Proceedings of the Pain Society ASM 2024

“It doesn’t define me”: a reflexive thematic analysis of people living well with Complex regional pain syndrome

McVicar T,¹ Bean D,² Lennox Thompson B³

¹Auckland University of Technology, Auckland, New Zealand (MHSc student)

²Auckland University of Technology, Auckland, New Zealand

³University of Otago, Dunedin, New Zealand

INTRODUCTION
Complex regional pain syndrome (CRPS) is a rare but debilitating condition. CRPS symptoms can vary from highly distressing to mild, with individuals maintaining employment and leading meaningful lives. The perspectives of people with CRPS are rarely explored, with most attention paid to the difficulties and shortcomings of healthcare and society. To our knowledge, no study has attempted to understand how people learn to live well despite experiencing long-term CRPS.
AIMS
To understand how individuals with long-term CRPS live well despite their pain.
METHODS
Data from in-depth interviews were analysed using a reflexive thematic analysis. Participants were New Zealand-based, diagnosed with CRPS (type I or II) >12 months ago and self-identified as “living well” with CRPS.
RESULTS
Three overarching themes were identified from the thematic analysis: 1) making sense of an unknown threat, 2) addressing the threat, and 3) accommodating a new life. Experiencing CRPS disrupted participants’ sense of self through physical limitations, loss of independence, alteration in self-image, and withdrawal from meaningful occupations. Participants engaged in a sensemaking process facilitated by a diagnosis and specialist care, allowing them to address the multifaceted threat posed by CRPS. Rebuilding a new life post-CRPS required adjustment and accommodation. Participants recognised they needed to let go of their pre-CRPS lives and recalibrate their foundational values.
CONCLUSIONS
“Living well with CRPS” was about understanding, adjusting and accommodating to maintain engagement in values-based actions.

A meta-epidemiological study on the reported treatment effect of pregabalin in neuropathic pain trials over time

Harris IA,¹ Cheng E,¹ Lewin A,¹ Cheik-Hussein M,¹ Lin N,¹ McAuley J¹

¹UNSW Sydney, Australia

INTRODUCTION
Pregabalin is a drug used to treat neuropathic pain, and its use has increased substantially since 2007. Early trials found a strong treatment effect on pain for post-herpetic neuralgia and diabetic neuropathy. However, more recent studies have failed to replicate these results.
AIMS
This meta-epidemiological study aimed to assess change in the reported effectiveness of pregabalin in neuropathic pain trials over time, and if a change is present, determine any associated factors.
METHODS
We performed electronic searches for published trials in Medline, Embase and Cochrane Central Register of Controlled Trials databases, and unpublished trials on ClinicalTrials.gov, the EU Clinical Trials Register and the Australian New Zealand Clinical Trials Registry with no restrictions. Included randomised, placebo-controlled trials of pregabalin for treatment of neuropathic pain in adults. Two authors independently extracted study data: sample size and mean baseline, end-point and change in pain scores with measures of variance, trial end year, publication year, clinical indication, funding source, country of study, treatment duration, treatment dose, mean age and percentage male. We defined treatment effect as the mean difference in pain scores between pregabalin and placebo groups at trial end-point and assessed for change over time using a random-effects meta-regression, adjusted for sample size, indication, treatment duration (weeks) and treatment dose.
RESULTS
We included 38 randomised published trials (9,038 participants) and found between 2003 and 2020, the reported treatment effect of pregabalin decreased by 0.4 points (95% CI: 0.3 to 0.6; p<0.001) on an 11-point pain scale per 5-year interval, from 1.3 points (95% CI: 1.0 to 1.5) in trials conducted in 2001–2005, to 0.3 (95% CI: -0.1 to 0.7) in trials conducted in 2016–2020. The reported treatment effect was lower than the minimal clinically important difference (MCID) of 1.7 points across all time periods, doses and most indications, and was not found to be associated with study characteristics.
CONCLUSIONS
The reported treatment effect or analgesic efficacy of pregabalin from clinical trials has diminished over time. Clinical recommendations may need to be re-evaluated to account for recent evidence and to consider whether pregabalin therapy is indicated.

Curiosity with patient: a hermeneutical analysis of pain, context and care

Lagerman P¹

¹APM Workcare, Auckland, New Zealand

INTRODUCTION
When engaging in acts of care with people living with pain, the range of issues clinicians and clients have to deal with are bewilderingly complex, constantly throwing up new questions and possibilities. A natural curiosity, then, is a necessary prerequisite for any skilled, mature clinician. Most theories of curiosity emphasise the acquisition of information, and chronic pain is commonly understood in biomedical terms, with contemporary pain self-management fostering a positivist approach, and, through the acquisition of skills and strategies, proposes recovery.¹
AIMS
To demonstrate the interconnected nature of curiosity and how fostering a curiosity with context can reconcile the delivery of care.
METHODS
I present a hermeneutical analysis of pain self-management literature and argue the style of curiosity is currently constrained by normative (biomedical, behavioural and biomechanical) healthcare practices. This affects how care is delivered in pain management programmes.
RESULTS
In pain management, the dominant delivery of strategies adopts a positivist approach focussing on normative (biomedical, behavioural and biomechanical) practice. In essence, pain management practices are underpinned by an acquisition of knowledge, a curiosity that is constrained and instructed by predominant models of care. Through an analysis of historical and philosophical texts, it is proposed that curiosity is multiple beyond a singular drive to acquire knowledge.² Curiosity can be referred to as a relational practice to cultivate new ways of delivering pain care otherwise.
CONCLUSIONS
Curiosity is a necessary skill in pain self-management and complements acts of pain care more broadly, yet it can become constrained by predominant normative practices. This presentation proposes that curiosity is less of a skill and more of a relational process. It can cultivate new ways to deliver care that liberates the needs of individuals living with persistent pain.
REFERENCES

1.       Walumbe JN. Self-management of chronic pain: a critical interpretive inquiry [dissertation]. Oxford (UK): University of Oxford; 2022.

2.       Zurn P. Curiosity and Power: The Politics of Inquiry. Minneapolis (US): University of Minnesota Press; 2021.

Helping medical students gain confidence and competence for chronic pain and other persistent somatic symptoms: research, training workshops and a basket of resources (“Te Kete”)

Hamish Wilson,¹ Cassie Withey-Rila,¹ Martyn Williamson,¹ Tony Dowell,² Maria Kleinstaeuber³

¹University of Otago, Dunedin, New Zealand

²University of Otago, Wellington, New Zealand

³Utah State University, USA

INTRODUCTION
Many patients present to primary care with persistent somatic symptoms (PSS) including chronic pain, functional neurological symptoms, irritable bowel syndrome, tension headaches, chronic fatigue and so on, many of which are associated with stigma and negative medical bias.

AIMS
Medical student knowledge acquisition and skills related to these conditions has not been explored in Aotearoa.

METHODS
Eleven focus groups were conducted with final year medical students at Otago Medical School (OMS), and 10 interviews were conducted with clinical or teaching staff. Data were analysed by thematic analysis. Preliminary results and emerging institutional outcomes will be presented.

RESULTS
At present, formal teaching about chronic pain and other PSS for students is sparse, inconsistent and uncoordinated. Clinician interviews revealed a diverse range of attitudes, clinical skills and self-confidence in relation to these conditions. Students are disappointed and disconcerted by their observations of variable role modelling or negative bias and feel poorly equipped to work with such patients. In general, senior medical students currently know little about the neuroscience of sensation, are unable to make a positive diagnosis and do not know how to offer an explanation.

CONCLUSIONS
Recommendations to OMS include developing more coherent curricula for these conditions and incorporating contemporary neurosciences into the curriculum. Meanwhile, we have developed communication skills workshops and resources for local students to increase their knowledge, skills and explanations. Teaching and Te Kete are based largely on pain neuroscience education, somatisation models and clinical implications of the sympathetic nervous system. Copies of Te Kete will be available.

High intensity exercise may worsen temporal summation, but not conditioned pain modulation, in chronic neck pain: a randomised crossover trial

Chen KK,¹ Hutchinson MR,² Paul R,³ de Zoete RMJ¹

¹School of Allied Health Science and Practice, The University of Adelaide, South Australia, Australia

²School of Biomedicine, The University of Adelaide, South Australia, Australia

³Adelaide Medical School, The University of Adelaide, South Australia, Australia

INTRODUCTION
Physical exercise is the first treatment of choice for chronic neck pain (CNP), yet the mechanisms of effect of different exercise intensities are poorly understood. The presence of central sensitisation (CS) possibly mediates the effects of exercise on patient-reported outcomes.
AIMS
To investigate the effects of high- and low-intensity exercise on measures of CS in people with CNP.
METHODS
This was a randomised crossover trial (n=35 people with CNP, 63.2% female, age= 36.5±14.1 years). Participants performed a high-intensity (INV_HIGH) and a low-intensity (INV_LOW) aerobic exercise session in randomised order, 1 week apart. CS measures included conditioned pain modulation (CPM), a measure of descending pain inhibition and temporal summation (TS), a measure of facilitatory pathways. CPM was assessed in series, using a cold pressor test as conditioning stimulus and pressure pain threshold as test stimulus. TS was assessed using PinPrick over the cervical region.
RESULTS
After INV_HIGH, there was a significant increase in CS (mean difference=0.51±1.24, p=0.02). No differences were found after INV_LOW (mean difference=-0.06±1.37 p=0.80). No changes in CPM were found after INV_LOW and INV_HIGH.
CONCLUSIONS
High-intensity aerobic exercise had a detrimental effect on pain facilitatory pathways, whereas low-intensity exercise did not worsen outcomes. To avoid exacerbation of central sensitisation outcomes, these results suggests that low-intensity exercise might be a better option than high-intensity exercise. These findings may assist in the development of personalised approaches to exercise therapy.
REFERENCES

1.       Chen KK, Hutchinson MR, Rolan P, de Zoete RMJ. Effect of exercise on chronic neck pain and central sensitization: A protocol for a randomized crossover trial. Exp Physiol. 2023;108(5):672-682. doi: 10.1113/EP091065.

High-definition transcranial infraslow pink noise stimulation for chronic low back pain: a pilot, safety and feasibility randomised placebo-controlled trial

Adhia DB,¹ Mani R,¹ Turner P,¹ O’Leary F,¹ Hall M,¹ Reynolds JNJ,¹ Vanneste S,² De Ridder D¹

¹University of Otago, New Zealand

²Trinity College Dublin, Ireland

INTRODUCTION
In people with chronic low back pain (CLBP), neuroimaging studies demonstrate altered electrical activities in cortical areas responsible for pain modulation, emotional, and sensory components of pain experience (i.e., pregenual and dorsal anterior cingulate cortex [pgACC, dACC], and somatosensory cortex [SSC] respectively).¹ Treatments targeting to change electrical activities of these key brain regions may produce clinical benefits.²
AIMS
To determine feasibility, safety and acceptability of a novel neuromodulation technique, high-definition transcranial infraslow pink noise stimulation (HD-tIPNS), in people with CLBP, and explore its effects on pain and disability.
METHODS
A pilot triple-blinded (participant, treating therapist and outcome assessor) randomised placebo-controlled trial. Participants with CLBP (n=40) received 20 sessions of either HD-tIPNS (targeting pgACC, dACC, SSC) or sham stimulation. Feasibility and safety measures were collected, and acceptability of intervention was assessed post-intervention. Brief pain inventory and Roland-Morris Disability Questionnaires were administered at baseline, immediately post-intervention and at 1-week, 1-month and 3-months post-intervention. Data were analysed descriptively.
RESULTS
Feasibility data includes recruitment rate (28%), randomisation (100%), dropouts (8%) and treatment adherence (91%). No serious adverse events were reported. Participants reported moderate to high levels of acceptability (Mean±SD:2.57.2±2.5) and treatment satisfaction (Mean±SD:6.3±2.5). A higher proportion of participants in HD-tIPNS group demonstrated a clinically meaningful reduction in pain severity (70%), interference (65%) and disability (65%), when compared to sham stimulation group at 3-months post-intervention.
CONCLUSION
HD-tIPNS is a safe and an acceptable approach for treating CLBP. A fully powered trial is feasible and warranted to test effectiveness of HD-tIPNS in people with CLBP.
REFERENCES

1.       De Ridder D, Vanneste S, Smith M, Adhia D. Pain and the triple network model. Front Neurol. 2022;13:757241. doi: 10.3389/fneur.2022.757241.

2.       Adhia DB, Mani R, Reynolds JN, et al. High-definition transcranial infraslow pink noise stimulation for chronic low back pain: protocol for a pilot, safety and feasibility randomised placebo-controlled trial. BMJ Open. 2022;12(6):e056842. doi: 10.1136/bmjopen-2021-056842.

How people in Aotearoa New Zealand with endometriosis sustain employment, barriers and enablers: a qualitative interpretive description study

Drummond Quin C,¹ Herkt J,² Jeffery H²

¹Otago Polytechnic Te Pūkenga, Dunedin, New Zealand (Presenter)

²Otago Polytechnic Te Pūkenga, Dunedin, New Zealand (Co-author)

INTRODUCTION
Endometriosis is a chronic and incurable condition impacting one in 10 women in Aotearoa New Zealand.¹ Endometriosis symptoms include painful periods, pelvic pain, fatigue, painful intercourse, bloating, urinary frequency and urgency, irritable bowel syndrome, fertility delay and infertility.
AIMS
The study was conducted to gain knowledge concerning the barriers and enablers that impact the ability of people with endometriosis to sustain employment.
METHODS
This is a qualitative study using Thorne’s interpretive description. Purposive sampling was used to gain six participants with a confirmed diagnosis of endometriosis and in paid employment. Data were collected using semi-structured interviews and analysed using Braun & Clarke’s thematic analysis.
RESULTS
Themes developed around the barriers and enablers to sustaining employment in Aotearoa New Zealand with endometriosis. This included 1) it’s more than just a bad period, 2) choosing to tell others, and 3) finding a way through.
CONCLUSIONS
Delegates will be introduced to a range of perspectives on the experience of sustaining employment with a diagnosis of endometriosis and an opportunity to consider the role of occupational therapists in working with this population. Delegates will be introduced to opportunities for future research within this population.
REFERENCES

1.       Ministry of Health – Manatū Hauora. Diagnosis and management of endometriosis in New Zealand [Internet]. Wellington (NZ): Ministry of Health – Manatū Hauora; 2020. Available from: https://www.health.govt.nz/publication/diagnosis-and-management-endometriosis-new-zealand

Improving outcomes from pain management programmes in Aotearoa New Zealand: hearing the voices of Māori

Jones DK,¹ Mowat RM,² Lewis GN,³ Cook C²

¹Auckland University of Technology, Auckland, Aotearoa New Zealand

²Department of Nursing, Auckland University of Technology, Aotearoa New Zealand

³Health and Rehabilitation Research Institute, Auckland University of Technology, Aotearoa New Zealand

INTRODUCTION
There are inequities for Māori in relation to chronic pain, including a disproportionate prevalence of chronic pain, a greater impact of pain and reduced benefit from chronic pain services in the long-term. Māori have a holistic orientation to health that incorporates spiritual, relational and environmental dimensions. This worldview shapes experiences of pain and pain management. However, these views may not be incorporated in current pain management programmes.

AIM
To determine the experience of Māori who had attended a 3-week pain management programme run in a bicultural urban centre in Aotearoa New Zealand.

METHOD
An interpretive descriptive methodology was used. Six participants were individually interviewed regarding their experiences of attending the programme. The interviews were recorded, transcribed, coded, and the data analysed using thematic analysis.

RESULTS
Four themes were developed. The programme provides respectful care described the caring, supportive nature of the programme, which contrasted with previous negative experiences with the healthcare system. Education enables tino rangatiratanga (self-determination) described how the provision of knowledge facilitated participants to make their own healthcare choices. Whanaungataunga (relationship) is valued as much as pain-specific content described the value of the social and relational aspects of the programme. Where is the tikanga? described the lack of traditional Māori protocols and health views, which meant the programme was experienced as medical and Western-oriented.

CONCLUSIONS
Recommendations for change were centred around providing options for patients to engage with traditional treatments, incorporation of tikanga and promoting ongoing social connections with both the clinic and the patient’s local community.

Interdisciplinary pelvic pain self-management in a small group format: replication of pilot outcomes in clinical practice.

Joseph K,¹ Mills J¹

¹Pelvic Pain NZ

INTRODUCTION

Pelvic pain is a common, disabling and burdensome condition affecting many thousands of women in New Zealand. Current biomedical end-organ directed management approaches fail to bring relief for many with or without endometriosis. International literature, however, demonstrates that whole-person pain self-management approaches can improve pain and quality of life.

A pilot study of a 6-week small group interdisciplinary pain self-management intervention for women living with pelvic pain demonstrated clinically significant improvement for 88% of participants across a number of domains, with no clinically significant deterioration on any measure.

Following this successful pilot, the intervention was delivered as a treatment option for women with pelvic pain attending a private pelvic pain clinic. Outcome measures and free-text feedback were collected for ongoing quality improvement.

AIMS
To confirm the efficacy and acceptability of a group self-management programme for women with pelvic pain in real-world clinical practice.

METHODS
Using a within-subject pre-and-post design, the participants completed self-report measures prior to, immediately and at 6- and 12-months following participation.

RESULTS
Results demonstrate clinically significant gains immediately following and up to 12 months after participating in a group self-management programme for pelvic pain.

CONCLUSIONS
Consistent with the pilot, this small-group pain self-management programme demonstrates improvements in wellbeing and self-efficacy for women living with pelvic pain.

REFERENCES

1.       Joseph K. The Development and Delivery of a Specialised Multidisciplinary Pain Management Group Programme for Women with Chronic Pelvic Pain [Master’s thesis]. Dunedin (NZ): University of Otago; 2020.

2.       Joseph K, Mills M. Improvements from small group multidisciplinary pain management intervention for women living with pelvic pain maintain at 12 months. Aust N Z J Obstet Gynaecol. 2023; 2024. doi: 10.1111/ajo.13817.

miRNAs involved in neuropathic pain can be reliably measured in saliva

Kovanur Sampath K,¹ Papannarao JB,² Roberts E,² Schwenke D,² Katare R²

¹Waikato Institute of Technology, Te Pūkenga, Hamilton, New Zealand

²Department of Physiology, Heart Otago, University of Otago, Dunedin, New Zealand

BACKGROUND
miRNAs have been shown to be dysregulated in neuropathic pain conditions such as diabetic painful neuropathy. While invasive techniques such as blood samples are routinely used to collect and analyse miRNAs, the use of non-invasive techniques such as salivary samples for analysing miRNAs involved in neuropathic pain has been minimal.¹ Therefore, the objective of this study was to determine if miRNAs involved in neuropathic pain can be measured reliably in salivary samples comprising of healthy European and Pacific population.

METHODS
Participants were recruited via advertisements on notice boards, social media, word of mouth and pamphlets. Saliva samples were collected from healthy European and Pacific participants. Samples were stored in -80°C until analysis. Total RNA was extracted using miRNEasy kit (Qiagen) following manufacturer’s protocol, and the concentration was measured using Nanodrop (Thermo Fisher). Twenty nanogram of total RNA was then reverse transcribed, followed by amplification using specific primers against miR-16, -124, 132 and -134. miR-24 was used as the internal control (all primers from Thermo Fisher).²

RESULTS
A total of 37 healthy participants (19 European and 18 Pacific; age range: 22–57 years) were included in the study. Results showed that four different miRNAs (miR-16, miR-124, miR-132 and miR-134) that have been demonstrated to be associated with neuropathic pain were expressed and reliably measured in all the salivary samples.

CONCLUSION
All the miRNAs identified in our study have been shown to be involved in neuropathic pain and inflammation. Hence, further research is required in this area to investigate the feasibility of extracting and analysing these miRNAs in people with neuropathic pain.
 
REFERENCES

1.       Kovanur Sampath K, Belcher S, Hales J, et al. The role of micro-RNAs in neuropathic pain—a scoping review. Pain Rep. 2023;8(6):e1108. doi: 10.1097/PR9.0000000000001108.

2.       Katare R, Caporali A, Zentilin L, et al. Intravenous gene therapy with PIM-1 via a cardiotropic viral vector halts the progression of diabetic cardiomyopathy through promotion of prosurvival signaling. Circ Res. 2011;108(10):1238-1251. doi: 10.1161/circresaha.110.239111.

The efficacy of interdisciplinary pain management for complex regional pain syndrome: an observational study

Bean D,¹ Lewis G,² Magni N,² Pollard C,³ Aamir T,³ Tuck N²

¹Auckland University of Technology, Auckland, New Zealand; Te Whatu Ora – Waitematā, Auckland New Zealand

²Auckland University of Technology, Auckland, New Zealand

³The Auckland Regional Pain Service, Te Whatu Ora Te Toka Tumai Auckland, New Zealand

BACKGROUND
Interdisciplinary pain management programmes (IPMPs) are gold standard care for chronic pain and are recommended for people with complex regional pain syndrome (CRPS). However, no controlled trials have assessed their efficacy for CRPS.

AIMS
To examine the efficacy of IPMPs for CRPS by comparing outcomes for people with CRPS with two groups for whom the efficacy of IPMPs is well established: those with chronic low back pain (LBP) and chronic widespread pain (CWP).

METHODS
Retrospective data from people with CRPS (N=66) who had completed a 3-week IPMP at The Auckland Regional Pain Service were compared with age- and sex-matched controls with LBP (N=66) and CWP (N=66) who had completed the same programme. Measures of pain intensity, pain-interference, pain catastrophising, pain self-efficacy, depression, anxiety and stress pre- and post-programme, and at 1, 6 and 12 months were extracted. Latent class analysis was used to identify recovery trajectories, and Chi-squared analyses were used to identify whether outcome differed according to diagnostic group.

RESULTS
Two recovery trajectories for pain interference and for pain intensity were identified. Following IPMPs, 58% of people were classified as belonging to a positive pain interference reduction trajectory, while 12% were shown to be on a positive pain intensity reduction trajectory. Recovery trajectories were equal across the three diagnostic groups (CRPS, LBP, CWP) for both pain interference (χ2=1.8, p=0.4) and intensity (χ2=0.2, p=0.9).

CONCLUSION
IPMPs lead to significant improvements in pain intensity and pain interference, and are equally effective for people with CRPS, LBP and CWP. This supports current guidelines that people with CRPS should engage in IPMPs.

The lived experience of chronic pain for Māori: how can this inform service delivery and clinical practice? A systematic review and qualitative synthesis

Bean D,¹ Antunovich D,² Romana J,³ Lewis G,⁴ Morunga E⁵

¹Te Whatu Ora – Waitematā; Auckland University of Technology, Auckland, New Zealand

²Te Whatu Ora – Te Tai Tokerau, Northland, New Zealand

³Te Whatu Ora Counties Manukau, Auckland, New Zealand

⁴Auckland University of Technology, Auckland, New Zealand

⁵The University of Auckland; Te Whatu Ora Te Toka Tumai, Auckland, New Zealand

BACKGROUND
In Aotearoa New Zealand, Māori have a higher prevalence and report a greater impact of chronic pain than non-Māori. However, only a small body of research has investigated how Māori experience pain and whether services currently provide culturally responsive treatment. This research has not yet been synthesised.

AIMS
To synthesise the literature describing experiences of chronic pain and pain management for Māori, and to understand how this experience could inform service delivery and clinical practice.

METHODS
We systematically searched for qualitative research on Māori chronic pain experiences (Scopus, Medline, PsycINFO, NZ Research, Research Square). Data extracted were coded and synthesised using thematic analysis.

RESULTS
Seven studies were included. Three themes encapsulated the data: 1) a multidimensional view of pain and pain management: Māori expressed a holistic and integrated understanding of the multiple factors that influence pain and its management, 2) a responsibility: respectful tikanga-informed care: the experiences of Māori participants with healthcare highlight a need for anti-racist approaches, and a clinical responsibility to practise manaakitanga and tikanga, and 3) tino rangatiratanga: a desire for knowledge, choice and autonomy in pain management: Māori valued the empowering nature of knowledge about pain, and information and support to make decisions about treatment, including options for Western and traditional management.

CONCLUSION
Health services need to: understand and respect the multidimensional aspects of pain, minimise racism and discrimination, use whakawhanaungatanga and tikanga-informed practices and provide appropriate information to support tino rangatiratanga for pain management.

The role of micro-RNAs in neuropathic pain—a scoping review

Kovanur Sampath K,¹ Belcher S,¹ Hale J,¹ Thomson OP,² Farrell G,³ Gisselman AG,⁴ Katare R,³ Tumilty S³

¹Waikato Institute of Technology, Hamilton, New Zealand

²University College of Osteopathy, London, UK

³University of Otago, Dunedin, New Zealand

⁴Tufts University, Phoenix, USA

BACKGROUND
Neuropathic pain can be caused by a lesion or disease of the somatosensory system characterised by pathological neuro-immune alterations. At a molecular level, microRNAs (miRNAs) act as regulators of gene expression orchestrating both immune and neuronal processes. Thus, miRNAs may act as essential modulators of processes for the establishment and maintenance of neuropathic pain. The objective/aims of this scoping review was to explore and chart the literature to identify miRNAs that are dysregulated in neuropathic pain.

METHODS
The following databases were searched from inception to March 2023: PubMed, EBSCO, CINAHL, Cochrane Library and Scopus. Two independent reviewers screened, extracted data and independently assessed the risk of bias in included studies. The JBI critical appraisal checklist was used for critical appraisal. A narrative synthesis was used to summarise the evidence.

RESULTS
Seven studies (total of 384 participants) that met our eligibility criteria were included in this scoping review. Our review has identified different miRNAs that are commonly involved in the chronic neuropathic pain conditions including miR-132, miR-101 and miR-199a. Our review findings further suggest that expression of miRNAs to be significantly associated with increased diabetic disease duration, HbA1C levels and fibrinogen levels.

CONCLUSIONS
Our review findings suggest that there is clear association between miRNA expression and chronic neuropathic pain conditions. Therefore, increasing the specificity by selecting a candidate miRNA and identifying its target mRNA is an area of future research.

A Phase III, international, multi-centre, double-blind, dose increment, parallel-arm, randomised controlled trial of duloxetine versus pregabalin over 14 days for opioid unresponsive neuropathic cancer pain

Matsuoka H,^1,2 Lee J,² Fazekas B,² Oyamada S,³ Yamaguchi T,⁴ Satomi E,⁵ Currow DC²　

¹Department of Psycho-Oncology, Supportive and Palliative Care Development Center, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan

²IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia

³Department of Biostatistics, Japanese Organisation for Research and Treatment of Cancer (JORTC) Data Center, Arakawa-ku, Tokyo, Japan

⁴Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan

⁵Department of Palliative Medicine, National Cancer Center Hospital, Chuoh-ku, Tokyo, Japan

INTRODUCTION
Management of neuropathic cancer pain (NCP) refractory to regular opioids remains an important challenge. Gabapentinoids and duloxetine offer the potential of analgesia in opioid refractory NCP, but there has been no head-to-head comparison.

AIMS
The aims of this study are to assess the analgesic efficacy of duloxetine compared with pregabalin in patients with opioid refractory NCP and to build the standard pharmacological treatment.

METHODS
An international, multicentre, double-blind RCT is planned. Patients’ eligibility criteria include: adults with NCP refractory to opioids, BPI-item 3 ≥4 despite of an adequate trial of regular opioid medication. Participants will be randomised to duloxetine or pregabalin arm. Dose escalation is until day 14.¹ The primary endpoint is defined as the mean difference in BPI item 3 at day 14 between groups.²

RESULTS
A sample size of 160 patients will be enrolled, and at the time of abstract submission (30 November 2023), 99 cases have been enrolled, with case accumulation expected to be completed by the end of 2024. The dose schedule of each drug requires discussion. As the starting dose differs between Australia and Japan, it was necessary to determine a uniform dose for the international study. The dose titration schedule has been devised to maximise the likelihood of benefit while minimising the risk of adverse events. We have defined the initiation dose and maximum dose of duloxetine and pregabalin from the results of a recent systematic review and meta-analysis and the National Comprehensive Cancer Network guideline of adult cancer pain.

CONCLUSIONS
The planned double-blind multicentre RCT will be the first to evaluate the efficacy of pharmacological treatment on well-defined NCP, and the results of this study contribute to the establishment of the standard pharmacological treatment for opioid refractory NCP.

REFERENCES

1.       Dworkin RH, O’Connor AB, Backonja M, et al. Pharmacologic management of neuropathic pain: evidence-based recommendations. Pain. 2007;132(3):237-51. doi: 10.1016/j.pain.2007.08.033.

2.       Atkinson TM, Mendoza TR, Sit L, et al. The Brief Pain Inventory and its “pain at its worst in the last 24 hours” item: clinical trial endpoint considerations. Pain Med. 2010;11(3):337-46. doi: 10.1111/j.1526-4637.2009.00774.x.

What is the effectiveness of manual therapy in people with upper back pain? A scoping review

Carter A,¹ Belcher S,¹ George F,¹ Lewington BA,¹ Kovanur Sampath K¹

¹Waikato Institute of Technology, Te Pūkenga, Hamilton, New Zealand

INTRODUCTION
Upper back pain (UBP), often referred to as thoracic spine pain, is a prevalent musculoskeletal condition with significant implications for individuals’ quality of life. Manual therapy (MT) techniques are commonly used by physiotherapists and osteopaths to manage upper back pain. However, the efficacy of such interventions in UBP is unclear and requires further investigation. Hence, the aim of this review was to scope available evidence to understand the effectiveness of MT in the management of UBP.

METHODS
A systematic search was conducted across multiple electronic databases, including PubMed, OneSearch, EBSCOhost, CINAHL Ultimate, Medline and Google Scholar from 2000 to 2023. Two independent reviewers assessed the articles for inclusion and a third reviewer was utilised if required. A JBI critical appraisal tool was utilised to evaluate the risk of bias in included studies.

RESULTS
Six studies (295 participants) met inclusion criteria (four randomised control trials [RCT] and two case reports were included). The review evidenced that MT interventions may have some positive effects in terms of reduced pain, improved function and quality of life in the short-term (up to 4 weeks).

DISCUSSION
The findings suggest that MT may positively impact people with UBP. However, these findings are derived from a small number of studies. Hence, more research is required to clarify review findings, especially regarding potential long-term effectiveness of MT in this cohort.

Women with surgical mesh injury present with potentially modifiable risk factors for persistent post-surgical pain and would consider prehabilitation

Joseph K,¹ Mills J¹

¹Pelvic Pain NZ

INTRODUCTION

Between 50–75% of those with a surgical mesh injury will undergo surgical removal of mesh. These patients commonly present with a number of modifiable risk factors for persistent post-surgical pain that could be targets for prehabilitation.

AIMS

To compare psychosocial risk factors in women with surgical mesh injury with other patients referred for specialist pain management.

To explore the attitude of women with surgical mesh injury towards a prehabilitation programme that would target these risk factors.

METHODS

An audit of intake psychometric measures completed by women with pain from surgical mesh injuries was compared to the profile of all adult women referred for specialist pain management in New Zealand. To explore attitudes of women with a surgical mesh injury towards prehabilitation, a patient survey was sent to a sample of 1 year of women presenting with mesh injury.

RESULTS

Comparison of psychosocial measures demonstrated equivalent average severity across a range of psychosocial measures. Ninety-one percent of those surveyed were planning or had already undergone mesh removal surgery. Of these, 89% were open to a prehabilitation programme.

CONCLUSIONS

Modifiable risk factors for poor post-surgical pain outcomes that are targeted by prehabilitation for those with persistent pain are found as frequently in those with pain resulting from mesh injury. Attitudes to prehabilitation by this group appear to be favourable and therefore this warrants further exploration.

REFERENCES

1.       Abbott S, Unger CA, Evans JM, et al. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study. Am J Obstet Gynecol. 2014;210(2):163.e1-8. doi: 10.1016/j.ajog.2013.10.012.

2.       Shebeshi D, Allingham SF, Tardif H, White JM. Profile of adult patients referred for specialist pain management in New Zealand, ePPOC Information Series No. 1. University of Wollongong Research Online. 2021.

Prevalence and profile of New Zealand osteopaths treating people experiencing headaches and migraines

Ferreira AP,¹ Vaughan B,² Draper-Rodi J,³ Muddle L,⁴ McIntyre C,³ Treffel L,⁵ Fleischmann M,⁶ Cerritelli F,⁷ Steel A,⁴ Kovanur Sampath K⁸

¹Instituto Brasileiro de Osteopatia/IBO, Rio de Janeiro, Brazil

²The University of Melbourne, Melbourne, Australia

³University College of Osteopathy, London, UK

⁴University of Technology Sydney, Australia

⁵Institut Toulousain d’Ostéopathie, IRF’O, Toulouse, France

⁶RMIT University, Melbourne, Australia

⁷COME Collaboration, Italy

⁸Waikato Institute of Technology, Te Pūkenga, Hamilton, New Zealand

BACKGROUND
Headache disorders are an important cause of pain and disability and substantially affect quality of life. Osteopaths are primary healthcare practitioners who primarily manage musculoskeletal conditions including headaches and migraines in their practice. However, there is a lack of data concerning the profile of Aotearoa New Zealand osteopaths treating these conditions. Hence, the aim of the study was to describe the profile of New Zealand osteopaths treating people experiencing headaches and migraines.

METHODS
The Osteopathy Research Connect-NZ (ORC-NZ), a practice-based research network (PBRN) for the New Zealand osteopathy profession was established, and recruitment occurred between August to December 2018.

RESULTS
Two hundred and seventy-seven (277) respondents provided responses to the headache and migraine items on the ORC-NZ practice questionnaire. Of these respondents, 235 (84.8%) indicated treating headaches often, and 107 (38.6%) indicated treating migraines often. Osteopaths who reported “often” treating patients with migraines and headaches were more likely to report clinically supervising associates and to be co-located with a general practitioner. These osteopaths may use diagnostic imaging often as an assessment tool. In terms of management, they tend to use HVLA, are likely to treat TMJ in case of migraine and the thoracic spine for patients with headaches. Further, New Zealand osteopaths frequently refer patients with migraines and/or headaches to other practitioners and are aware of an inter-professional approach required for this patient population.

CONCLUSION
Aotearoa New Zealand osteopaths treat people with headaches and migraines frequently and demonstrate a good understanding of an inter-professional/multi-disciplinary approach required to manage these patients.