Multidisciplinary Treatment Approaches 1

10th World Congress on Pain, List of topics

X. Zhang Pain Management Center, Yueyang Hospital of Traditional Chinese Medicine, Yueyang, China

Aim of Investigations: To observe the therapeutic effect of combined Chinese traditional and western medicine for treatment of cervical spondylosis.

Methods: Ninety-eight cases of cervical spondylosis were differentiated as three types: nerve root type, vertebroarterial type, and mixed type, according to clinical signs and syndromes, imaging detections (x-ray, CT, TCD and MRI). They were treated by nerve blocks (cervical plexus, paravertebral nerve, greater and lesser occipital nerve block etc.) with pain-relieving solution which contains Chinese drugs and western medicine, combining of traditional manipulation and cervical traction accordingly, and the therapeutic effects was compared.

Results: All cases were followed-up for an average of 18 months. 32 of 48 patients with the nerve root type obtained excellent (66.7%), 13 good (27.0%), 3 effective (6.3%), the excellent and good rate was 93.7% with a total effective rate of 100%. 18 of 29 patients with the vertebroarterial type obtained excellent (62.1%), 8 good (27.6%), 2 effective (6.9%), 1 no effective (3.4%), the excellent and good rate was 89.7% with a total effective rate of 96.6%. 11 of 21 patients with the mixed type obtained excellent (52.4%), 5 good (23.8%), 4 effective (19.0%), 1 no effective (4.8%), the excellent and good rate was 76.2% with a total effective rate of 95.0%.

Conclusions: The combination of Chinese traditional and western medicine therapy is one of the most effective method in treatment of cervical spondylosis, and the shorter the course of illness, the better the therapeutic effect.

K. Karjalainen1, R. Roine, H. Hurri3, P. Mutanen, P. Rissanen4, H. Pahkajrvi, T. Pohjolainen5 1 Finnish Institute of Occupational Health, Helsinki, Finland , 2 Helsinki and Uusimaa Hospital Group, Helsinki, Finland , 3 ORTON Rehabilitation, Helsinki, Finland , 4 National Research and Development Centre for Welfare and Health, Helsinki, Finland , 5 Social Insurance Institution, Helsinki, Finland

Aim of Investigation: To evaluate the effectiveness and costs of mini-intervention and the incremental effect of a worksite.

Methods: We randomized 164 patients with subacute low back pain to a mini-intervention group (A), a worksite-visit group (B) or a usual care group (C). Patients in A(n=56) and B(n=51) underwent one assessment by a physician plus physiotherapist. B received a worksite-visit in addition. Patients in C(n=57) were treated in municipal primary health care. All patients received a leaflet on back pain. Pain, disability, specific and generic health related quality of life, satisfaction with care, days on sick leave, and use and costs of health care consumption were measured at 3,6 and 12-month follow-ups.

Results: During the entire follow-up, fewer subjects had daily pain in A and B than in C. (AvsC,P=0.002) (BvsC,P=0.030). In A pain was less bothersome (AvsC,P=0.032) and interfered less with daily life (AvsC,P=0.040) than in C. Average sick leaves were 19 days in A, 28 days in B and 41 days in C (AvsC,P=0.019). Treatment satisfaction was better in A and B than in C, and total health care and sick leave costs were least in A.

Conclusions: Low-cost mini-intervention reduces daily back pain symptoms and sickness absence, and improves adaptation to pain and patient satisfaction among patients with subacute low back pain. A worksite-visit does not improve effectiveness.

Acknowledgements: Supported by grant from The Social Insurance Institution of Finland

T. Goodrich, S. King1< B.> Behavioral Medicine, Hospital for Joint Diseases, New York, NY

Aim of Investigation: To examine the functional and behavioral responses of patients admitted to an 18-Day Inpatient Pain Rehabilitation Program.

Method: Eighty-one patients admitted to the multidisciplinary Inpatient Pain Rehabilitation Program at the Hospital for Joint Disease completed a series of measures upon entrance to the program and again on the day of discharge. These measures included, a demographic questionnaire, the McGill-Melzack Pain Questionnaire, the Oswestry Pain Questionnaire (a self-report instrument that provides an average level of impairment based on ten different functional activities), the patients current pain level on a scale from 0-100, and the Becks Depression Inventory (BDI).

Results: Patients demonstrated improvement from time of admission to the time of discharge. At discharge patients showed statistically significant improvement in Pain level (p<. 01), overall Oswestry score (p<. 01), sleep quality (p<. 01), activity level (p<. 01) on the MMPQ, and the BDI (P<. 01). In addition, there were significant effects found for the sub-scales of the Oswestry including, sexual activity, standing, walking social activity and pain intensity (All P values <. 01). There were no identifiable predictive demographic factors.

Conclusions: There is limited research on the effectiveness of inpatient rehabilitation programs for chronic pain and this study shows that such programs can have a significant impact on pain patients. This study demonstrates that a multi-disciplinary approach to rehabilitation is an effective means of treating chronic pain, as well as an effective method of improving patients sleep quality, physical functioning, and patients mood. Further studies will be conducted to determine if these improvements can be maintained over time.

C.P. van Wilgen1,22, G.J. Versteegen1, M. van Wijhe1 1 Anesthesiology, University Hospital Groningen, Groningen, Netherlands , 2 Rehabilitation, University Hospital Groningen, Groningen, Netherlands

Aim of investigation: To evaluate long term outcomes of an individual clinical multidisciplinary cognitive behavioral program for patients with non-specific incapacitating chronic pain (median pain duration 3 years).

Methods: Questionnaires (SCL-90, RAND-36) of 10 patients who were admitted to our hospital for the cognitive behavioral program were analyzed. Patients were included if they were diagnosed, after a multidisciplinary assessment, as having non-specific chronic pain.

Questionnaires were filled out at multidisciplinary assessment (T1); and 1 year after completion of the program (T2).

Five sub scales of the SCL-90 (anxiety, depression, somatization, hostility, and sleep disturbances), and all subscales of the RAND-36 were analyzed. Quality of life was calculated from the RAND-36 (1.6 * mental health + physical functioning)/ 2.6 .

Results: Significant improvements on the SCL-90 were found for: anxiety (mean T1:17-meanT2:14 p:.013 ), depression (30-22 p:.047), somatization (30-22 p:.004).and sleep (8-7 p:.016).

Significant improvements on the RAND-36 were found for: pain (mean T1:40 -mean T2:53 p:.009), mental health (60-73 p:.002), role limitations physically (8-47 p:.008) physical functioning (36-57 p:.002), health changes (31-81 p:.001), and Quality of life (51-67 p:.001). All other outcomes on the SCL 90 and RAND 36 improved as well, but not significantly.

Conclusion: This multidisciplinary cognitive behavioral program has long lasting effects on diminishing pain, improving psychosocial functioning as well as physical functioning and quality of life of patients with long existing chronic pain.

S.M. Cordeiro1</SUP< TD> Cronic Pain and Paliative Care, Hospital for the Public workers of So Paulo City, Sгo Paulo, Brazil

AIM OF INVESTIGATION -To evaluate the number of myofascial pain patients and to make a new aprouche to their work and quality of life.

METHOD-In a period from january/2000 to december/2001 we have seen 1920 patiens and from them we took a randomized sample of 155 patients.

From this sample we have 62 patients(40%)that are in a complete funcional activity ,57 patients(36,7%) that are in a partial funcional activity,what means that they shoudn't do all their tasks, only that that don't worse their fisical condition,21 patients(13,5%) that are economicaly dependents of the public workers, and 15 patients(9,6$) retired from the Public Service.

RESULTS- This sample has myofascial pain do to: general muscle-squeletical disorders in 89 patients(57,4%) with 19 patiens ( 12,2%)with low-back pain and 6 patiens ( 3,5%)with carpal tunnel sindrome.

When we compare the number of patiens in total function or partial function we see that their number is almost similar, so we may have Public Service Units that are working with half of their capacity or the workers are doing works that they should'nt.The next step of this trial is to show how the multidisciplinary treatment began in january 2000 has improoved the performance at work and quality of life and to stablish conditions at work places to receive tihs kind of patients and make them more useful for their units.

Conclusion -This is a first evaluation of work conditions for patiens that are classified as partial function workers of So Paulo Mayor Service based on the Cronic Pain and Paliative Care of the Hospital for the Public Workers of So Paulo City and we believe that it will change the formal aspects and considerations for their employes.

C. Moreira, G. Barros, F. Cordon, A. Rocha1< L. Takito, D.> Pain Management Service, Unesp Medical School, Botucatu - SP, Brazil

Aim of Investigation: The Pain Management and Palliative Care Service of the Sao Paulo State University, Botucatu, has as main target the oncologic patients and theirs relatives. This study relates the domiciliary assistance, with focus on the Nurse activities in the palliative care. This is a wide and new activity for Brazilian environment, and it is a huge operational challenge.

Methods: The multidisciplinary team performs domiciliary visitations twice a week, on the afternoons. The nurse activity has as main goal to improve the triploid patient-relative-caregiver; identify nurse related general or specific problems; nurses diagnosis; care planning; accomplishment of the plans; follow up of the patients. The study evaluated the domiciliary activities for the period of one year.

Results: Cancer patients with pain complains counts 99% of the survey. 200 home visits were performed on the Botucatus city. The average age of the patients was 40 90 years old, of both sexes. The sponsor of the assistance is the Brazilian Official Public Health System (SUS), and the patients have a low financial and social status. The follow up interval was determined by the general health status of the patient. Post-decease visitation was performed one month after the event.

Conclusion: The nurse assistance on the domiciliary environment is fundamental for the quality of care provided to the patients.

A.C. de Blecourt1< Schiphorst H.R.> Dept of Rehabilitation Medicine, University Hospital, Groningen, Netherlands

AIM OF INVESTIGATION: To describe the results of a multidisciplinary rehabilitation program for children with chronic disabling musculoskeletal pain.

METHODS: A 3 month inpatient rehabilitation program has been developed with a graded physical exercise program combined with a cognitive behavioral approach. The aim of the program is not primarily pain reduction, but an increase of the activity and participation level, and a decrease of medical consumption. At study-entry the level of motor and social activities was monitored as well as VAS (0-100 mm) on pain and global assessment (the last by the patient and by the physician), and medical consumption. Recordings were: baseline at first contact, second on day of admission, third on day of discharge and last 3 months after discharge.

RESULTS: Seventy consecutive children were included in the program, 64 girls and 6 boys. Mean age was 15 yrs (range 8-21, SD 2.56). Results show marked improvement in motor performances (94%), school attendance and decreased medical consumption. As a side effect there was a marked reduction (p< 0.001) in pain scores after discharge as well (mean pain level at baseline was 57 mm, at the start of the program 59, at discharge 40 and at follow-up 36).

CONCLUSION: Chronic musculoskeletal pain in children must be seen from a biopsychosocial perspective and treatment should not be focussed at one aspect or be conducted by one discipline. A multidisciplinary rehabilitation program for children with chronic disabling musculoskeletal pain improved their level of motor abilities and social participation and reduced pain and medical consumption.

L. Wolfgang11, T. Jan2 1 munich pain center, 81539 Mьnchen, Germany , 2 Pain center, Rehaklinik Bellikon, 5454 Bellikon, Switzerland

AIM OF INVESTIGATION: The SUVA, a swiss insurance company for accidents in Switzerland, launched a pain project to measure the effects of an inpatient treatment for patients with chronic pain.

METHODS: The concept of the study was a prospective clinical trial, patients were assigned by the insurance agencies. Before treatment, every patient was evaluated by an interdisciplinary pain team. Everyone was included who was willing to take part and had a minimum of physical fitness (e.g. be able to walk). The assessment of the quality of life(before treatment and 6 months after) was performed by the questionnaire sf 12. In the end, complete data was available from 67 patients. 16 of these patients were in other institutions in an outpatient treatment (they wanted a treatment near home), their results were taken as a control. Due to the high chronification, 78% were included in a structured anti-chronification program, the others underwent interventions.

RESULTS: The inpatient treatment group showed a statistically significant positive result. The physical well-being part of the SF 12 increased about 12%. Psychological disorders were denied even in the beginning and of course there was no change.

Chronification seemed to be the most important predictor for the results. There was a significant correlation between old cases and bad outcome.

CONCLUSION: Even with a negative selection of pain patients (high chronicity, financial demands on the insurance company), it is possible to achieve an improvement in the quality of life (self-estimated), if you can provide a high quality of pain management.

On the other hand, this kind of treatment is expensive, and the increase in quality of life did not mean return to work in the majority of the cases.

J. Davidson1</SUP< TD> Occupational Therapy, Prince Henry Hospital, Little Bay, NSW, Australia

AIM OF INVESTIGATION: The Disabilities of the Arm Shoulder and Hand Scale is a 30 item self completed questionnair which was developed to measure the function and symptoms associated with any condition of the upper limb. The aim of this study was to analyse the results of using the assessment on 3 years of consequetive patients.

METHODS: Over a 3 year period, Occupational Therapists at Prince Henry Hospital and Eastern Suburbs Pain Clinic have used this measure on all patients with musculo-skeletal injuries affecting the upper limb

RESULTS: Data has been collected for 195 patients. 61 had sufferred upper limb amputations. 30 had Complex Regional Pain Sydrome. 14 were brachial plexus injuries. The remainder were tenosynovitis, shoulder capsulities, fractures and nerve entrapment. 21 patients were measured again after a period of treatment.

All but one of the top 22 scores were compensable injuries. Twelve of the bottom 25 scores were non-compensable injuries. The lowest score was 6 for a unilateral amputatee while the highest score was 88 for 2 patients - one with CRPS and one with a below elbow amputation with multiple injuries to all 4 limbs due to electrocutions. CRPS accounted for 10 of the 15 highet scores. Amputees accounted for 5 of the 10 lowest scores.

CONCLUSIONS The scale measures patient's perception of their disability including function status, sleep status, self esteem and pain. Patients with CRPS has have more greater pereception of severe disability that unilateral upper limb amputees. The scale is a valuable assessment tool that provides some insight into their perception of their disability and ultimately this is what rehabilitation staff are treating.

N. Adams12, G. Chitty2, T. Korpfkamp2 1 Centre for Research in Health Care, Liverpool John Moores University, Liverpool, United Kingdom , 2 Wirral Hospital NHS Trust, Liverpool, United Kingdom

AIM OF INVESTIGATION: Few guidelines exist for the assessment and management of fibromyalgia (FMS) patients' and treatment approaches are rarely standardized. Several studies have found favorable outcomes with a combined management programme of exercise and cognitive-behavioral therapy(CBT). However, methodological issues in the studies themselves and factors such as the heterogeneity of programmes, differences in assessment instruments and outcome appraisal makes overall evaluation difficult. The aim of the current study is to assess the effectiveness of a standardized pain management programme (PMP) consisting of exercise, education and cognitive-behavioral therapy by comparing patients attending a 6 week PMP with patients receiving treatment as usual (TAU).

METHODS: Patients (n=60) who fulfil ACR (1990) criteria for FMS are referred from rheumatology clinics at Wirral Hospitals NHS Trust. Following a short interview, they are assessed using the Fibromyalgia Impact Questionnaire (FIQ), Modified Zung Inventory, modified Somatic Perception Questionnaire (MSPQ) McGill Pain Questionnaire (MPQ) and Coping Strategies Questionnaire (CSQ). Patients are randomly allocated to either the PMP or TAU groups and assessed pre- and post-intervention and at 6 month follow-up. Ethical approval was obtained prior to commencement of the trial.

RESULTS: Data collection is ongoing. Preliminary results and analysis indicate a significant reduction in fibromyalgia impact scores (p0.05) and a significant reduction in catastrophizing (p0.05) post-intervention.

CONCLUSIONS:Results will inform practice and recommendations for management will be made.

C. Eccleston11, G. Crombez2 1 Pain Management Unit, University of Bath, Bath, United Kingdom , 2 Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium

Aim of investigation: To examine the factors that predict disability associated with chronic pain in a clinical sample of adolescents and accompanying parents. It was hypothesised that disability could be predicted by adolescent current pain status and coping attempts.

Methods: 69 adolescents with chronic pain (41 girls, mean age of 14, mean chronicity of pain of 4 years, most common diagnosis was CRPS) were referred for treatment at an interdisciplinary pain management unit. Prior to treatment all adolescents completed a battery of child questionnaires, including self-report of recent pain and mood, the Functional Disability Index (FDI), the Spence Child Anxiety Scale (SCAS), and the Pain Coping Questionnaire (PCQ). Their accompanying parents (mother = 54, father = 12, grandparent = 3) completed a battery of questionnaires, including Hospital Anxiety and Depression (HAD) and the Parenting Stress Index (PSI).

Results. A stepwise multiple regression analysis was used. Pain in the last week (= 0.39) and mood in the last week (= -0.33) were significant (P<0.01) predictors of adolescent rated disability. In a next step, frequency of attempts at coping (= 0.21) was also significant. In a third step, parental distress had a unique contribution in predicting functional disability (= 0.26) and extinguished the effect of frequency of coping.

Conclusions: Disability in adolescents can be accounted for by their recent experience of high pain and low mood, and by high parental distress. Adolescent general anxiety and depression have no predictive value. Effects of coping are mediated by parental stress.

Acknowledgements: None

R.D. Shick1< B.S. Ong-Lam, M.C. Burton, H.J.> Psychiatry, St. Paul's Hospital, Vancouver, BC, Canada

AIM OF INVESTIGATION: To see if females with fibromyalgia (FM) respond similarly to a multidisciplinary 4 week day pain program than females with other causes of chronic pain.

Methods: 66 FM subjects and 46 subjects with pain in the cervical, thoracic area, lower back, spine, upper shoulders and limbs completed 2 Inventories: Multidimensional Pain and Basic Personality, pre/post program and 6mth after. MPI taps support, pain severity/ interference, life control, affective distress, activity levels, punishing, solicitous and distracting responses. BPI taps anxiety, denial, social isolation, depression, hypochondriasis, self-depreciation. Paired samples and independent samples t-tests showed significant differences (p=.05). Effect size (ES)showed clinically meaningful response to treatment.

Results: Before treatment the groups were similar on all measures except hypochondriasis. The FM group was more concerned with physical complaints (=p<.007). Both gained from the program, more so the spinal group who had significantly less anxiety, depression, self-depreciation, pain severity and pain interference, and more life control. Both had major clinical change in a decrease of affective distress and increase of life control. (ES=>.83. These changes were not sustained by the FM group at followup. The non-FM group maintained moderate gains at follow-up mostly with less anxiety, self-depreciation and pain interfering in their lives and in increased life control (ES=>.43 & <.60).

Conclusions: Females with FM responded differently compared to NonFM subjects. They failed to sustain the gains made by treatment. We conclude that female patients with FM require more innovative treatment strategies in order to ensure that treatment benefits are maintained.

M. Goossens12, J. Vlaeyen2,3 1 Institute for
Rehabilitation Research, Hoensbroek, Netherlands , 2 PKC, University Hospital, Maastricht, Netherlands , 3 DMKEP, Maastricht University, Maastricht, Netherlands

Aim of investigation. Although international literature suggests that multidisciplinary pain management programs (MPM) are effective, these programs have not been implemented in the Dutch health care. An important reason for this is the lack of a national consensus. This study aimed to survey 1)the number of Dutch institutions performing an MPM, 2)the content and nature of MPM 3)the bottlenecks.

Methods: Aim 1) short questionnaire to 349 Dutch health Institutions. Aim 2 and 3)questionnaire to institutions performing an MPM. Questions include content and organisation of the MPM and bottlenecks, requirements and advisable changes of the program.

Results: The response to questionnaire 1 was 57%; 105 institutes perform an MPM. The response on questionnaire 2 was 65%; 24 rehabilitation centre, 25 hospitals and 11 primary health care institutions. The general goal of the MPM seems; coping with pain due to improvement in level of functioning. The treatment principles, content and theoretical foundations are very diverse. In general 5 disciplines are involved in the program. Selection criteria are very general, duration and frequency of the MPM program differ enormous. 72% of the institutions evaluate the program, but evaluation is differently performed. Mostly used bottlenecks are the lack of consensus on treatment principles, a treatment protocol, adequate patient selection, refresher courses for the team. Conclusion: There is an urgent need to protcolise MPM, with consensus about the theoretical concept, minimal treatment principles, organisation, selection criteria and evaluation.

Acknowledgments: Pain Management and Research Centre, Maastricht

E. Witkamp, W. Oldenmenger1< de R.> Pain Expertise Center, Erasmus University Medical Center, Rotterdam, Netherlands

Aim of Investigation: Research shows that multidisciplinary pain treatment to chronic pain patients leads to pain reduction and is more effective than monodisciplinary pain treatment. A multidisciplinary pain team exists of 2 or more disciplines of which every discipline has their own specific contribution. We investigated the extent to which hospitals in the Netherlands treat their patients multidisciplinary and how these pain teams conduct pain treatment.

Methods: We approached all hospitals in the Netherlands by telephone and asked them to fill in a questionnaire regarding pain treatment in general, the presence of a multidisciplinary pain team and their tasks and functions.

Results: In total 137 hospitals were approached. The response rate was 94%. From all hospitals, 42 hospitals (31%) diagnose and treat their patients multidisciplinary. In 62 hospitals, a pain team with two or more disciplines was available for pain treatment. An average pain team exists of five different disciplines, most frequently anaesthesiology (98%), nursing (63%), psychology (58%), physiotherapy (47%) and neurology (40%). 42 of the 62 pain teams (68%) perform direct patient care. Other tasks are developing treatment protocols and patient casuistry, development of research proposals and conducting pain research.

Conclusions: In 45% of the hospitals a multidisciplinary pain team exists. The constitution of a pain team and also their tasks and functions differ substantially per hospital. The progressing knowledge regarding the effectiveness of a multidisciplinary approach of complex pain patients has only lead in a minority of hospitals to the realisation of multidisciplinary pain teams. More effort is needed to realise nation wide availability of multidisciplinary pain teams.

B. Fullen1< D. Crowley, Brennan, L. Hawksworth, R.> Pain Service, Adelaide and Meath Hospital, Dublin 24, Ireland

Aim of Investigation To assess the effect of the Physiotherapy component of a multidisciplinary pain management programme on patients functional capacity, mood, muscle tenderness and aerobic function.

Methods 12 patients were randomly divided into an exercise or control group. The groups were age and sex matched. The exercise group attended 3 days a week for 4 weeks. The control group continued with their routine home exercise programme.

Measurements used included the H.A.D Scale, the Mc Gill Pain Questionnaire, a pulmonary function test and Simmonds battery of functional tests. Muscle tenderness was assessed using a pressure algometer

Results There were clinically significant findings in the treatment group on functional testing; stair climbing increased by 27 steps and the 5 - minute walk test by 45.8 feet more than the control.

The mean depression and anxiety scales reduced in the treatment group. Muscle tenderness of the cervical and thoracic spine also reduced.

The baseline predicted VO2 max was 90.5% and 84.7% for the test and control groups respectively.

Using a 2 sample t-test to analyse the average difference of each group (post treatment pre treatment) none was statistically significant.

Conclusion Overall the Physiotherapy component of the pain management programme had a clinically significant effect on both physical and psychological testing. Of note the aerobic power of the population was within normal range.

ACKNOWLEDGMENTS With thanks to Susan Coote MISCP for advice in the preparation of this abstract.

D. Lieberman FRCA1< Y. FRCA, Grady D. FRCS Makin MRCP Wilmshurst> Anaesthesia & Pain Medicine, South Manchester University Hospital NHS Trust, Southmoor Road, Wythenshawe, Manchester, M23 9LT, United Kingdom

Aim of Investigation To asses the effectiveness and cost efficiency of a multidisciplinary chronic refractory angina service.

Introduction The Greater Manchester Chronic Refractory Service was established in the summer of 2001 to provide a coordinated multidisciplinary CRA service for the 4.5 million population of Greater Manchester, following the UK Chronic Refractory Angina Guideline.

The individual treatments of the guideline have been described in the literature and their efficacy is established. The coordination of these treatments into a multidisciplinary service is challenging and prospective outcome data including cost analysis data has not yet been presented. The outcome data for the initial cohort of patients treated between August 2001 and July 2002 will be presented in the poster.

Service staff & structures Consultant in Pain Medicine two outpatient & two half day theatre sessions per month

Clinical Psychologist one outpatient session per week

Specialist Nurse one outpatient session per week

Secretary to support above

Nursing & Support Staff for two half day theatre sessions per month

Results The outcome data to be presented in the Poster will include:

New York Heart Association functional classification

Canadian Cardiovascular Society grading of angina of effort

Medication use

Hospital admissions for angina

GP consultations for angina

Angina symptoms

Angina frequency

Angina severity

Thoughts concerning angina

Physical activity

A cost analysis of the service

10th World Congress on Pain, List of topics

10th World Congress on Pain. International Association for the Study of Pain, San Diego, California, USA August 17-22, 2002