10th World Congress on Pain, List of topics

PAIN AND ANXIETY DURING MAMMOGRAPHY IN WOMEN WITH FIBROMYALGIA
U. Haemmerer, Anesthesiology, University of Utah, Salt Lake City, UT

Aim of Investigation: Pain during mammography is prevalent. Patients with fibromyalgia (FM) are characterized by diffuse hyperalgesia to pressure pain. The main purpose of this study was to evaluate whether FM patients would be susceptible to experience pain during mammography.

Methods: A questionnaire was sent out to 100 women over the age of forty, who were randomly selected from the database of FM patients, who expressed interest in participating in university based research. Seven participants were not reachable because of change of address. 59 patients responded yielding a response rate of 63 %. Patients were asked to rate pain and anxiety during their last mammography and Pap smear on the scale of 0-10.

Results: The mean age was 57 (SD=6). Mean pain scores were 4.32 (SD= 2.47) for mammography and 2.45 (SD=2.16) for Pap smear; the difference was statistically significant (p<.05). Mean anxiety scores were 2.33 (SD=2.74) during mammography and 2.22 (SD=2.35) during Pap smear, non-significant difference.

Conclusions: Women with FM experience a moderate amount of pain during mammography. These women rated mammography as significantly more painful than Pap smear, although the anxiety levels were comparable between the two procedures. Pain is one of the deterrent for women from undergoing mammography, which is a best screening tool for breast cancer. The results suggest that better pain management during the procedure may be needed for those women susceptible to discomfort during mammography.

Acknowledgments: This project was supported by NIH grants R55 AR44230 and R01AR46303 to the second author.

THE PAIN EXPERIENCE OF WOMEN UNDERGOING SECOND TRIMESTER TERMINATIONS FOR FETAL ANOMALIES
S.L. Williamson, A. Unruh, Education women's Health, IWK HEalth Centre, Halifax, NS, Canada , School of Occupational Therapy, Dalhousie University, Halifax, NS, Canada

Aim of Investigation: The purpose of this study was to examine the pain experience of women undergoing a second trimester termination for a fetal anomaly. The study will describe: 1) the intensity and nature of pain experienced; 2) the relationship between women's anticipated and actual pain experience at the time of delivery; and, 3) nurses' and patients' assessment of pain at the time of delivery.

Methods: All women (n=28) meeting the inclusion criteria were approached by the research assistant (RA) upon admission to the inpatient unit. The RA met with the woman to obtain consent. The RA met with the woman prior to the induction to complete the Pre-Induction and Delivery Interview.The RA approached the primary nurse to obtain consent to complete the Pain Experience Nursing Questionnaire. Prior to discharge, the RA met with the woman and completed the Post Induction and Delivery Questionnaire and the Short Form McGill Pain Questionnaire.

Results: The data collection period for this study is (November 2001 -May 2002). Preliminary results will be available.

Conclusions: The information gained from this study will increase our understanding of the pain experience of women undergoing a second trimester termination for a fetal anomaly, and provide direction toward more effective pain assessment and management.

Acknowledgements: This study was funded by the IWK Health Centre's, Research Assistantship Award and Research Grant.

GENERALISED AND SITE-SPECIFIC HYPOALGESIA OF LATE PREGNANCY IN WOMEN WITH AND WITHOUT PELVIC PAIN
P. Bajaj, H. Bajaj, P. Arendt-Nielsen, Laboratory for Experimental Pain Research, SMI, Aalborg, Denmark

AIM OF INVESTIGATION: Evaluation of pain responses in women during pregnancy by the visual analog scale (VAS) and pressure pain threshold (PPT).

METHODS: Thirty subjects were examined once in each trimester of pregnancy. Pain related to present pregnancy was recorded on a 0-10 cm VAS. The PPT(kPa)was assessed by an electronic pressure algometer, at referred pain sites (sacrum, back, pubis) and no pain control sites (thigh, arm).

RESULTS: Twelve subjects reported pain during pregnancy (sacrum, pubis and back,P>0.05) while 18 did not. The pain started at 7.90.9 wk (trimester1, n=9), at 182 wk (trimester2,n=2) and at 30 wk (trimester3, n=1). The pain VAS was greater in trimester3 (50.5) and trimester2 (4.90.5) as compared to trimester1 (2.70.4)(P<0.003). In all subjects, PPT showed a main effect for trimester, being greater in trimester3 as compared to trimester1 and 2 (P<0.002). PPT was reduced in the pain group (278.39) as compared to the no pain group (446.611) (P<0.001). Post-hoc analysis showed that in trimester3 the PPT increased at both referred pain and control sites in the pain group (P<0.002), while in the no pain group the PPT increased only at the presumed sites of referred pain (P<0.001).

CONCLUSION: The study demonstrates for the first time that pregnancy-induced hypoalgesia is generalized in women with pelvic pain, and present at presumed referred pain sites in women without pelvic pain. This suggests an activation of the descending noxious inhibitory system in late pregnancy, that is generalized in women with pelvic pain, and site-specific in women without pregnancy-related pain, associated with only selective activation of spinal segments with projection from the uterus and cervix.

ACKNOWLEDGEMENT: Danish National Research Foundation.

COURSE OF TEMPOROMANDIBULAR DISORDERS (TMD) THROUGH PREGNANCY
K.H. Huggins, L. Mancl, K. Saunders, S.F. Dworkin, Oral Medicine, University of Washington, Seattle, WA , Group Health Cooperative, Seattle, WA

Aim of Investigation: Describe the presence and intensity of TMD pain, pain on palpation and presence of other pains during each trimester of pregnancy and 1-year post-partum (PP) among TMD cases.

Methods: 14 pregnant women referred by an HMO for TMD care within the prior year completed questionnaires about their TMD and other pains and underwent an RDC/TMD examination at 3mo. (T1), 6 mo. (T2) and 9 mo. (T3) of pregnancy and PP. Data were analyzed using Repeated Measures Analysis of Variance to determine if there were within subject differences over pregnancy and 1 year after delivery.

Results: Women were on average 28 yrs old and educated beyond high school. Decreases in mean pain intensity scores (0-10) were observed between T1 and T2, with pain rising again late in pregnancy. Worst pain: T1=6.8, T2=4.9, T3=5.3, PP=5.6, p<.02. Average Pain T1=4.6, T2=3.5, T3=4.2, PP=3.8, ns. Mean numbers of painful extraoral muscle sites (0-16) were: T1=7.1, T2=6.4, T3=6.5 and PP=7.9, ns. Over pregnancy, the percent of women with headache decreased: T1=92%, T2=75%, T3=58%, (PP=75%), joint pain decreased, T1=83%, T2=67%, T3=50%, (PP=50%); frequency of other pains similarly decreased, while back pain increased: T1=75%, T2=92%, T3=100%, (PP=75%).

Conclusions: TMD pain intensity scores, pain on palpation and presence of pains were highest at T1, lowest at T2, and began to rise again at T3, some findings were significant. These initial findings from an ongoing study suggest that pain is lowest when estrogen levels are rising most rapidly (T2); lower levels of estrogen are associated with higher levels of pain and more pain sites.

Acknowledgements: Supported by NIH R01 DE12470.

PHANTOM BREAST SYNDROME
A.R. Cunha, Dept of Anaesthesia, Hospital de Base, São José do Rio Preto, Brazil , Dept of Anaesthesiology, College of Medicine, University of Sao Paulo State, Botucatu, Brazil

AIM OF INVESTIGATION: The "Phantom Breast Syndrome" observed after mastectomy, is not well known among health care professionals. The objective of this retrospective study is to evaluate the incidence of Phantom Breast Syndrome and its characteristics.

METHODS: Sixty-eight mastectomized women were interviewed by a standardized questionnaire, taking into consideration age, marital status, pregnancy, number of deliveries, breast- feeding, histology of the tumor, radiotherapy and/or chemotherapy. As to the syndrome, questions related to the presence, time of onset and duration, intensity of pain, improvement or worsening factors and the presence of emotional symptoms were asked. The variables were analyzed by descriptive statistics and Mann-Whitney and Goodman non-parametric tests.

RESULTS: Phantom Breast Sensation and Pain were observed in 37 and 22 women, respectively, whereas the Phantom Breast Syndrome was observed in 14. Most of them were married, mean age was 55.7 years and mean weight was 65.2 kg. Pregnancy and number of deliveries prevailed in 85.4% and 80.9% breast-fed their children. Infiltrating ductal carcinoma was observed in 83.8% and radiotherapy and/or chemotherapy in 89.7%. Emotional changes were observed in 38.3% of the patients.

CONCLUSIONS: Due to the high incidence of physical and emotional discomfort caused by the phantom breast sensation and/or pain, it is important that they are diagnosed and treated.

VARIABILITY IN TEMPOROMANDIBULAR DISORDER (TMD) PAIN ACROSS THE MENSTRUAL CYCLE
L. LeResche1, S.F. Sherman, J. Zhang, Z. Mancl, L.A., University of Washington, Seattle, WA

Aim: To assess changes in levels of clinical TMD pain in relation to phases of the menstrual cycle.

Methods: Women with normal menstrual cycles (FNC, n=25), women using oral contraceptives (FOC, n=32) and men (n=15) with TMD pain were identified from an orofacial pain clinic. All met RDC/TMD criteria for myofascial pain and arthralgia. Subjects kept daily diaries over 3 consecutive menstrual cycles (3 mo. for men), reporting average and worst pain on 100mm VAS scales, and general and premenstrual symptoms using items of the SCL-90 somatization scale and the PMS Diary. To test for cyclic variation in pain and symptoms, cycles were standardized to 28 days and data were grouped into 9 periods/cycle (days 1-3, 4-6, 7-9, 10-12, 13-15, 16-18, 19-21, 22-24, 25-28). A mixed-effects linear regression model, including a random subject effect and slope (to remove differences in subjects' average response levels and linear trends over time) was used to test for a cycle effect separately for each subject group.

Results: Groups differed on mean age, but not race or education. Overall levels of average pain, worst pain and symptoms did not differ across subject groups; the female groups did not differ on PMS symptom levels. For FNC, peak pain levels were seen during menses at days 1-3 (ave. pain=30.4; worst pain=40.2) with a secondary peak around ovulation (days 13-15, ave. pain=24.6; worst=29.6); ave. pain, p<0.01; worst, p<0.001. In FOC there was a single peak at days 1-3 (ave.=33.1; worst=44.7, p's<0.15). Men's pain ratings showed significantly lower variability than those of women.

Conclusions: TMD pain in women is highest at times of lowest estrogen, but rapid estrogen change may also be associated with high pain in some women.

Acknowledgements: Supported by NIH R01 DE12470.

PAIN PERCEPTION, AUTONOMIC RESPONSE TO PAIN AND ANXIETY IN WOMEN WITH VULVAR VESTIBULITIS SYNDROME
MICHAL GRANOT, MICHAEL FRIEDMAN, DAVID YARNITSKY, DEPARTMENT OF NEUROLOGY, RAMBAM MEDICAL CENTER AND TECHNION FACULTY OF MEDICINE, HAIFA, ISRAEL M. Grano,^, Nursing, University of Haifa, Faculty of health and Walfare Studies, Haifa, Israel

Aim of investigation: To determined the role of anxiety, pain psychophysics and autonomic response to noxious stimuli to predict the mechanism of pain processing in Vulvar Vestibulitis Syndrome (VVS).

Methods: 109 women (68 VVS, 41 controls) participated in the study. Anxiety level was assessed before painful tests. Psychophysical tests included heat pain threshold (HPT) and magnitude estimation of tonic heat pain (46C) both at the forearm. Heart rate was recorded before during and after tonic pain. Power spectrum analysis was performed for low frequency (LH), high frequency (HF) and LF/HF ratio, an index of sympathovagal balance.

Results: VVS women showed increased anxiety scores (39.211 vs. 31.910, p=0.015), lower HPT (40.32 vs. 42.22, p=0.013), higher tonic pain (64.719.6 vs. 53.018.3, p=0.0083). VAS increased along the tonic stimulation in VVS (63.120 to 77.925 - temporal summation), decreased in controls (59.814 to 52.913 - adaptation) (p=0.017). The post pain LF/HF was higher in VVS (5.94) than in controls (3.73, p=0.0096). Regression analysis showed that higher anxiety state, lower HPT, and increased post pain LF/HF are predictive variables for VVS.

Conclusion: VVS can be predicted by higher anxiety state preceding pain stimulation, enhanced pain perception and sympathetic predominance subsequently to painful stimulation. Augmentation of pain processing probably relates to the increased temporal summation that was demonstrated in VVS. This systemic augmentation of pain processing should be taken into consideration in the therapeutic approach in VVS.

HOW DOES HAVING NON-MALIGNANT PAIN INFLUENCE FEMALE SEXUALITY?
B.S. Laursen,^, Department of Nursing Science, Hospital of Aalborg, Aalborg, Denmark

Aim of Investigation: To study the connection between sexuality and chronic non-malignant pain in female patients. To investigate the pain threshold in female patients with chronic non-malignant pain and compare the measurements with healthy controls.

Methods: The investigation consists of three independent studies. The main study is a descriptive, explorative study in qualitative design,in which the qualitative interview is used as method. The subjects in the interview-guide are identity and integrity in relation to the patients sexuality and marital relations. Ten patients with the diagnose of chronic non-malignant pain are interviewed. The other two studies are cross sectional studies. In the first study the pressure pain threshold is measured at seven different points of the body in forty female with the diagnose of chronic non-malignant pain and in forty healthy female. The second study exposes the patients state of pain, state of depression, state of health and consumption of medicine in forty female with the diagnose of chronic non-malignant pain and in forty healthy female, by use of questionnaires.

Results: At present (halfway in the study) the results indicate that problems with sexuality is common in female with the diagnosis of chronic non-malignant pain. Not only problems with the physical sex life, but problems concerning feelings, experiences, thoughts and actions, which are connected with being a woman.

Conclusion: As nurses we must never suppose that just because the patient has raised no question about her sexuality that there are no concerns. Concentrated attention must be given to the issue of sexuality just as it is given to other aspects of pain care because our sexuality is one of the most fundamental parts of our humanity.

ORAL CONTRACEPTIVE USE, PREMENSTRUAL AND GENERAL SYMPTOMS IN CLINICAL PAIN PATIENTS
M. Perron-Burdick, S.F. Mancl, L.A. Sherman, J. LeResche, L.,Oral Medicine, University of Washington, Seattle, WA

Aim of Investigation: To assess the relationship between clinical pain status, oral contraceptive (OC) use and premenstrual symptoms.

Methods: Data were collected from female TMD clinic pain patients with normal menstrual cycles (PNC, n=45), TMD pain patients using OC's (POC, n=48), and women without TMD pain with normal cycles (NP, n=40). Pain patients met RDC/TMD criteria for myofascial pain and arthralgia. Subjects completed the SCL-90 somatization scale, the Premenstrual Assessment Form (PAF), Coping Strategies Questionnaire (CSQ), and rated menstrual pain on a 0-10 scale. ANOVA was used to compare means across all three groups and t-tests to compare the two pain groups.

Results: POC were younger than both non-OC groups (27.3yrs vs 32.4yrs for PNC; 31.6yrs for NP, p<.01), but mean pain duration was similar for PNC and POC (7.4 vs 7.0 yr, ns). PNC and POC did not differ on CSQ catastrophizing. On the PAF, the three groups did not differ on hostility/anger or impulsivity. POCs had the highest scores on lability and atypical depression, and differed significantly from NP on these scales. The 13 remaining PAF scales, which assess physical and psychological symptoms, showed a stair step pattern (PNC>POC>NP). PNC differed significantly from NP for all scales, but PNC differed significantly from POC only for general physical discomfort. A similar pattern (PNC>POC>NP) was observed for somatization and average and worst menstrual pain (all p's<0.001).

Conclusions: TMD patients using OCs report fewer symptoms than patients not using OCs, though this difference is not always statistically significant. OCs may have an ameliorating effect on both premenstrual and general symptoms in women with clinical pain.

Acknowledgements: Supported by NIH R01 DE12740.

DO PAIN SELF-EFFICACY BELIEFS AND PAIN COPING STRATEGIES RELATE TO PAIN EXPERIENCE DURING MAMMOGRAPHY?
A. Asghari, School of Psychology, Univ of Shahed, Tehran, Iran

AIM OF INVESTIGATION: To examine pain experience during mammography and its relationship with pain self-efficacy beliefs and coping strategies.

METHODS: 150 women completed the Pain Self-Efficacy Questionnaire (PSEQ) prior to mammogram. Immediately after mammography, all subjects completed a modified version of Coping Strategies Questionnaire (CSQ). Ratings of pain intensity were also collected, using a Visual Analog Scale.

RESULTS: Up to 86% of women reported the mammogram as painful. Considerable variability in pain ratings was found, with some women reporting severe pain and others reporting little or no pain. A series of multiple hierarchical regression analyses were conducted to determine the degree to which CSQ and PSEQ scores could predict pain severity. When scores on CSQ were entered in the regression analysis as the first block, results indicated that subjects high on catastrophising and coping self-statements reported more severe pain, while subjects high on the scale of ignoring pain endorsed less severe pain. After controlling for the effects of coping strategies, self-efficacy beliefs could significantly predict pain severity, indicating that women endorsing lower levels of self-efficacy beliefs were more likely to report higher levels of pain during examination.

CONCLUSIONS: The findings of this study signify the importance of pain coping strategies and pain self-efficacy beliefs in understanding mammography pain. While the greater use of catastrophising and coping self-statements was predictive of more severe pain, the greater use of ignoring pain could predict lower levels of pain intensity. These findings suggest that pain self-efficacy beliefs are an important determinant of pain severity associated with mammography.

BELGIAN WOMEN AND MENSTRUAL PAIN
H.D. Malonne, M. Foulon, M. Vanschoor, A. Violon, J. Wielandt, L. Goubert, J. Van Hoek, Physiology and Pharmacology, ULB, Brussels, Belgium , ² PAB, Brussels, Belgium

Aim of investigation -To assess the prevalence of menstrual pain in the Belgian population To peer into how Belgian women deal with this kind of pain

Methodology The research has been conducted by face-to-face interviews at respondents residence by Omnibus methodology. We polled a sample of 540 women representative for the Belgian female population of 15 years and older. Interviews took place in the week of 11-17 July 2001.

The following data represent a small part of a large survey about pain and its management in general.

Results 16% of the women claimed to suffer sometimes from menstrual pain, with an equally spread of active and non-active women. Most of them (90%) are experiencing these kind of pain every month, with a high correlation level with headache. For 3 quarters of them the pain lasts at least one day, taking even for more than 60% several days.

More than 3 on the 4 concerned women qualify the pain they are suffering as severe. 6 on the 10 feel uncomfortable with this, 10% considering the problem as handicapping their daily life.

The major consequence of menstrual pain is evoked in terms of emotional disturbances, being put in a bad mood and quickly loosing temper for things belonging to ordinary daily life.

74% of the women suffering from menstrual pains claim to take painkillers, the most cited brands being Nurofen, Dafalgan and Dafalgan Codeine, taken by more than half of them.

Conclusions The main symptoms associated with menstrual pain are emotional and daily living disturbances which strongly require a rational therapeutic approach by healthcare professionals.

Acknowledgments The PAB is sponsored by Boots Healthcare Belgium

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