by designed drugs (DREADDs): the mutated Gq-coupled muscarinic receptor M3 (hM3D) selectively sensitive to the ligand clozapine-N-oxide (CNO). Methods: Heterozygous Nav1.8-Cre pups were injected with AAV2/9 particles coding for hSyn-DIO-hM3D-mCherry. Hargreaves and automated von Frey were used to assess CNO-induced thermal and mechanical hypersensitivity in the DREADD-Gq adult mice, as well as the contribution of TRPV1 to the sensitization process. Results were verified in vitro in DRG cultures.
Results: We report a novel transgenic mouse model based on hM3D-mediated sensitization of peripheral nociceptors, without administration of any external noxious stimuli or injury. Systemic activation of hM3D induced by CNO evoked strong nocifensive behavior with reduced locomotion, squinting and ruffled fur. Intradermal paw injections of CNO resulted in acute thermal hyperalgesia and mechan-ical allodynia, as well as localized edema and redness indicative of neurogenic inflammatory activation.
Discussion/Conclusions: These findings demonstrate for the first time the chemogenetic control of peripheral sensitization in behaving mammals. Our results provide a proof-of-concept demonstration that chemogenetic interrogation of the contribution of specific classes of genetically-identified primary afferents to peripheral sensitization is possible. Chemogenetic preclinical pain models combining effective spatial penetrance with neuronal selectivity have the potential to facilitate drug development and target validation for chronic pain relief. Introduction/Aim: The social modulation of pain is nuanced by factors such as state-dependent motivation, relationships and stress. Previous work suggests that social contact in rodents and humans results in a cascade of endogenous opioids that reduce sensitivity to acute pain stimuli. However, the role of social relationship, type of pain stimulus and its influence on socially rewarding interactions remains unknown. Methods: Here we sought to uncover the influence of social reunion on subsequent pain responding and social interactions. To test this, we injected CFA (complete Freud's adjuvant) or saline into the hindpaw of adult C57 mice. Cagemate dyads were either both in pain (CFA-CFA), one in pain (CFA-SAL) or control (SAL-SAL) and were separated for 24 hours following injection. Dyads were then tested for mechanical pain sensitivity and then reunited with their cagemate for 1 hour. Following reunion, dyads were re-assessed for changes in mechanical pain. In our second set of experiments, we tested how social reunion between separated siblings or strangers effects acute pain responses using a hot-plate test. Either separated siblings or strangers were reunited and acute pain was tested at 3 time points.
Results: We find that conspecifics experiencing inflammatory pain demonstrate increased mechanical pain sensitivity following social reunion, 1 day and 1 week following injection. Furthermore, allogrooming and social approach behaviours between conspecifics in pain during reunion were significantly reduced when compared to saline controls. In our second set of experiments, we find that reunion between siblings causes analgesia to acute pain stimuli, whereas social interactions with a stranger result in hyperalgesia.
Discussion/Conclusions: Overall, our results demonstrate a different profile of social interactions and pain depending on the type of pain experienced and social relationship. Introduction/Aim: C-tactile (CT) afferents convey affective touch signals and are stimulated via light and slow stroking of hairy skin. It has been suggested that CT afferents become dysfunctional in chronic pain, potentially accounting for clinical reports of pain in response to previously innocuous stimuli. Human studies describe CT projections to a network that includes the insula, amygdala, and prefrontal cortex. However, there is not an analogous network in a mouse model. Activation of CT afferents in mice has been proposed to have analgesic effects; the lack of a mouse network provides a challenge for animal researchers who wish to explore therapeutic benefits of CT activation. Our current work aims to describe an activational network of affective touch in mice. Methods: To stimulate CT afferents, a "gentle touch" protocol was used: an experimenter applied a stroke to a mouse using a gloved finger, while a non-stroked mouse remained undisturbed to serve as a comparison. Western Blot c-fos analysis was used to compare brain activation between stroked and non-stroked animals. ROIs were chosen based on the human literature.
Results: Preliminary immunoblots revealed: (1) higher relative c-fos expression in the amygdala and hypothalamus of stroked vs. non-stroked animals, and Introduction/Aim: Spinal cord lamina I neurons function as a hub of nociception, and exhibit hyperexcitability in chronic pain models. This hyperexcitability has been linked to clinical symptoms including allodynia and hyperalgesia. Changes in calcium dynamics have been implicated in chronic pain, however their function in lamina I neurons is poorly understood. Consequently, we investigated activity-driven calcium dynamics in lamina I neurons using simultaneous twophoton calcium imaging and electrophysiology.
Methods: We made current-clamp electrophysiological recordings from lamina I neurons in rat spinal cord slices, loading the calcium indicator OGB-1 and control fluorophore AF-594 via the patch pipette. Relative calcium concentration before, during, and after action potential generation was quantified as ΔG/R, the change in OGB-1 intensity as compared to the control fluorophore AF-594.
Results: Over 150 lamina I neuron recordings were generated. In 98% of neurons, the threshold for measurable ΔG/R change was a single action potential. This calcium increase was observed in the nucleus, somatic cytosol, dendrites, and dendritic spines. Calcium responses did not degrade along dendrites from 20µm to 160µm away from the soma, suggesting active backpropagation. We found no differences when comparing calcium responses by cellular morphology (fusiform, multipolar, or pyramidal) or firing-type (tonic, phasic, single spike, delayed).
Discussion/Conclusions: The capability of a neuron to produce action potential-induced calcium entry is highly correlated with excitability of a neuron, as it can lead to short or long-term increases in synaptic efficacy. Our findings suggest that all lamina I neurons produce action potential-induced calcium entry which backpropagates into their entire dendritic arbour. Introduction/Aim: The most significant barrier to effective pain management in cancer patients without an active disease is the limited knowledge and skills of many physicians who manage pain. The purpose of this survey was to assess the educational needs and interests of primary care physicians treating chronic pain in the continuum of cancer. Methods: A survey was mailed out to primary care physicians across Canada. The physician's demographics, knowledge and confidence with practical management, opinions on strategies to optimize prescribing, goals with chronic pain management, evaluation of barriers and gaps, and topics of interests were collected.
Results: A total of 161 responses were collected. Majority of physicians (90%) acknowledged their lack of sufficient knowledge about chronic pain management in cancer patients without an active disease. Only 10% of the respondents were confident in managing these patients. The three most cited barriers physicians face when managing chronic pain were the coverage of medications, concern about patient opioid misuse or abuse, and patient noncompliance. Physicians were most interested in learning about these three topics: Treatment guidelines; Pharmacological treatment options; and nonpharmacological treatment options for chronic pain which would help improve their ability to manage these patients appropriately. Other topics of interest include pathophysiology of chronic pain in continuum of cancer and pain assessment.
Conclusions: Physicians who manage chronic pain related to cancer treatment in patients without an active disease have knowledge deficiencies. By understanding physicians' educational needs and interests, relevant strategies can be developed and initiated to close these knowledge gaps. Introduction/Aim: To explore factors associated with sub-elite athletes playing through pain in gymnastics, rowing and speed skating.
Methods: We conducted semi-structured interviews with athletes, coaches and rehabilitation specialists. Coach participants were recruited through their Introduction/Aim: As more restrictions are imposed on prescription opioid access, diversion of products across the United States-Canada borders is likely. The StreetRx Program was studied to quantify this cross-border trafficking of prescription oxycodone products manufactured in Canada and used in the United States (US).
Methods: StreetRx is a publicly accessible website which collects anonymously reported street price data