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Fundamentals of pain management in wound care Sarah Coulling Underlying mechanisms

Abstract Under treated pain can result in a number of potentially serious sequelae (Australian and New Zealand College of Anaesthetists, 2006), including delayed mobilization and recovery, cardiac complications, thromboses, pulmonary complications, delayed healing, psychosocial problems and chronic pain syndromes. This article considers pain management in the context of painful wounds. An international comparative survey on wound pain (European Wound Management Association, 2002) found that practitioners in the wound care community tend to focus on healing processes rather than the patient’s total pain experience involving an accurate pain assessment and selection of an appropriate pain management strategy. Procedural pain with dressing removal and cleansing caused the greatest concerns. An overview of simple, evidence-based drug and non-drug techniques is offered as potential strategies to help minimize the experience of pain. Key words: Pain

n

Pain Management

n

Wound Care

P

ain is said to be a combination of physical and mental discomfort (McCaffery amd Pasero, 1999). There are many definitions of pain, the following definition provided by the International Association for the Study of Pain (IASP, 1979) demonstrates the physical and psychological processes of pain: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.’

The experience of pain is unique and complex. It can be influenced by many factors, including: past and present medical history, prognosis, beliefs, anxiety, fear, expectations, previous experience and culture (Figure 1). This article considers pain management in the context of painful wounds. An overview of simple, evidence-based drug and non-drug techniques is offered as potential strategies to help minimize the experience of pain.

McCaffery and Pasero (1999) describe a primitive pain pathway that is not rigid but rather dynamic as it becomes sensitised in response to injury, to protect the body from further damage and aid tissue healing. Pain results from the initial sensitization of receptors (nociceptors) along nerve fibres. This generates an electrical charge that is conducted to the spinal cord where a further central sensitization mechanism occurs before transmission to the brain where pain is perceived and understood. Neurones in the brain descend back down the spinal cord and release substances such as naturally occurring opioids and neurotransmitters, e.g. serotonin and norepinephrine that inhibit the transmission of impulses and modulate pain through a descending inhibitory pathway mechanism. Opioids (natural or man made) play an important role in pain control by locking onto opioid receptors (mainly in the brain and spinal cord and some in the periphery), preventing the transmission of pain. In the spinal cord pain is amplified even though sensations may remain the same or even reduced. Known as ‘wind up’ this process is often persistent in inflamed, malfunctioning or damaged nerves giving rise to increased sensitization. Pain can be broadly classified as being either nociceptive or neuropathic. The former is an appropriate physiological response experienced when sensory nerves are activated. Neuropathic pain, on the other hand, is a product of abnormal nerve processing. This leads to either excess stimulation of the pain pathways which alter the balance between painful and non-painful inputs to the central nervous system (Wells and Woolf, 1991) and explains ongoing pain, particularly with chronic leg ulcers and ischaemia. A ‘multimodal approach’ to pain management entails combining several pain relieving techniques with different mechanisms of action on the pain pathway; this allows a reduced dose of each drug and thereby lessens the risk of side-effects while giving better analgesia. To rely on a single drug to satisfy the analgesic requirements for a patient is optimistic, often necessitating a high dose, which increases the side effects. Figure 2 illustrates the many ways pain can be managed and how they are related to the pain pathway.

Assessment Sarah Coulling is Consultant Nurse, Acute Pain Service, Epsom and St Helier University Hospitals NHS Trust Accepted for publication: May 2007

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Painful wounds present in a variety of ways. Pain is felt by the patient in relation to its type (nociceptive and/or neuropathic) and its origin (epidermis, dermis, subcutaneous tissue, underlying muscle, or bone). Constant dull pain is typical of inflammatory nociceptive pain whereas burning, shooting, stabbing, ‘electric shock like’ descriptors are

British Journal of Nursing, 2007 (TISSUE VIABILITY SUPPLEMENT), Vol 16, No 11


TISSUE VIABILITY associated with neuropathic pain, caused by malfunctioning or damaged nerves. Assessment of wound pain should not only include a thorough evaluation of the pain origin, but also must consider bacterial colonization, arterial insufficiency, contractures, and peripheral neuropathy. In addition, pain is a multifaceted symptom with contributing influences, including, psychosocial obstacles to recovery that further add density to pain characteristics. However effective analgesic techniques may be in theory, in practice they often fail because they are not used in conjunction with regular pain assessment. Good, ongoing assessment is vital and regarded as a cyclical process which involves performing a pain assessment, intervening, and then reassessing. Information must be gathered during the assessment process from a variety of sources to get the truest, most objective picture (McCaffery and Pasero, 1999). This should include details about the pain itself, what it means to the patient, how it effects them and their families; pain scores, vital signs, observations of nonverbal queues, common side-effects (nausea, constipation, drowsiness), medication history and current prescriptions should all be taken into account (Table 1). Empathetic and non-judgemental interview techniques by staff will enable the patient to feel at ease and the use of open-ended questions will permit unbiased responses. Using pain scoring as a pain assessment tool is an effective way of improving pain control (Gould et al, 1992). The purpose of tools and rating scales is to translate the patient’s subjective experience of pain intensity into quantifiable numbers or objective descriptors. See Figure 3 for wellvalidated tools/scales. At Epsom and St Helier University Hospitals NHS Trust the following scales are used for assessment: Pain score: on movement and deep breathing/coughing, using a 1-10 pain score: 1–3 = Mild 4–6 = Moderate 7–10 = Severe Sedation score: action if >2: 0 = Awake 1 = Intermittent dozing 2 = Mostly asleep 3 = Difficult to wake S = Asleep, rousable Nausea and vomiting score: action if >1: 0 = None 1 = Nausea only 2 = Nausea/occasional vomiting 3 = Frequent vomiting. Assessment tools are available for vulnerable patient sub-groups: older people, children, confused/cognitively impaired, sedated and those who can not communicate verbally. These creatively consider non-verbal descriptors and incorporate the importance of involving family and care giver perspectives. Local Acute Pain Teams can provide readers with further details of assessment techniques recommended for vulnerable groups.

British Journal of Nursing, 2007 (TISSUE VIABILITY SUPPLEMENT), Vol 16, No 11

14 days undisturbed

Mepitel, with Safetac® soft silicone adhesive technology, is a popular wound contact layer choice in the UK. One of the reasons for this is that it can be left in place for up to 14 days, whilst only changing the secondary absorbent dressing1. In addition, unlike other wound contact layers, it has been clinically proven not to adhere to the drying wound bed, so minimises pain to the patient on removal2,3,4. This combination results in cost-effective and undisturbed wound healing. How would you like 14 days undisturbed? Freephone: 0800 7311 876 (24 hrs), email: info.uk@molnlycke.com, www.molnlycke.co.uk 1. Eagle M, Clinical report, Mölnlycke Health Care (1998), Taylor R, JoWC, Vol 8, No 9 (1999), p. 429-430, Young T, Community nurse, 5, No 10 (1999), p. 53-54. 2. Dykes P. The link between the peel force of adhesive dressings and subjective discomfort in volunteer subjects. Journal of Wound Care 2003,12 (7): 260-262. 3. Dykes P. The Effect of Adhesive Dressings on the Stratum Corneum of Normal Skin (Data on file). 4. Hollinworth H. Nurses' views about trauma and pain at dressing changes: results of survey. Journal of Wound Care 2000:8 369-373.

UK211010703

Psychological factors n Sex n Age n Cognitive level n Experiences of pain n Beliefs and motivation n Cultural values

Noxious stimlus, tissue damage

Situational factors n Expectation n Control n Healthcare provision

Pain sensation

Emotional factors n Fear n Anger n Anxiety n Depression n Frustration

Figure 1. Factors affecting the experience of pain.

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Figure 2. Multimodal approach to pain relief in the pain pathway.

Alternative therapies Perception Cortex

Entonox, TENS (endogenous, opioids) Thalamocortical projections

Thalamus

Epidural opioids Subarachnoid opioids

TENS (“gate” theory) Epidural Subarachnoid Celiac plexus

Local anaesthetics

Modulation Transmission

Systemic opioids paracetamol

Intravenous Intrapleural Incisional

Local anaesthetics

Transduction Spinothalamic tract

NSAIDS

Primary afferent nociceptor Noxious stimulus

Management of painful wounds: drug therapies The following guidelines describe the most commonly used drugs following a three-step, combination model first described by the Word Health Organization in 1986 for cancer pain management (WHO, 2007). The emphasis is on regular analgesia, according to the patients’ pain intensity, selecting drugs with different modes of action (multimodal) and PRN co-prescriptions of analgesia for breakthrough pain. The idea being to move to the next step if the previous one is ineffective. 1. Simple non-opioid analgesics: paracetamol +/- nonsteriodal anti-inflammatory drugs (NSAIDs) (if not contraindicated)

2. Weak opioids: codeine, dihydrocodeine, tramadol + paracetamol +/- NSAID (if not contraindicated) 3. Strong opioids: morphine, oxycodone, fentanyl, buprenorphine) + paracetamol +/- NSAID (if not contraindicated). Severe pain starts at peak intensity and hopefully improves over time, so analgesia may be started at a higher level and stepped down as pain improves. Analgesic choice should be determined by the ‘step’ most appropriate to the patient’s level of pain.

Principles of stepped analgesia ■ ■

Table 1. Assessment of pain ●

● ● ● ●

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About the pain: Site, Onset, Character, Radiation, Alleviation factors, Time, Exacerbation causes, Severity (useful acronym ‘SOCRATES’) Pain score, its meaning and effects on daily activities Facial expression, body movements, reports from family or others Is prescribed analgesia optimum? Is it being given? What were they on before? Vital signs and side-effects of analgesia and/or pain (i.e. sedation, nausea and vomiting, constipation)

A patient can receive paracetamol with opioids (regardless of its potency, dose or route) Patients should be made aware of the side-effects and risks of opioid use in the short-term: constipation, nausea, vomiting and drowsiness, and in the long-term: tolerance, dependence and addiction Ensure a safe environment for patients requiring parenteral (intravenous (IV), intramuscular (IM), subcut (SC), epidural) opioids. See local protocols for staffing, area on ward, emergency drugs and equipment. Patients receiving opioids (especially for the first time) must have documented timed observations on: amounts

British Journal of Nursing, 2007 (TISSUE VIABILITY SUPPLEMENT), Vol 16, No 11


Figure 3. Examples of pain scales.

Pain intensity scales ■

Simple Descriptive Pain Intensity Scale*

Moderate pain

Mild pain

No pain

Worst possible pain

Very severe pain

Severe pain

0-10 Numeric Pain Intensity Scale*

0

1

2

3

4

5

6

7

8

9

Moderate pain

No pain

10

Worst possible pain

Visual Analog Scale (VAS)**

Due to first pass metabolism in the portal circulation patients need more oral morphine to get the IV/IM/SC equivalent (multiply IV/IM/SC dose by 2.5 times to get the oral equivalent), e.g.10mg IV/IM/SC morphine = 25mg oral. Consider patient’s opioid requirements at discharge to ensure GP is informed and an early follow up for monitoring is arranged.

Paracetamol and NSAIDs Paracetamol is perhaps the safest centrally acting analgesic given for nociceptive pain. Both NSAIDs and paracetamol act alongside opioids and significantly reduced opioid requirements and possibly the reduction of unwanted opioid-induced sideeffects (Oxford pain Research Trust, 2003; Australian and New Zealand College of Anaesthetists (ANZCA), 2005). There are many different NSAIDS which have differing effects, but tend to have the same major potential problems/ contra-indications which can be remembered easily using the mnemonic of ‘BRAGHH’ - never give NSAIDs if: Bleeding, Renal impairment, Aspirin-sensitive asthma, Gastric irritation, Hypotension or Heart failure problems (Table 2).

Opioids

Table 2. Contraindications of non-steroidal antiinflammatory drugs - BRAGHH

Naturally occurring or endogenous opioids are released in response to stimuli such as pain or stress. All opioids, endogenous and man made (i.e. morphine, codeine etc.) act on opioid receptors and affect the transmission and modulation of pain signals to the brain as well as producing the side effects associated with opioid analgesia such as central nervous system depression, nausea and constipation. (Wells and Woolf, 1991; ANZCA, 2005). Conflicting views exist as to whether opioids are of benefit in the treatment of neuropathic pain, there is some evidence that opioids may be effective for only certain sub-groups of patients. For example, oxycodone has been shown to provide relief in the treatment of post-herpetic neuralgia (shingles) and tramadol for treatment of diabetic neuropathy (Harati et al, 1998; Watson and Babul, 1998). These opioids would be alternatives instead of morphine and codeine and are particularly useful for complex wound pains. Opioids can be given via a variety of routes for moderate to severe pain and for procedural pain such as dressing changes, all have their advantages and disadvantages (Table 3).

Bleeding

Amitriptyline

Pain as bad as it could possibly be

No pain * If used as a graphic rating scale, a 10 cm baseline is recommended. ** A 10cm baseline is recommended for VAS scales

■ ■

administered, pain, respiratory depression, sedation, nausea and vomiting Give PRN anti-emetics for patients on IV or IM/SC opioids: see local nausea and vomiting guidelines The opioid antidote (antagonist) naloxone must be available for features of overdose with morphine (drowsiness, respiratory depression). NB. naloxone has a shorter half life than morphine so may need repeating and analgesia reviewed.

Platelet adhesiveness is reduced, caution in those on antigoagulant therapy or with bleeding problems Renal impairment Care in those with high creatinines, those who are hypovolaemic, with low urine output or on ACE inhibitors Aspirin-sensitive 10% of asthmatics are sensitive to NSAIDs, though most can asthmatics tolerate them Gastric irritation Care if history of gastrointestinal ulceration. Patients at risk of gastrointestinal problems from conventional NSAID’s may require a gastro-protective agent (e.g. a proton pump inhibitor – omeprazole or lanzoprazole). Hypotension NSAIDs compromise renal perfusion particularly in hypotensive states Heart failure May worsen due to NSAID induced fluid retention ACE = Angiotensin-converting enzyme; NSAID = Non-steroidal anti-inflammotory drug

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This tricyclic anti-depressant (TCA) is recommended for neuropathic pain symptoms. It acts by modulating pain by increasing the concentration of neurotransmitters (serotonin and noradrenaline) in the central nervous system and blocking neural re-uptake. A systematic review of controlled trials of TCAs supports the effectiveness of these drugs for allodynia, burning and more recently for shooting neuropathic pains (McQuay and Moore, 1998).

Anticonvulsants Anticonvulsants (gabapentin, pregabalin and carbamazepine) are used for neuropathic pain and have been shown to be particularly effective for pain that is lancinating and in hyperalgesia. Analgesia is thought to result from the reduction

British Journal of Nursing, 2007 (TISSUE VIABILITY SUPPLEMENT), Vol 16, No 11


Exercise

Table 3. Summary of common opioids Route

Opioid

Oral

Weak: codeine, dihydrocodeine, tramadol. Strong: Morphine, oxycodone Morphine, diamorphine, fentanyl Codeine and morphine suppositories Morphine, fentanyl, oxycodone, tramadol Fentanyl, buprenorphine patches Buprenorphine, fentanyl Diamorphine, fentanyl, morphine (nebulised or aerosol spray) Morphine (in a gel or splashed diluted in normal saline) Diamorphine, fentanyl

Subcut/IM Rectal Intravenous Transdermal Transmucosal Intranasal Topical Epidural/spinal

in neuronal hyperexcitability by the suppression of electrical charges and the conduction of pain signals. These drugs are also said to reduce wind-up (McQuay and Moore, 1998; ANZCA, 2005).

Entonox Entonox is a gas mixture comprising 50% nitrous oxide and 50% oxygen. Entonox has a rapid onset and short duration of action and is therefore an ideal agent for short-term analgesia required for dressing changes. There are cautions and contradictions for its use which should be checked before use (Evans, 2003; BOC Medical, 2004). For example, caution should be taken with patients on opioids or benzodiazepines as it may increase respiratory depression or potentiate sedation; nitrous oxide can impair bone marrow function in long term use and cause anaemia; Entonox rapidly diffuses into airfilled spaces and should never be used if air is entrapped within the body (i.e. pneumothorax, emphysema, intestinal obstruction).

Non-drug therapies Dressing changes Dressing removal can be the most painful part of a dressing procedure, closely followed by cleansing of the wound (Moffatt et al, 2002). Therefore, certain factors must be considered (Briggs et al, 2002): ■ Avoid any unnecessary stimulus to the wound (drafts, prodding, poking) ■ Handle wounds gently – be aware even slight touch can cause pain ■ Select a dressing which is: appropriate for the type of wound; maintains moist wound healing to reduce friction at the wound surface; minimizes pain and trauma on removal; remains in situ for a longer period to lessen the need for frequent dressing changes. Also consider products such as foams, hydrocolloids, gels, alginates and soft silicones. ■ Reconsider dressing if removal is causing a problem with pain or bleeding/trauma, or if soaking is required for removal ■ Read manufacturers’ instructions on removal technique.

Wound debridement/repacking deep cavity wounds ■

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May be best undertaken in theatre using general anaesthesia or sedation and local anaesthesia – liaise with anaesthetic department Analgesia as above, particularly Entonox.

Historically bed rest was thought to aid the relief of symptoms (Wilson, 1996), however there is strong evidence now available against bed rest and inactivity due to harmful effects which may lead to chronicity, such as: loss of strength, endurance, flexibility, loss of control, fear avoidance, depression, withdrawal, loss of role function, dependent passive behaviours (Main and Williams, 2002). Wound healing will also benefit from guided exercise (Heinen et al, 2004). Keeping active is well known to improve cardio-respiratory function as well help in the reduction of stress and pain with the release of natural opioids, endorphins and serotonin.

Cutaneous stimulation Acupuncture and transcutaneous electrical nerve stimulation (TENS) are forms of cutaneous stimulation, as is massage. Acupuncture is one of the oldest forms of therapy and has its roots in ancient Chinese medicine that considers the balance of energy forces within the body. Western scientific theories propose that acupuncture and TENS might act by principles of the gate control theory of pain – that is by inhibiting pain transmission in the spinal cord through the stimulation of the sensory (touch) fibres. The placebo response is also suggested to result from both therapies, pain relief associated with a placebo is well documented (Rowbotham, 2001). Direct tissue stimulation, the placebo effect and the sympathetic one-to-one attention of an holistic healthcare professional are thought to stimulate the production of naturally occurring opioids (endorphins), serotonin and acetylcholine within the central nervous system which enhances analgesia (McCaffery and Pasero, 1999). Patents with allodynia and neuropathic sensations may, however, find light touch/cutaneous stimulation painful.

Psychosocial options Psychosocial welfare must be considered as part of holistic care: reduced activity, mood swings, not going out, over protective carers, being unable to work, for example, can be real problems. Patients with long-term pain are often misconceived as malingerers or not believed because their symptoms seem disproportionate to their injury/wound. Keeping active, as much as is reasonably possible, in work and play, helps patients to feel empowered and involved. Cognitive behavioural therapy (CBT): Some studies cite the benefits of functional restoration in returning patients back to work. Drawing on the principles of health promotion, success is measured on objective function rather than subjective suffering. CBT or ‘talking therapies’ encourages patients to think about their problems and goal set towards achievable solutions using mental and physical techniques to reduce their negative pain experience by concentrating on what they can do rather than what they can not do. CBT helps patients to restructure the way they think about problems and pain, aiming to change patterns of behaviour (Turk, 2003). CBT can be provided in its simplest forms by all practitioners such as advice on pacing and in more

British Journal of Nursing, 2007 (TISSUE VIABILITY SUPPLEMENT), Vol 16, No 11


depth by experts experienced in this field (i.e. chronic pain clinicians, clinical psychologists, some GPs, specialist nurses, physiotherapists and occupational therapists.). Relaxation: May be defined as ‘a state of relative freedom from both anxiety and skeletal muscle tension’, a quieting or calming of the mind and muscles (McCaffery and Pasero, 1999). There is a decrease in sympathetic nervous system arousal resulting in a lower blood pressure, reduced respirations, pulse rate and muscle tone. A combination of both physical and behavioural strategies is used to achieve a state of relaxation, e.g. controlled breathing exercises, visual or guided imagery or progressive muscle relaxation (Kazanowski and Laccetti, 2002; Roykulcharoen and Good, 2004). Distraction: Distraction from pain may be defined as focusing attention on stimuli other than the pain sensation. Patients refocus their attention by increasing other sensory input, especially hearing, seeing, touching and moving (McCaffery and Pasero, 1999). Most patients can practice distraction with little assistance, but to be successful the method used must be something which appeals to the patient. Distraction is a simple but effective technique which can be used in both acute and chronic pain conditions. Strategies used may include reading, listening to music, watching television, reciting poetry, playing cards/board games, sketching, play (for children) having a conversation or going for a walk.

Conclusion This article has illustrated that controlling wound pain can play a major role in improving quality of life. The patients’ total pain experience must be carefully assessed using a variety of methods. Pain management plans can then be tailored to patients depending on their needs using drug therapies (regular combinations of simple analgesia, NSAIDs, opioids and drugs that alter the chemical transmission

KEY POINTS ■ Under treated pain can result in a number of potentially serious sequelae, including delayed mobilization and recovery, cardiac complications, thromboses, pulmonary complications, delayed healing, psychosocial problems and chronic pain syndromes. ■ It is important to accurately assess pain using a recognized scale for consistency, i.e 1–10 and the patient’s story. ■ Understand patients’ unique needs by communicating effectively and nonjudgementally. ■ Minimize the severity of the patient’s pain through pharmacological and non-pharmacological methods that facilitate comfort and promote recovery. ■ Allow patients to communicate unrelieved pain so that they can receive prompt and effective treatment. ■ Avoid, or effectively manage, the side-effects of therapies.

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of pain and nerve conduction) and non-drug therapies (dressing selection, CBT, distraction, guided imagery, pacing, relaxation, distraction, cutaneous stimulation and exercise) to deal with the pain. Adequate pain relief is not only important for humanitarian considerations but also for economic reasons. Good pain relief should allow for ambulation, alimentation, and facilitate patient rehabilitation, resulting in shorter hospital stays. The quality of pain management is at the top of the patient’s agenda (Healthcare Commission 2005) and good pain management by all staff is central to enabling this (Royal College of Anaesthetists, 2000; ANZCA, 2005). All Trusts should have an acute pain service to provide nursing and medical staff with the knowledge and tools required to give patients good pain relief and a speedy resolution of acute pain problems. This avoids the costs of inadequate pain control, protocol violation and adverse outcomes, in line with clinical governance. Effective pain relief is therefore an essential component of best quality patient BJN care, the 5th vital sign.

Australian and New Zealand College of Anaesthetists (2005) Acute Pain Management: Scientific Evidence. Department of Health, Australia. Available at: www.anzca.edu.au/publications/acutepain.pdf (last accessed 25 May 2007) BOC Medical (2004) Entonox Controlled Pain Relief Reference Guide. BOC Medical, Manchester Briggs M, Torra JE, Bou I (2002) Pain at wound dressing changes: a guide to management. In: Calne S (ed). EWMA Position Document: Pain at Wound Dressing Changes. Medical Education Partnership Ltd, London: 2–7 Evans A (2003) Use of Entonox in the community for control of procedural pain. Br J Community Nurs 8(11): 488–94 European Wound Management Association (2002) Pain Position Document. Available at: http://www.Tendra.com/Files/Tendra/safetac/ENGLISH.pdf (last accessed 25 May 2007) Gould T, Crosby D, Harmer M (1992) Policy for controlling pain after surgery; effect of sequential changes in Management. Br Med J 305: 1187–93 Harati Y, Gooch C, Swenson M et al (1998) Double-blind randomized trial of tramadol for the treatment of the pain of diabetic neuropathy. Neurology 50(6): 1842–6 Heinen M, van Achterberg T, op Reimer W, van de Kerkhof P, de Laat E (2004) Venous leg ulcer patients: a review of the literature on lifestyle and painrelated interventions. J Clin Nurs 13(3): 355–66 International Association of the Study of Pain (1979) Pain terms: a list of definitions and usage. Pain 6: 249–52 Kazanowski MK, Laccetti M (2002) Interventions for pain relief. In: Pain. Slack incorporated, Thorofare, NJ McCaffery M, Pasero C (1999) Pain Clinical Manual. 2nd edn. Mosby, New York Main CJ, Williams AC (2002) Clinical review. ABC of psychological medicine: musculoskeletal pain. BMJ 325: 534–7 McQuay H, Moore A (1998) An Evidence-Based Resource for Pain Relief. Oxford University Press, Oxford Moffatt CJ, Franks PJ, Hollinworth H (2002) Understanding wound pain and trauma: an international perspective. In: Calne S, ed. EWMA Position Document: Pain at Wound Dressing Changes. Medical Education Partnership Ltd, London: 2–7 Oxford Pain Research Trust (2003) Acute Pain - Conclusions. Oxford Pain Research Trust, Oxford. Available at: http://www.jr2.ox.ac.uk/bandolier/ booth/painpag/#Acute (last accessed 25 May 2007) Rowbotham D (2001) Endogenous opioids, placebo response, and pain. Lancet 357(9272): 1901 Royal College of Anaesthetists (2000) Raising the Standard. Lack J et al, eds. Royal College of Anaesthetists, London RoykulcharoenV, Good MJ (2004) Systematic relaxation to relieve postoperative pain. J Adv Nurs 48(2): 140–8 Turk D (2003) Cognitive-behavioral approach to the treatment of chronic pain patients. Reg Anesth Pain Med 28(6): 573–9 World Health Organisation (2007) Cancer Pain. WHO, Geneva. available at: www.whocancerpain.wisc.edu/ (last accessed 25 May 2007) Watson CP, Babul N (1998) Efficacy of oxycodone in neuropathic pain: a randomised trial in post-herpetic neuralgia. Neurology 50: 1837–41 Wells J, Woolf C (1991) A Series of Expert Reviews: Pain Mechanisms and Management. British Medical Bulletin. Churchill Livingstone, Oxford Wilson P (1996) On rest and pain. Clin J Pain 12(3): 163

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