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\"Although pain is a universal human experience, many view the pain of others as private, resistant to language, and, therefore, essentially unknowable. And, yet, despite the obvious limits to comprehending another's internal state, language is all that we have to translate pain from the solitary and unknowable to a phenomenon richly described in literature, medicine, and everyday life. Without denying the private dimensions of pain, All in Your Head offers an entirely fresh perspective that considers how pain may be configured, managed, explained, and even experienced in deeply relational ways. Drawing on ethnographic fieldwork in a pediatric pain clinic in California, Mara Buchbinder explores how clinicians, adolescent patients, and their families make sense of puzzling symptoms and work to alleviate pain. Through careful attention to the language of pain--including narratives, conversations, models, and metaphors--and detailed analysis of how young pain sufferers make meaning through interactions with others, her book reveals that however private pain may be, making sense of it is profoundly social\"--Provided by publisher.

Although pain is a universal human experience, many view the pain of others as private, resistant to language, and, therefore, essentially unknowable. And, yet, despite the obvious limits to comprehending another's internal state, language is all that we have to translate pain from the solitary and unknowable to a phenomenon richly described in literature, medicine, and everyday life. Without denying the private dimensions of pain,All in Your Headoffers an entirely fresh perspective that considers how pain may be configured, managed, explained, and even experienced in deeply relational ways.Drawing on ethnographic fieldwork in a pediatric pain clinic in California, Mara Buchbinder explores how clinicians, adolescent patients, and their families make sense of puzzling symptoms and work to alleviate pain. Through careful attention to the language of pain-including narratives, conversations, models, and metaphors-and detailed analysis of how young pain sufferers make meaning through interactions with others, her book reveals that however private pain may be, making sense of it is profoundly social.

Abstract Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, −7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (−£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care.

Evidence-based treatment of chronic pain requires a multidisciplinary approach grounded in the biopsychosocial model. Implementing this approach within health systems relies on its acceptance by both healthcare providers and patients. While pioneering multidisciplinary pain clinics can serve as a model for implementation, a systematic effort is needed to share knowledge effectively and broadly. In the current paper we provide an overview of the knowledge translation initiatives undertaken at our Transitional Pain Service (TPS) at Toronto General Hospital, a state-of-the-art multidisciplinary pain program established in 2014 for patients at risk of developing chronic pain after surgery. The TPS team strives to enhance acceptance of this model of care among patients and providers, facilitate the establishment of similar clinics, and promote patient understanding of the integrated multidisciplinary pain care approach. Guided by the Knowledge to Action (KTA) framework, knowledge translation activities undertaken by our TPS team include clinician training, resources and outreach activities for providers, and patient education. Resource development was preceded by consultation and needs assessment among patients and providers and feedback from both groups was incorporated as part of the development process. The tailored resources were disseminated via the TPS clinic website and monitoring of online usage enables continuous evaluation of engagement. Barriers to engagement with the resources were examined through patient surveys and staff interviews. Based on these activities, we offer insights gained by our team throughout the knowledge translation process and provide recommendations for other clinical teams who wish to undertake similar initiatives.

We investigated if human reminder phone calls in the patient's preferred language increase adherence with scheduled appointments in an inner-city chronic pain clinic. We hypothesized that language and cultural incongruence is the underlying mechanism to explain poor attendance at clinic appointments in underserved Hispanic populations. Pragmatic randomized controlled clinical trial Innercity academic chronic pain clinic with a diverse, predominantly African-American and Hispanic population All (n=963) adult patients with a scheduled first appointment between October 2014 and October 2015 at the Montefiore Pain Center in the Bronx, New York were enrolled. Patients were randomized to receive a human reminder call in their preferred language before their appointment, or no contact. We recorded patients' demographic characteristics and as primary outcome attendance as scheduled, failure to attend and/or cancellation calls. We fit Bayesian and classical multinomial logistic regression models to test if the intervention improved adherence with scheduled appointments. Among the 953 predominantly African American and Hispanic/Latino patients, 475 patients were randomly selected to receive a language-congruent, human reminder call, while 478 were assigned to receive no prior contact, (after we excluded 10 patients, scheduled for repeat appointments). In the experimental group, 275 patients adhered to their scheduled appointment, while 84 cancelled and 116 failed to attend. In the control group, 249 patients adhered to their scheduled appointment, 31 cancelled and 198 failed to attend. Human phone reminders in the preferred language increased adherence (RR 1.89, CI95% [1.42, 1.42], (p<0.01). The intervention seemed particularly effective in Hispanic patients, supporting our hypothesis of cultural congruence as possible underlying mechanism. Human reminder phone calls prior in the patient's preferred language increased adherence with scheduled appointments. The intervention facilitated access to much needed care in an ethnically diverse, resource poor population, presumably by overcoming language barriers. Culturally sensitive, language-congruent, patient-centered outreach can overcome barriers to access and engage minorities in an inner-city pain clinic. On the left panel, the English-only-speaking provider fails to establish rapport and trust with his chronic pain patient. On the right panel, culturally-sensitive, language-congruent staff engages the Latina patient in a warm patient-provider relationship already in the first telephone contact. [Display omitted] •Poor attendance at scheduled pain clinic appointments indicates barriers to healthcare.•Reminder phone calls in the patient’s preferred language increase adherence with scheduled appointments.•Rigorous research in health care disparities can improve access to pain services, while saving health care resources.•Language-centered interventions to enhance adherence may be more effective in culturally-congruent subpopulations.

BackgroundRapid Access Chest Pain Clinics (RACPC) are widely used for the outpatient assessment of chest pain, but there appears to be limited high-quality evidence justifying this model of care. This study aimed to review the literature to determine the effectiveness of RACPCs.MethodsA systematic review of studies evaluating the effectiveness of RACPCs was conducted to assess the quality of the evidence supporting this model. Outcomes related to effectiveness included major adverse cardiovascular events, emergency department reattendance, cost-effectiveness and patient satisfaction. Study quality was assessed using the RoB 2 tool, Newcastle-Ottawa quality assessment tool or the Consolidated Criteria for Reporting Qualitative Studies checklist, as appropriate.ResultsThirty-two studies were eligible for inclusion, including one randomised trial. Five analytical cohort studies were included, with three comparing outcomes against non-RACPC controls. Three qualitative studies were included. Most reports were descriptive. Findings were consistent with RACPCs being associated with favourable clinical outcomes, reduced emergency department reattendance, cost-effectiveness and high patient satisfaction. However, there was significant heterogeneity in care models, and overall literature quality was low, with a high risk of publication bias.ConclusionWhile the literature suggests RACPCs are safe and efficient, the quality of the available evidence is limited. Further high-quality data from adequately controlled clinical trials or large scare registries are needed to inform healthcare resource allocation decisions.PROSPERO registration numberCRD42023417110.

RationaleLiterature shows that breast pain alone has no significant association with breast cancer. Currently, patients experiencing these symptoms are often referred to breast cancer diagnostic clinics (BCDCs), leading to an increase in unnecessary anxiety and overutilisation of already strained secondary care resources. The East Midlands Breast Pain Pathway (EMBPP) aims to establish a new pathway that improves patient care and eases pressure on BCDCs, as well as being cost-beneficial and providing a positive patient experience.Aim and objectivesThis study aims to evaluate the impact of the EMBPP on patient care, including safety, costs incurred by the health system and patient experience.MethodsThe EMBPP was analysed quantitatively and qualitatively using data extracted from the community breast pain clinics (CBPCs), BCDCs, patient-reported outcome measures, clinic costs, family history data and staff interviews.ResultsBreast cancer incidence within the cohort of patients with a full 12-month follow-up period was shown to be 3.7 per 1000 patients, below the population estimates in the literature. There was no delay to care for those who were diagnosed with breast cancer after attending a CBPC. The clinics were found to be cost-beneficial, with a cost-benefit ratio of 1.26 in year 1, 1.40 in year 2 and 1.56 in year 3. The pathway was positively received by patients, with 98.7% indicating that they would recommend the service.ConclusionFollowing on from previous audits and analysis of the EMBPP pathway, this national evaluation has shown that CBPCs are effective across multiple Cancer Alliances, National Health Service (NHS) Trusts and demographics. The CBPC offers a positive patient experience and is cost-beneficial and safe, with no evidence of a delay to care for the patients.

Background: Surgical options for thoracic pain are limited and carry significant risk and morbidity. Spinal cord stimulation has the potential to be used for treatment of thoracic pain, as it has been useful for treating multiple types of chronic pain. Conventional tonic stimulation is limited in the treatment of thoracic pain, as it can produce paresthesia that is difficult to localize. Conversely, high-frequency spinal cord stimulation (HF-SCS) does not activate dorsal column Aβ fibers and does not produce paresthesia, and thus may be more beneficial in treating thoracic back pain not manageable with tonic stimulation. Objectives: To evaluate (1) the efficacy of 10 kHz HF-SCS for patients with chronic thoracic pain; and (2) appropriate paresthesia-free lead placement and programming targets for 10 kHz HF-SCS for patients with chronic thoracic pain. Study Design: Retrospective case series. Setting: Multisite academic medical center or pain clinic. Methods: A retrospective chart review was performed on 19 patients with thoracic back pain who underwent HF-SCS implantation. These patients had lead placement and stimulation between the T1-T6 vertebral levels. Outcome measures collected include location of device implant, stimulation settings, and pain scores at baseline, end of trial, and 1, 6, and 12 months postimplant. Followup phone calls collected information on if the patient reported functional improvement, improved sleep, or decreased pain medication usage. A Wilcoxon signed-rank test compared differences in mean pain scores across time points. Results: Significantly decreased Visual Analog Scale scores were observed with 17/19 (89.5%) patients demonstrating response to therapy (> 50% reduction in pain scores). These results were sustained relative to baseline at 1, 6, and 12 months postimplant, depending on length of followup. Many patients also reported functional improvement (17/19), improved sleep (14/19), and reduction in use of pain medications after implantation (9/19). A total of 15/19 patients reported best relief when contacts over T1 or T2 vertebrae were used for stimulation. Limitations: This study is limited by its retrospective design. Additionally, including documentation from multiple sites may be prone to selection and abstraction bias. Data were also not available for all patients at all time points. Conclusions: HF-SCS may be a viable option for significant, long-lasting pain relief for thoracic back pain. There may also be evidence for anatomically based lead placement and programming for thoracic back pain. Randomized, controlled trials with extended follow-up are needed to further evaluate this therapy. Key words: Thoracic pain, back pain, spinal cord stimulation, high frequency, 10 kHz

Abstract Objective Diagnosis of patients with occipital headache can be challenging, as both primary and secondary causes must be considered. Our study assessed how often migraine is screened for, diagnosed, and treated in patients receiving greater occipital nerve blocks (GONBs) in a pain clinic. Design Institutional review board–approved, retrospective observational study. Setting Academic multidisciplinary pain clinic. Subjects One hundred forty-three consecutive patients who received GONBs. Results About 75% of patients had been evaluated by neurologists and about 25% by non-neurologist pain specialists only, and 62.2% of patients had photophobia, phonophobia, and nausea assessed. Compared with patients who had been evaluated by non-neurologists, patients who had been evaluated by a neurologist were more likely to have photophobia, phonophobia, and nausea assessed (75.9% vs 20.0%, odds ratio [OR] 12.6, 95% confidence interval [CI] 4.90 to 32.2); more likely to be diagnosed with migraine (48.1% vs 14.3%, OR 5.6, 95% CI 2.0 to 15); less likely to be diagnosed with occipital neuralgia (39.8% vs 65.7%, OR 0.3, 95% CI 0.2 to 0.8); and equally likely to be diagnosed with cervicogenic headache (21.3% vs 25.7%, OR 0.8, 95% CI 0.3 to 1.9). Among patients diagnosed with migraine, 82.5% received acute migraine treatment, 89.5% received preventive migraine treatment, and 52.6% were documented as receiving migraine lifestyle counseling. Conclusions Of the patients in this study who had occipital headache and received GONBs, 62.2% were assessed for migraine, and most received appropriate acute, preventive, and lifestyle treatments when diagnosed. Patients seen by neurologists were significantly more likely to be screened for and diagnosed with migraine than were those evaluated by non-neurologist pain medicine specialists only. All clinicians should remain vigilant for migraine in patients with occipital headache.

BackgroundInterprofessional collaboration (IPC) is vital for delivering safe, holistic patient care, particularly in outpatient interventional pain clinics where precision and teamwork are crucial. Despite its importance, IPC within outpatient pain medicine remains understudied, and the Readiness for Interprofessional Learning Scale (RIPLS) has not been used longitudinally in outpatient pain medicine.ObjectivesThe primary objective of this quality improvement (QI) project was to evaluate and enhance readiness for interprofessional learning among clinical staff in an outpatient pain clinic, measured over 6 months in an outpatient pain clinic.MethodsThis initiative took place from October 2021 to April 2022 in an academic institution’s hospital-based outpatient pain clinic. We administered the RIPLS survey to 15 participants of various clinical roles at baseline and again 6 months after a simulation-based intervention. The simulation included small group didactic sessions and immersive clinical scenarios depicting acute complications in interventional pain procedures. We used descriptive statistics to compare preintervention and postintervention survey responses, stratifying by professional role. Qualitative feedback was collected to explore participants’ perceptions of the training and its impact.ResultsBoth physician and non-physician groups reported high baseline RIPLS scores, with no statistically significant difference between or within groups over 6 months. Although mean RIPLS scores did not significantly change, participants consistently described positive attitudes towards collaborative practice. Qualitative feedback underscored the importance of structured simulation for reinforcing team roles, communication strategies and crisis management skills.ConclusionThis project demonstrates that simulation-based training can sustain high levels of interprofessional readiness among outpatient pain clinic staff over time, suggesting utility for maintaining collaborative behaviours in a setting where safety and teamwork are paramount. Future efforts could investigate whether similar interventions improve IPC in clinics with lower baseline readiness, as well as explore longer follow-up periods or larger sample sizes to detect nuanced changes in collaboration metrics.