ASEAPS Congress 2019 Kuching, Malaysia

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8th ASEAPS Congress 2019 Kuching, Malaysia

ABSTRACT BOOK

8TH ASEAPS CONGRESS www.aseaps2019.com

Buildin Collaboration I Pai Managemen

11th – 14th April 2019

Pullman Kuching, Kuching, Sarawak, MALAYSIA

Association of South-East Asian Pain Societies (ASEAPS) PRE-CONGRESS WORKSHOPS

Pain Management Refresher Course 11th April 2019 (Thursday) l Olympia 1 Room, Level 1

Time Topic Musculoskeletal Pain (with Focus on Osteoarthritis) 0830 0900 Prof Lars Arendt-Nielsen Update on Diagnosis, Classification and Treatment of Peripheral Neuropathic Pain 0900 0930 Prof Andrew S. C. Rice Central Pain Conditions: From Mechanism to Treatment 0930 1000 Prof Troels S. Jensen 1000 1030 Tea Break Pain Syndromes in Cancer Survivors 1030 1100 Assoc Prof Sasikaan Nimmaanrat Update on Acute Pain Management – What is New? (ERAS, Ketamine, Gabapentinoids, Peripheral 1100 1130 Nerve Blocks, etc) Dr Andi Muhammad Takdir Musba Engaging the Patient in Pain Coping Skills (Including an Introduction/Synopsis on CBT) 1130 1200 Prof Michael K. Nicholas Pain Management in Trauma Patients 1200 1230 Prof Ramani Vijayan 1230 1330 Lunch Managing Pain in Children - General Principles 1330 1400 Assoc Prof Stefan J. Friedrichsdorf Episodic Pain in Cancer Patients 1400 1430 Assoc Prof Cynthia Goh Challenges When Managing Pain in the Elderly 1430 1500 Assoc Prof Roger C. Goucke Update on Fibromyalgia 1500 1530 Prof Eva Kosek 1530 1600 Presentation of Certificates (Pain Camp Participants Only) Opening Ceremony 1730 1830 followed by Welcome Reception

Building Collaborations In Pain Management 2 PRE-CONGRESS WORKSHOPS

Ultrasound Workshop 11th April 2019 (Thursday) l Eiffel Room, Level 1

Time Topic Principles of Ultrasound in Pain Management 0830 0900 Dr Ahmad Afifi Mohd Arshad Knobology 0900 0930 Prof Babita Ghai 0930 1000 Tea Break Skill Stations - Acute Pain Blocks Station 1 : Upper Limb (Interscalene, Supraclavicular, Axillary Block) Dr Ng Kim Swan Station 2 : Lower Limb (Femoral, Adductor Canal, LFCN, Obturator Nerve Block) Dr Khoo Eng Lea Station 3 : Upper Trunk (Thoracic Paravertebral, Intercostal, PECS Block) Dr Ahmad Afifi Mohd Arshad 1000 1300 Station 4: Lower Trunk (Rectus Sheath, Transverse Abdominis Plane (TAP), Ilio-inguinal Ilio-hypogastric Nerve Block) Asst Prof Nantthasorn Zinboonyahgoon Station 5: Lumbar Region (Lumbar Epidural, Lumbar Plexus Block) Dr Lai Hou Yee Station 6: Sacral Region (Subgluteal Sciatic, Popliteal Nerve Block) Dr Lee Pui Kuan 1300 1400 Lunch Skill Stations - Chronic Pain Blocks Station 7: Head And Neck I (Superficial Cervical Plexus, Cervical Nerve Root, Stellate Ganglion) Assoc Prof Sasikaan Nimmaanrat Station 8: Head And Neck II (Cervical Medial Branch, Greater Occipital Nerve) Dr Ng Kim Swan Station 9: Shoulder Region (Acromioclavicular Joint, Bicipital Tendon, Glenohumeral Joint Injection, Subacromial Subdeltoid Bursa, Supraspinatus Tendon, Suprascapular Nerve) 1400 1700 Dr TCT Novy Station 10: Lumbar Spine (Lumbar Facet Joint, Lumbar Medial Branch) Dr Ahmad Afifi Mohd Arshad Station 11 : Hip And Knee Joint (Hip Joint, Injection, Muscle Injection) Prof Babita Ghai Station 12: Sacrum (Sacroiliac Joint, Piriformis Injection, Pudendal Nerve Block) Prof Philip W. H. Peng Opening Ceremony 1730 1830 followed by Welcome Reception

3 8th ASEAPS Congress 2019 PRE-CONGRESS WORKSHOPS

Transdisciplinary Approach in the Management of Pain 11th April 2019 (Thursday) l Machu Pichu Room, Level 2

Time Topic The Concept of Transdisciplinary in Pain Management 0830 0900 Assoc Prof Zubaidah Jamil Osman Assessment and Management of Patients: The ABCs of Motivational Interviewing Approach 0900 0930 Dr Shawn Lee Ji Kwan Pain Behaviour: Is It Always Bad? 0930 1000 Assoc Prof Zubaidah Jamil Osman 1000 1030 Tea Break Skill Stations Station 1 - Why Do I Have Chronic Pain?: Communicating Pain to Patients Assoc Prof Zubaidah Jamil Osman Station 2 - Physiotherapy Ms Syarifah Nora 1030 1230 Station 3 - Psychology Dr Shawn Lee Ji Kwan Station 4 - Occupational Therapy Ms Siti Nur Ayishah Basari 1230 1330 Lunch Case Studies 1330 1530 Different Aspects of Management on Each Case Summary and Conclusion 1530 1600 Q&A Opening Ceremony 1730 1830 followed by Welcome Reception

Building Collaborations In Pain Management 4 SCIENTIFIC PROGRAMME

12th April 2019 (Friday) - Congress Day 1

Start End Programme 0800 0810 Introductory Remarks by the Scientific Chairpersons Plenary 1: Regional Collaboration to Enhance Pain and Palliative Care Services 0810 0840 P1 Chairperson: Assoc Prof Zubaidah Jamil Osman Assoc Prof Cynthia Goh Plenary 2: Global Burden of Disease: The Impact of Pain 0840 0910 P2 Chairperson: Assoc Prof Sasikaan Nimmaanrat Prof Fiona Blyth President’s Forum - Building Collaborations Moderator: Prof Troels S. Jensen Prof Hasan Sjahrir (Indonesia) Dr Mary Suma Cardosa (Malaysia) 0910 1010 Prof Khin Myo Hla (Myanmar) Assoc Prof Maria Dolma Gudez-Santos (Philippines) Dr Nicholas Chua (Singapore) Assoc Prof Pongparadee Chaudakshetrin (Thailand) 1010 1040 Poster Viewing, Tea Break & Exhibit Visit Colosseum 1 Colosseum 2 Petra 1 Symposium 1 - Symposium 2 - Symposium 3 - Low Back Pain Paediatric Pain Head and Neck Pain Chairperson: Chairpersons: Chairperson: Prof Azlina Amir Abbas Assoc Prof Maria Dolma Prof Toh Charng Jeng Prof Myint Thaung Gudez-Santos Dr Yap Sau Hsien Dr Tang Swee Ping Managing Low Back Pain: Managing Procedural Pain in Do’s & Don’ts Primary Headache: Migraine S1.1 S2.1 Children S3.1 Dr Ozlan Izma Muhamed Dr Julia Shahnaz Merican Dr Tang Swee Ping 1040 1210 Kamil Preventing Fear Avoidance in Abdominal Pain in Children Medication Overuse S1.2 Low Back Pain S2.2 Assoc Prof Stefan J. S3.2 Dr Nicholas Chua Mr Lester E. Jones Friedrichsdorf Management of Low Back Pain: Do Guidelines Close Are Parents Perpetuating Cervicogenic Headache S1.3 the Gap between Evidence S2.3 Pain? S3.3 Assoc Prof Nuj Tontisirin and Practice? Dr Angela Yeo Siok Hoong Prof Jocelyn C. Que Q&A Q&A Q&A Mundipharma Lunch Symposium

The Real Burden of Pain – Exploring Solutions in Treatment and Access 1210 1310 Chairperson: LS1 Assoc Prof Cynthia Goh Speakers: Prof Lars Arendt-Nielsen Dr Henry Lu

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5 8th ASEAPS Congress 2019 SCIENTIFIC PROGRAMME

12th April 2019 (Friday) - Congress Day 1

Start End Programme 1310 1400 Lunch, Friday Prayers & Exhibit Visit Plenary 3: Signs and Symptoms of Sensitisation Across Chronic Pain Conditions 1400 1430 P3 Chairperson: Dr Ho Kok Yuen Prof Lars Arendt-Nielsen Plenary 4: Brain Imaging Of Chronic Pain 1430 1500 P4 Chairperson: Dr Andi Muhammad Takdir Musba Prof Karen D. Davis Colosseum 1 Colosseum 2 Petra 1 Symposium 4 - Symposium 5 - Symposium 6 - Latest Update in Pharmacology for Medicolegal and Ethical Issues Managing Challenging Cases Pain Management Chairpersons: Chairperson: Chairperson: Dr Francis O. Javier Assoc Prof Zubaidah Jamil Osman Prof Ramani Vijayan Dr Raveenthiran Rasiah Treatment Waitlists: COXIBs / NSAIDs: The Patient Impact and Service Managing Difficult Patients S4.1 Controversies S5.1 S6.1 Considerations Prof Michael K. Nicholas Dr Ho Kok Yuen Dr Anne L. J. Burke 1500 1630 Cannabinoids for Ethical Challenges in a Pathophysiology and Neuropathic Pain: Are They S4.2 S5.2 Death-Denying Environment S6.2 Treatment of Fibromyalgia Safe or Effective? Dr Ednin Hamzah Prof Eva Kosek Prof Andrew S. C. Rice

Update in Role of Ketamine Brain Imaging to Treat or Prevention of Complex S4.3 in Pain Management S5.3 Diagnose Pain: Ethical Issues S6.3 Regional Pain Syndrome Assoc Prof Nuj Tontisirin Prof Karen D. Davis Prof Merle F. Dela Cruz-Odi Q&A Q&A Q&A 1630 1700 Poster Viewing, Tea Break & Exhibit Visit

1900 Faculty Dinner (By Invitation Only) Onwards

Note: All single sessions take place in Colosseum 1 unless stated otherwise.

Building Collaborations In Pain Management 6 SCIENTIFIC PROGRAMME

13th April 2019 (Saturday) - Congress Day 2

Start End Programme Plenary 5 : Pain in Children 0800 0830 P5 Chairperson: Dr Angela Yeo Siok Hoong Assoc Prof Stefan J. Friedrichsdorf Plenary 6: An Overview of Neuropathic Pain in Infectious Diseases 0830 0900 P6 Chairperson: Prof Ramani Vijayan Prof Andrew S. C. Rice Colosseum 1 Colosseum 2 Petra 1 Symposium 7 - Symposium 8 - Symposium 9 - Cancer Pain Pain in Vulnerable Populations Using Internet-Based Technology Chairperson: Chairperson: to Advance Pain Management Assoc Prof Cynthia Goh Dr Mary Suma Cardosa Chairperson: Dr Kavita Bhojwani Assoc Prof Sasikaan Nimmaanrat Dr Shawn Lee Ji Kwan Chemotherapy-Induced Using Social Media as an Fragile Cancer Patients S7.1 Peripheral Neuropathy S8.1 S9.1 Advocacy Tool Dr Ednin Hamzah Dr Henry Lu Prof James F. Cleary 0900 1030 Management of Cancer Pain Long-Distance Education Pain in Older Adults S7.2 in Paediatric Patients S8.2 S9.2 Using Web-Based Tools Assoc Prof Roger C. Goucke Dr Edi Setiawan Tehuteru Prof Michael K. Nicholas Pain Assessment in Applying Technology in Intrathecal Drugs Delivery Survivors of Torture: A Delivering Psychological S7.3 for Cancer Pain S8.3 Case of Resilience versus S9.3 Interventions for Chronic Dr Ng Kim Swan Vulnerability Pain: A Study in Singapore Mr Lester E. Jones Dr Yang Su-Yin Q&A Q&A Q&A 1030 1100 Poster Viewing, Tea Break & Exhibit Visit Symposium 11 - Symposium 10 - Symposium 12 - Acute Pain Pain Management Programmes Pain Related Research Chairperson: Chairperson: Chairperson: Dr Raveenthiran Rasiah Prof Marzida Mansor Prof Choy Yin Choy Assoc Prof Pongparadee Dr Jimmy Barus Dr Nicholas Chua Chaudakshetrin Overview of Pain Improving Patient Outcomes Management Programmes Following Surgery Knowledge Translation S10.1 S11.1 S12.1 in Asia Assoc Prof Maria Dolma Prof Fiona Blyth Dr Yang Su-Yin Gudez-Santos 1100 1230 Training of Personnel Who Continuous Regional The Role of Sodium Run Pain Management Analgesic Techniques for Channels in Nerve Injury S10.2 Programmes S11.2 S12.2 Acute Pain Relief Pain Assoc Prof Zubaidah Jamil Dr Michael Beh Zhi Yuen Prof Troels S. Jensen Osman From West to East: Transition of Acute to Overcoming Challenges in Addressing Cultural Chronic Pain - Identifying Doing Research in ASEAN S10.3 Differences in Pain S11.3 The Risk Factors S12.3 Countries Management Programmes Dr Ahmad Afifi Mohd Assoc Prof Teekayu P. Jorns Dr Nattha Saisavoey Arshad Q&A Q&A Q&A

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Building Collaborations In Pain Management 7 SCIENTIFIC PROGRAMME

13th April 2019 (Saturday) - Congress Day 2

Start End Programme Colosseum 1 Colosseum 2 Petra 1 A Menarini Lunch Johnson & Johnson Lunch Symposium Symposium Managing Pain and Inflammation: Opioids and Treatment of Chronic Your Top 10 Questions Answered Pain: Controversies, Status and Chairperson: Future Directions 1230 1330 Dr Mary Suma Cardosa Chairperson: Speakers: Dato’ Dr Lim Boon Ping Dr Richard Wong Speaker: Dr Ho Kok Yuen Dr Alex Yeo Sow Nam Assoc Prof Maria Dolma Gudez- Santos 1330 1400 Poster Viewing & Exhibit Visit Symposium 15 - Symposium 13 - Symposium 14 - Pain Education Neuropathic Pain Pain Rehabilitation Chairperson: Chairperson: Chairperson: Prof Azlina Amir Abbas Prof Jocelyn C. Que Prof Khin Myo Hla Assoc Prof Maria Lilybeth Dr Lim Ern Ming Dr Wan Rohaidah Wan Ahmad R. Tanchocho Prescribing Exercise and Chemotherapy-Induced Promoting Undergraduate Ensuring Compliance for S13.1 Painful Neuropathies S14.1 S15.1 Pain Education Chronic Pain Patients Prof Troels S. Jensen Prof Nancy M. Rehatta 1400 1530 Ms Syarifah Nora Spectrum of Neuropathic Spine Sensitization in Pain Pain Education for Non-Pain S13.2 Pain in Myanmar S14.2 Rehabilitation S15.2 Specialists in the Philippines Prof Phyu Phyu Lay Prof Khin Saw Oo Prof Maria Salome N. Vios Exploring Comprehensive Rehabilitation for Cancer Impact of Cancer Pain Management of Painful Survivors S13.3 S14.3 S15.3 Education in Myanmar Diabetic Neuropathy Dr Sharon Anne Khor Kiat Prof Myo Myint Maw Dr Jimmy Barus Sim Q&A Q&A Q&A Best Poster Presentation (Colosseum 2) Chairperson: Dr Athena Tang Mee Yee Effects of Intravenous Magnesium Infusion for Total Knee Replacement Surgery under Spinal Anesthesia: A Randomized Double-Blinded Prospective Study BP1 Liew S L, Alvin O P, Jony S, Khor F K, Raman S. Rm, Dharmalingam Tk, Muniandy Rk, Thong F Y, Tan C V, Symeon M Correlated Factors with Neuropathic Pain among Industrial Workers in Vietnam: A Multi-Site Cross- BP2 Sectional Study 1530 1630 Tung T T, Bach X T Effectivity of Vitamin B Combination on Diabetic Neuropathy Patients: An Observational Study BP3 Rosa De L R S, Rizaldy T P PCA Ketamine-Morphine versus PCA Morphine as Analgesia in Postoperative Colorectal Surgery BP4 Patients Nurul Akasya A, Nita Salina A Role of Nitric Oxide Synthase Inhibitor in Alleviating Hyperalgesia and Allodynia in CCI-Induced BP5 Neuropathic Pain Mice Nur Khalisah K 1630 1700 Poster Viewing, Tea Break & Exhibit Visit

1930 Congress Dinner (refer to page 36 for more details) Onwards

Note: All single sessions take place in Colosseum 1 unless stated otherwise.

8 8th ASEAPS Congress 2019 SCIENTIFIC PROGRAMME

14th April 2019 (Sunday) - Congress Day 3

Start End Programme Plenary 7: Ultrasound for Musculoskeletal Pain Interventions 0800 0830 P7 Chairperson: Dr Ahmad Afifi Mohd Arshad Prof Philip W. H. Peng Plenary 8: The Other Opioid Crisis 0830 0900 P8 Chairperson: Prof James F. Cleary Dr Francis O. Javier, Philippines Colosseum 1 Colosseum 2 Petra 1 Symposium 16 - Symposium 17 - Symposium 18 - Interventional Musculoskeletal Pain Pain Classification Pain Management Chairperson: Chairperson: Chairperson: Prof Marzida Mansor Dr Jimmy Barus Dr Khoo Eng Lea Prof Khin Myo Hla Dr Lim Ern Ming Prof Khin Saw Oo Practical Management of Pain Diagnoses in ICD Perineural Steroids: What is Myofascial Pain 11: Implications for Pain S16.1 The Current Evidence? S17.1 S18.1 Assoc Prof Pradit Practitioners Dr Nicholas Chua Prateepavanich Prof Michael K. Nicholas 0900 1030 Acupuncture, Neuromodulation in the Complementary and Context of a Developing Nociplastic Pain: Do We Integrative Medicine: S16.2 Country S17.2 S18.2 Need a 3rd Descriptor? Evidence In Pain Asst Prof Nantthasorn Prof Eva Kosek Management Zinboonyahgoon Dr Yap Sau Hsien The Evaluation of Pain Hip and Knee Interventions : Pain Descriptors in Complicating Disabling S16.3 State of the Art Review S17.3 S18.3 Vernacular Languages Diseases Prof Philip W. H. Peng Dr Athena Tang Mee Yee Prof Angela B. M. Tulaar Q&A Q&A Q&A 1030 1100 Tea Break & Exhibit Visit Panel Discussion: Opioids - Getting The Balance Right Dr Ednin Hamzah Moderators Prof Ramani Vijayan Global and Regional Perspective on Opioid Use Prof James F. Cleary Dr Andi Muhammad Takdir Musba (Indonesia) 1100 1200 Dr Ozlan Izma Muhamed Kamil (Malaysia) Prof Myint Thaung (Myanmar) Assoc Prof Maria Lilybeth R. Tanchocho (Philippines) Dr Ho Kok Yuen (Singapore) Assoc Prof Supranee Niruthisard (Thailand) 1200 1230 Closing Ceremony - Presentation of Best Poster Presentation Award Note: All single sessions take place in Colosseum 1 unless stated otherwise.

9 8th ASEAPS Congress 2019 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Colour Code Assigned Presentation Session Presentation Schedule 12th April 2019 Morning Tea Break (1010 – 1040 hrs) *Poster Presenters will be on standby in front of their posters to receive questions 12th April 2019 Afternoon Tea Break (1630 – 1700 hrs) from delegates based on the colour 13th April 2019 Morning Tea Break (1030 – 1100 hrs) assigned to the poster code. 13th April 2019 Afternoon Tea Break (1630 – 1700 hrs)

Poster ID Abstract Acute Pain Evaluation of Pre-emptive Intravenous Parecoxib on Analgesic Sparing Effect in Patients with Total AP 01 Abdominal Hysterectomy Mohd Faeiz P , Mohd Erham M H, Nik Abdullah N M, , Siti Norazlina J Effects of Intravenous Magnesium Infusion for Total Knee Replacement Surgery Under Spinal Anesthesia: A Randomized Double-Blinded Prospective Study AP 02 Liew S L, Alvin O P, Jony S, Khor F K, Raman S. Rm, Dharmalingam Tk, Muniandy Rk, Thong F Y, Tan C V, Symeon M Intrathecal Morphine for Post-Cesarean Analgesia: Duration of Analgesia, Side Effects and Patient AP 03 Satisfaction S Shivali, T Prabha, Boo Jian A, Charlene C S L, Yeh Kuan Y, Bina Rai PCA Ketamine-Morphine versus PCA Morphine as Analgesia in Postoperative Colorectal Surgery Patients AP 04 Nurul Akasya A, Nita Salina A Pain Free Hospital Program Effort How to Maintain Pain Score 4 in Post-Operative Patients AP 05 Nur Hazalina Md S, Ungku Kamariah U A Pain Out Aspire Phase 1 Project Preliminary Acute Postoperative Pain Baseline Data in an University AP 06 Hospital Lim S M, Beh Z Y, Lim W L, Marzida Binti M, Ramani V S External Validation of a Predictive Model for Acute Postoperative Severe Pain After in - and Outpatient AP 07 Surgery Phooi S L Acute vs Chronic Pain is There Any Difference in Quality of Life AP 08 Farida N A, Tika P, Hermawan H The Analgesic Effects of Pentadecapeptide BPC 157 Studied on Incisional Pain Model in Rats AP 09 Rushin M D, Kim E, Kim H Fracture Reduction – Analgesia is the Most Important Not Sedation AP 10 Mohd Aizat Bin M, Ungku Kamariah U A, Nuur Nisarin T Intravenous Ketamine-Lignocaine Infusion for Pain Management in Wound Care AP 11 Muhammad Rahmat A H, Ungku Kamariah U A A Meta-Analysis on the Efficacy and Safety of Epidural Oxycodone versus Epidural Morphine for AP 12 Postoperative Pain Relief in Adults Chris B S, Nina B Sphenopalatine Ganglion Block Transnasal Approach: Post Spinal Anesthesia With Headache. AP 13 KB Ibrahim, NI Bahar.

Building Collaborations In Pain Management 10 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Acute Pain - Case Report It Was an Epidural Block; or Was it a Subdural Block? Possible Transient Ischemic Attack (TIA)? AP 14 SN Amani A, A Hazwan MN , W Rohaidah WA Benefits of Early Intervention Using the Combination of Gasserian and Sphenopalatine Ganglion Block on AP 15 Trigeminal Neuralgia at St. Lukes Medical Center Global City, Taguig City, Philippines Rainier T, Emmanuel Q. V, Jocelyn C. Q

Cancer Pain Neutrophil-to-Lymphocite Ratio in Primary Brain Tumor Patients Presenting with Versus Without CP 01 Headache Rissito C D, Kusumo D, Ahmad Asmedi Cancer Pain - Case Report Hygroma Post Intrathecal Catheter Insertion : A Case Report CP 02 Sze T K, Mazlila M A S, Mary S C, S Sushila Aromatase Inhibitor Induced Arthralgia - Management Approach from a Rehabilitation Perspective CP 03 R Mothi Babu , Tan Yeow L

Chronic Post-Surgical Pain Identifying Predictors of Postoperative Persistent Pain in Women with Breast Cancer in Malaysia CPS 01 Che G H, Nur Aishah T, Hwan-J Y, David L, Desmond Y, Violeta L Chronic Post-Surgical Pain - Case Report Spinal Cord Stimulation Therapy for Patients with Post-Surgical Spine Syndrome CPS 02 Kwan H P, Tae W K, Ju C Y, Do H K Effectiveness of Intrathecal Morphine Pump Procedure in Patients with Post-laminectomy Syndrome CPS 03 Kwan H P, Ju C Y, Tae W K, Do H K

Complementary and Alternative Therapies Effects of Acupuncture on Quality of Life and Pain in Patients with Chronic Pain CA 01 Rajesh Kumar M

11 8th ASEAPS Congress 2019 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Complementary and Alternative Therapies - Case Report The Use of Low Level Laser Therapy (LLLT) in Complex Regional Pain Sydrome (CRPS) CA 02 Rushin M D, Jon Y H, Kim E, Kim H Acupuncture-Assisted Anaesthesia in Breast Lump Excision a Case Series from Malaysia CA 03 Ju-Ying Ang, Kavita M B, Huan-Keat C Acupuncture Assisted Anaesthesia for High Risk Parathyroid Surgery CA 04 Dr Peggy Cheang Peak Chee, Kavita M B

Head and Neck Pain Oral Health-Related Quality of Life Patients with and without Temporomandibular Disorders in a Regional HN 01 Referral Hospital Zafirah H ,M Khamisah A K, Yuen K M Head and Neck Pain - Case Report Hydrotherapy for Chronic Neck Pain HN 02 Michael W Trigeminal Neuralgia Serial Case Report HN 03 Devi A S, Isti S

Interventional Therapies The Validation of Sonograph-Guided Medial Branch Blocks as Confirmed by Flouroscopy in Chronic IT 01 Lumbar Facet Joint Pain Farid Y Effectiveness and Safety of Ablation Radiofrequency in Trigeminal Patients in Sardjito Hospital, Indonesia: IT 02 Case Series Fauziah L J, Whisnu N T, Yudiyanta, M Ultrasound Guided Steroid Injection for Piriformis Syndrome in Sardjito Hospital: Case Series IT 03 Hana A, Indarwati S, Cempaka Thursina S S Case Series: Ultrasound Guided Triamcinolone Acetonide Injection for Frozen Shoulder in Sardjito IT 04 Hospital Siti Zulaikhah, Whisnu N T, Subagya

Building Collaborations In Pain Management 12 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Interventional Therapies - Case Report Unanticipated Improved Appetite After Diagnostic Celiac Plexus Block in Gallbladder Adenocarcinoma IT 05 Chris B S, Emmanuell V Ultrasound Guided of Stellate Ganglion Block for Primary Hyperhidrosis IT 06 Umairah M, Wan Rohaidah W A Pneumothorax Post Stellate Ganglion Block, Unrecognized Complication or Merely Coincidence IT 07 Ikhwan Wan M R, Wan Rohaida W A

Musculoskeletal Pain Prevalence Study of The Relationship of Chronic Back Pain and Depression Symptoms at Hospital Tuanku MP 01 Jaafar, Seremban Chanell F Z, Chen Y K, Jasmin N C W, Sinthia R, Philip G, Ng Saw Y Comparison of Clinical Outcome Low Versus High Fatty Infiltration of Posterior Muscle in Chronic Low MP 02 Back Pain Following Medial Branch Block 1 Years Follow Up Farid Y Correlates of Low Back Pain among Filipino Caregivers of Children with Disability MP 03 Maybelle A L Z, Hernan C. L The Modified Prasit Thai (Maneevej) Upper Extremities Stretching Exercise Combined with Ergonomic MP 04 Recommendations on Neck & Shoulder Pain in Nongkhai Hospital Workers Wanrattha T Correlates of Coping Among Filipino Migrant Workers in Malaysia with Musculoskeletal Pain MP 05 Hernan C L Review of Sonoelastography In the Assessment of Myofascial Pain Syndrome: A Novel Technique MP 06 Jing C, Tze C W The Difference of Depression Incidence in Osteoarthritis Patient with Oral NSAIDs and Intraarticular MP 07 Injection of Hyaluronic Acid in Dr Moewardi Hospital Central Java Anisa N, Mohammad Fanani, Nurhasan A P

13 8th ASEAPS Congress 2019 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Musculoskeletal Pain - Case Report Hip or Spine, Which One To Treat? A Case of Complex Hip Spine Syndrome in Body Builder MP 08 Mohd Azwan A, Redzal A H, Mariam G M The Role of Transdermal Buprenorphine in the Treatment in Elderly with Arthritis MP 09 S Bavani , Mohamad Aswad A A Rare Case of Chronic Tophaceous Gout with Disseminated Cutaneous Tophi and Renal Impairment Pain MP 10 Management Considerations Faisal P

Neuropathic Pain Depression Among Non-cancer Chronic Pain Patients at Pain Clinic, Queen Elizabeth Hospital, Sabah, NP 01 Malaysia T.Kumaravadivel D, Rajesh Kumar M Effectivity of Vitamin B Combination on Diabetic Neuropathy Patients: An Observational Study NP 02 Rosa De L R S, Rizaldy T P The Comorbidities Profile in Geriatric Patient with Neuropathic Pain NP 03 Patrick N N, Rizaldy T P Clinical Outcome of Percutaneous Epidural Neuroplasty in Lumbar Disc Herniation at Hardjolukito Air NP 04 Force Central Hospital, Yogyakarta Clara N B The Comparison of Symptom of Diabetic Neuropathy and Other Type of Neuropathy NP 05 Jesisca J, Rizaldy T P Effects of Cardamonin on Nitric Oxide Using Neuroinflammation LPS-Induced SH-SY5Y Human NP 06 Neuroblastoma Cell Model Nurul Syazwani Mohd S, Mohd Roslan S, Enoch K P Role of Nitric Oxide Synthase Inhibitor in Alleviating Hyperalgesia and Allodynia in CCI-Induced NP 07 Neuropathic Pain Mice Nur Khalisah K Pain Control in Chronic, Refractory CRPS by Continuous Brachial Plexus Analgesia NP 08 Andrzej Z, Piotr P Results of the Treatment of Chronic, Refractory CRPS with Ketamine Infusions NP 09 Andrzej Z, Piotr P, Zbigniew S

Building Collaborations In Pain Management 14 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Neuropathic Pain - Case Report 5% Lignocaine Patch on Chronic Low Back Pain NP 10 Kevin O Z K , Mohd Aswad A Role of Intravenous Ketamine Infusions in Alleviating Pain for Fibromyalgia Patient NP 11 Hadri K, Mohd Aswad A Neuropathic Pain Secondary to Complete Transection of the Sciatic Nerve NP 12 Maria Fe R A. E, Edwin J C Pregabalin as An Adjuvant to Diagnose and Manage Atypical Optic Neuritis, a Case Report NP 13 S Subhashini, P Muralitharan , N Gaayathri Deafferentation Pain in a Patient with Trigeminal Neuralgia Following Multiple Radiofrequency Ablations NP 14 a Case Report Nicole S. T-T, Emmanuell Q. V, Md Successful Treatment of Paediatric Lower Limb CRPS by Continuous Epidural Anaesthesia a Report of 2 NP 15 Cases Andrzej Z

Obstetrics and Labour Pain Retrospective Study: Comparison Between Effect of Epidural Infusion and Epidural Morphine on Pain OL 01 Score 48 hours Post-Operatively Among Caesarean Patient with Underlying Heart Disease Nur Liyana H, Afaf Azlin A, Husni Z Abd H, P Nanthini Evaluation on the Effectiveness of Post Caesarean Pain Management and Patient's Awareness of Pain OL 02 Lu E, Cheng S M Obstetrics and Labour Pain - Case Report Incidence of Neonatal Abstinence Syndrome (NAS) Among Infants with Prenatal Exposure to Transdermal OL 03 Buprenorphine for Maternal Pain Management Mohd Aiman A , Wan Rohaidah W A

15 8th ASEAPS Congress 2019 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Pain Education Knowledge, Attitude and Practice of Critical Care Nurses’ (CNS) Towards Critical Care Pain Observation PE 01 Tool (CPOT) Natrah A, Norimah S, Maniza M, Siti Aslina N Nurses Knowledge and Attitudes Towards Pain Management in Malaysia PE 02 Woo G K A Survey on Health Care Worker’s Perception towards a Pain Free Hospital PE 03 Li E N, R Usha , Eng C G, Syahanim S, M Maleni , Nurhidayah Z, Jahizah H Pain Service in East Timor PE 04 Flavio B de A Pain Education - Case Report The Role of Pharmacist in Pain-Free Hospital PE 05 Nadia Hani G

Pain In Children The Knowledge of Flacc Tool in the Management of Post-Operative Paediatric Pain Among Anaesthetic Nurses PC 01 Khairunnisa S, Amaliana S S, Asmahani Abd S, Izzaty N A, K Devanandhini, Ahmad Kamarul Z Abd R, M Malini, Mohd Azrul I EMLATMCream 5% Exploring the Usage of Eutectic Mixture of Local Anaesthesia (EMLA) in Paediatric PC 02 Departments in Malaysia V Sindhu , S Premaa , K Devanandhini , Amar-Singh H, J Netia , N Jeyaseelan Pain In Children - Case Report Surgical Treatment of the Pain of Chronic Pancreatitis in Adolescents a Report of 2 Cases PC 03 Nuraeiniza I, Beh Z Y, Lim S M, Lim W L, Marzida M, Ng R T, Yik Y I

Pain In Elderly Prescribing Patterns of Pain Treatment in Elderly with Chronic Pain PEL 01 Fransiscus B, Rizaldy T P The Clinical Pattern of Pain and Comorbidity in Geriatric Patients with Various Pain Condition PEL 02 Vincent O W, Rizaldy T P

Building Collaborations In Pain Management 16 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract The Characteristic of Pain in Elderly Patient with Hypertension in Indonesia PEL 03 Patrick N N, Rizaldy T P Pain Characteristic in Geriatric Patient with Sleep Disturbance PEL 04 Ranbebasa B B, Rizaldy T P

Importance of Pain Management in Elderly PEL 05 Jesisca J, Rizaldy T P The Correlation Between the Amount of Painkiller and the Risk of Gastrointestinal Bleeding in Elderly PEL 06 Patients Abraham Al J, Rizaldy T P The Characteristics of Pain in Elderly PEL 07 Rosa De L R S, Rizaldy T P Pain In Elderly - Case Report Is Sacro-Iliac Joint Dysfunction Succesfully Managed by Pulse Radiofrequency Ablation in Elderly within PEL 08 Long term Follow Up? Farid Y, Deasybherminawaty

Pharmacology Utilization of Intravenous Paracetamol in the Intraoperative Setting and Its Effect on Hemodynamic PH 01 Changes Munira Mohammad I, Marhanis S O The Effect of Granisetron and Ondansetron on Hemodynamic During Cesarean Section Under Spinal PH 02 Anesthesia Ahmad Nur I, Muhammad Ramli A

Pain In Other Vulnerable Populations Pain Management in Spinal Cord Injury are we Achieving Functional Improvement PV 01 R Shivani A Retrospective Study on Prevalence of Pain Among Chronic Kidney Disease Patients in a Palliative Care PV 02 Unit Saiful Adni Abd L , Choo Y L, Tan P W

17 8th ASEAPS Congress 2019 POSTER PRESENTATION @ FOYER AREA, LEVEL 2

Poster ID Abstract Pain In Other Vulnerable Populations - Case Report Erector Spinae Plane (ESP) Block Catheter Technique as Analgesic Adjunct in Traumatic Rib Fractures in PV 03 Intensive Care Units: A Report of 2 Cases Siew G H, Beh Z Y, Lim S M, Mohamad Fadhil H J, Marzida M

Others Correlated Factors with Neuropathic Pain Among Industrial Workers in Vietnam: A Multi-Site Cross- OT 01 Sectional Study Tung T T, Bach X T Correlation of HBA1C Level with Electrodiagnostic Parameters of Diabetic Autonomic Neuropathy OT 02 (Sympathetic Skin Response and Interval R-R Study) Isnaini A High Opioid Dose Escalation to 100 and 200mg per Day in Patients with Long Term Opioid Therapy: Sex OT 03 Difference Che S Z Characteristics of Mixed Pain Patients in Dr Zainoel Abidin Hospital Banda Aceh, Indonesia OT 04 Dessy R E, Oktavia W H, S B Association of Pain Intensity and Sleep Quality in Low Back Pain and Chronic Migraine OT 05 Raden Ajeng D P, Yuneldi A, Nirwan S Others - Case Report Paravertebral Block as Surgical Anaesthesia for Video Assisted Thoracoscopy and Lung Biopsy in High Risk OT 06 Patient: A Case Report Ahmad Shafwan A, Beh Z Y, Kevin Ng W S, Noorjahan Haneem Md H, K Sivakumar Gaucher’s Disease OT 07 Pheakdey N Establishment of Chronic Pain Services International Islamic University Malaysia Medical Centre (IIUMMC) Experience OT 08 Abdul Hadi M, Nor Zamzila A , Norliza O , Syazwani T , Norhasmira Z, Nurul Hafiza M.N, Siti Azura A , Norharyani M.R , Mohd Mahyuddin M.I , Muhama

Building Collaborations In Pain Management 18 PRC01

Musculoskeletal Pain: With focus on osteoarthritis

Lars Arendt-Nielsen

Aalborg University, Denmark

Today’s management of osteoarthritis (OA) consists mainly of symptomatic treatment of pain. New safe and more efficient treatment paradigms are needed for OA but such a development requires a solid fundamental understanding of the central pain mechanisms involved in OA.

In the individual patient little association is found between joint damage, local inflammation, and pain as the central nervous system due to sensitization amplify the peripheral nociceptive input. Recently degree of sensitization (spreading extra-segmental sensitization), descending pain control, and central temporal and spatial integration are some of the individual central nervous system factors playing a role for pain amplification, pain severity and hence the disconnect between extend of damage and pain intensity perceived by the patient. Although the peripheral sources of pain in OA are not well understood we know that continuous nociceptive barrage from joint and extraarticular nociceptors will eventually activate the central sensitization processes with pain amplification and expansion of the receptive fields for the dorsal horn neurons (perceived pain areas will increase). It has consistently been shown that pain intensity, pain durations, and number of OA locations are important drivers for such central sensitization in OA.

Better understanding of the individual fundamental central pain mechanisms may improve patient profiling, help individualizing management, suggest new treatment options and thereby advance development of new therapies. Techniques for assessing the central pain sensitization mechanisms in OA patients have been developed and provide the opportunity to quantify pain mechanisms such as temporal summation, descending inhibition, and spreading sensitization. Such pain biomarkers can help to phenotype OA patients based on the role of the various central pain sensitization mechanisms involved. We have recently shown that such biomarkers can predict which patients are most vulnerable to develop chronic post-operative pain after knee replacement.

PRC02

Update on the diagnosis, classification and treatment of peripheral neuropathic pain

Andrew SC Rice

Imperial College London, United Kingdom

This Refresher Course presentation will cover recent developments in the diagnosis, classification and treatment of peripheral neuropathic pain. It will draw on key guidelines and other publications published by International Association for the Study of Pain (IASP) and its Special Interest Group on Neuropathic Pain (NeuPSIG). The style and content of the lecture will be tailored towards providing useful information for clinicians and a framework for colleagues to take home and use in their daily clinical practice.

The starting point will the 2011 revision of the IASP definition of neuropathic pain. The speaker will describe how this definition can be used by the clinician to ask two simple, but critical, questions:

1. Is a lesion or disease of the somatosensory system? 2. Is the pain neuropathic?

The discussion will then flow into a description of the diagnostic grading system that was naturally developed from the definition. By using this system each patient can be described as having “possible”, “probable” or “definite” neuropathic pain. The speaker will describe how this approach can be easily and rapidly used in the context of a routine clinical consultation.

The World Health Organisation’s publication “International Classification of Disease” (ICD) is the long-established global standard for medical coding and disease classification. ICD is often used to plan healthcare policy and set research priorities at international and local levels. In some healthcare systems an accurate ICD code is an important tool for efficient re-imbursement at practice level. Thanks to investment by IASP, and the efforts of many members, the 2018 11th Revision (ICD-11) for the first time includes a comprehensive pain classification. The speaker will demonstrate the ease of locating appropriate codes for neuropathic pain using the online version of ICD-11.

The workshop will then go on to describe the 2015 NeuPSIG treatment guidelines for neuropathic pain. These were developed from a robust and exhaustive systematic review and meta-analysis of the evidence. Finally, the session will end with a look into the future to see how current research, especially around biomarker discovery, is establishing a framework for developing personalized medicine approaches for treatment of neuropathic pain, at the individual patient level.

PRC03

Central Pain Conditions: From Mechanisms to Treatment

Troels S. Jensen

Dept. of Neurology and Danish Pain Research Center, Aarhus University Hospital, DK-8200 Aarhus N, Denmark.

Central pain (CP) represent different neuropathic pain conditions, where lesions of somatosensory pathways in the central nervous system (CNS) are assumed to be responsible for the pain. CP are - as their peripheral counterparts - characterised by pain in those body parts that corresponds to the brain or spinal cord territories, whose function has been disrupted by the CNS lesion. The distribution of pain in CP represents only a fraction of the area with reduced sensation, indicating that deafferentation is necessary for the pain. The occurrence of evoked pain, summation and aftersensations in the same body parts with reduced sensory discrimination indicates that hyperexcitability in addition to hyposensitivity also is a manifestation of CP. These findings have led to the proposal that partial or complete loss of afferent input result in hyperexcitability in certain neuronal pools and hence pain. The etiology of central neuropathic pain are multiple and includes pains caused by stroke, by spinal cord injury, by immunological disorders such as multiple sclerosis and transverse myelitis. Treatment trials in patients with central pain may contribute to unravel mechanisms underlying these pain conditions. Tricyclic antidepressants has a pain relieving effect which may be related to a restoration of ascending monoaminergic input to the thalamus. Lidocaine an unspecific sodium channel blocker has in double-blind controlled trials shown efficacy on pain and evoked abnormality in patients with post stroke pain and in spinal cord injury pain. Lamotrigine a sodium channel blocker is efficacious in post stroke pain and possibly in incomplete spinal cord injury. Gabapentin and pregabalin both antihyperalgesics are likewise effective in relieving pain in spinal cord injury pain. Cannabinoids have a pain relieving effect in MS.

PRC05

Update on Acute Pain Management – What is New? (ERAS, Ketamine, Gabapentinoids, Peripheral Nerve Blocks, etc)

Takdir A.M. Musba

Department of Anesthesiology, Intensive Therapy and Pain Management Faculty of Medicine, Hasanuddin University, Indonesia

Acute pain management is very important because some negative effects due to the inadequate pain relief. On the other hand, the selection of analgesia for acute pain need to be more carefully and consider the patient pre-existing disease or injury and co-morbidity. That’s why we need the balance between risk and benefit. An understanding to clinical application of analgesia options needs by doctor who will treat acute pain, either long-used analgesia or some new analgesia. Many studies and clinical application now focused on the opioid choices, non-opioid analgesic such as Ketamine, Dexmedetomidine and recently the using of nerve block and regional analgesia.

Opioids still the standard analgesia for moderate to severe acute pain and no one kind of opioid superior compared to the others so the selection depends on patient condition and needs.

Ketamine is old new drug which is currently widely used as low-dose analgesia which can reduce the side effects and the choice for opioid tolerance or opioid induced hyperalgesia. In addition, ketamine stereoisomers has been available in several countries which can provide adequate analgesia with minimal side effects.

Dexketomidine, alpha-2 adrenergic antagonist, has been the choice of analgesia for patients with acute pain especially in intensive care whose need strong analgesia with rapid onset and offset with minimal effects on organ systems.

The role of nerve blocks in the treatment of acute pain was popular due to the increasing use of ultrasound guiding which gives the precise injection location, good analgesia and minimization the use of a number of local anesthetics. The ERAS (Enhanced Recovery After Surgery ) concept introduced for better outcome for perioperative patient and analgesia modality play a big role on this concept such as epidural analgesia perioperative for abdominal surgery and the titration of opioid using and optimalize non-opioid analgesic such as gabapentinoid.

PRC07

Pain Management in Trauma Patients

Ramani Vijayan

University Malaya Specialist Centre, Kuala Lumpur, Malaysia Hospital Kuala Lumpur

Introduction Injury due to road traffic accidents and violent conflict is a significant cause of severe pain. It is mainly acute pain, with varying degrees of intensity and leads to considerable suffering both at the time of injury and later during rehabilitation. Acute Pain is also the most frequent reason for visits to the emergency department.

Management Pain management is therefore a critical part of trauma care. Untreated or inadequately treated pain intensifies the effect of trauma on haemodynamic instability. It increases the incidence of complications including the chances of developing chronic pain and post-traumatic stress disorders later. Despite an increased understanding of acute pain physiology and the availability of drugs to treat acute pain, pain following trauma is not addressed appropriately around the world, as can be seen by several surveys.

There are multiple reasons for this inadequacy. They include inadequate assessment of severity, excessive concerns with haemodynamic stability and respiration, opiophobia or an unfounded fear of addiction in the use of opioids and a wide variation in what patients and doctors find is optimum pain relief. Having protocols in place and training in the use of these protocols has improved pain management in many emergency departments.

Pain management depends on the general condition of the patient, severity of injury, age of the patient and other compromising issues such as chest trauma and airway compromise. General principles of care remain the same as with any acute pain situation. They are assessment of severity using appropriate tools and formulating an analgesic plan depending on the severity of pain. The use of the analgesic ladder is encouraged with opioids being used for moderate and severe pain and the addition of other multimodal analgesics for opioid sparing. Having protocols in place and regular reassessment is important.

Three problematic and challenging areas will be elaborated: 1) Pre-hospital analgesia 2) Pain management for blunt chest injuries and 3) Analgesia for the elderly who are prone to falls and fractures.

PRC08

Managing Pain in Children - General Principles

Stefan J. Friedrichsdorf, MD, FAAP

Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN (USA); University of Minnesota, Minneapolis, MN (USA)

Withholding evidence-based analgesia to hospitalized infants and children in pain is not only unethical, but may cause immediate and long-term harm. Analgesic treatment is mandatory for children when they undergo painful procedures and no avoidable suffering is acceptable nowadays, even for so- called minor interventions. In 2019 it would be considered inappropriate to perform elective painful procedures in children without treatment to avoid or minimize pain, because poorly managed pain has serious short- and long-term consequences.

Based on the 2012 WHO guidelines, the presenter will discuss evidence-based safe multi-modal analgesia, which may include one, several or all of the following approaches in the effective treatment of an individual child: • Pharmacology (e.g. simple analgesia and/or opioids and/or adjuvant analgesia) • anesthetic interventions (e.g. neuroaxial analgesia, nerve blocks) • rehabilitation (e.g. physical therapy, occupational therapy, sleep hygiene) • psychology (e.g. cognitive behavioral therapy), and • age-appropriate positioning and integrative ("non-pharmacological) therapies, such as breathing techniques, self-hypnosis, distraction etc.

Multimodal analgesia act synergistically for more effective pediatric pain control with fewer side effects than any single analgesic or modality.

PRC10

Challenges When Managing Pain in the Elderly

Roger Goucke

Consultant, Department of Pain Management, Sir Charles Gairdner Hospital, PERTH Western Australia

The pharmacokinetics and pharmacodynamics seen in elderly patients are different and require caution with analgesic use. Examples of important changes will be discussed.

This should encourage us to explore all evidence based non-pharmacological options. A variety of non-pharmacological pain management strategies for the older person are available. These include: movement and physical activity, traditional and complementary approaches and nutrition. The issues of managing pain in those aged individuals with dementia and cognitive impairment will also be briefly discussed.

PRC11

Update on Fibromyalgia

Eva Kosek

Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Fibromyalgia (FM) is a multisymptomatic chronic pain syndrome that can best be understood as a systemic disease. The multitude of symptoms such as generalized pain, tenderness, fatigue, disturbed sleep, irritable bowel and bladder and frequently also anxiety and depression pose high demands on the diagnostic work-up of the patients. The lecture will focus on how to investigate and diagnose FM patients with special reference on strategies to communicate the disease to the patient. An orientation of the pathophysiological mechanisms of FM will be given as a basis for rational strategies of a step-up treatment care model. The possible treatments that can be offered at a primary care setting by an individual care giver as well as algorithms to be used at specialized pain clinics applying multimodal, team-based treatments will be discussed. The importance of practical skills such as how to inform the patient, how to motivate patients to accept physical activity/exercise as a treatment modality and how to try to make adequate yet realistic life style changes will be discussed. The importance of good coping skills and sleeping habits will be reviewed. Finally, a brief orientation regarding drug therapy for FM will be provided.

US01

Principles of Ultrasound in Pain Management

Ahmad Afifi Mohd Arshad

Pain Management Clinic, Department of Anaesthesia & Intensive Care, Hospital Sultanah Bahiyah, Kedah

Ultrasound has become an indispensable tool for clinicians in recent decades. A centuries-old maxim that says ‘in a nation of the blinds, a one-eyed man is king’, very nearly summarises the ultrasonography role in diagnostic and therapeutic medicine.

Insonation of tissues, surrounding vital structures such as nerves and vessels as well as diagnostic features of particular conditions, to name a few, are undeniable advantage of using ultrasound guidance in pain assessment, examination and intervention. In some intervention, ultrasound guidance has become gold standard in safety and treatment efficacy, one such example is stellate ganglion block.

Current recommendations for profiency and training are based on pain physicians’ scope of practice and dificulty level of procedural interventions. A certain set of profiency skills is to be acquired by the physician in order to perform any recommended procedures. These range from understanding basic operational system of ultrasound, image optimization and interpretation of sonoanatomy, as well as attaining skills at needle-probe interactions.

Further reading: 1. Narouze, S. N., et al. (2012). "The American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian Federation of Pain Societies Joint Committee recommendations for education and training in ultrasound-guided interventional pain procedures." Reg Anesth Pain Med 37(6): 657-664. 2. Gofeld, M. (2008). "Ultrasonography in pain medicine: a critical review." Pain Pract 8(4): 226-240.

US02

Knobology Babita Ghai Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

The safety and efficacy of ultrasound (US)-guided pain management interventions relies heavily upon a comprehensive understanding of machine “knobology.” Despite differences in appearance and layout, the standard instrumentation and functionality remain essentially the same and all US machines share the same basic operative functions that users must appreciate in order to optimize the image. This lecture will provide an instructive discussion of the essential functions universal to modern ultrasound machines (the general ultrasound apparatus design, the most common probe types available, and the system controls used to manipulate the images obtained) with focus in use for USG guided pain management interventions. I will discuss 1. Basics of performing US such as ergonomics, optimizing probe handling, stabilizing probes selection of probe frequency etc. 2. Identifying different tissue types and understanding ultrasound terminology such as Echogenicity, Scanning planes, Ultrasound views, Angle of incidence, Anisotropy, ultrasound wave frequency, image resolution, penetration 3. US probes: I will dicuss various parts and types of the probe. Most of ultrasonography can be accomplished using one of four basic types of probes: (1) curvilinear, (2) linear, (3) sector/phased, and (4) intracavity. For pain management interventions usually linear or curvilinear probes are used depending upon depth of tissue. 4. Image production and system controls: To produce US images for evaluation, the machine and probes work in concert to transmit, receive, and depict sound waves. 5. Adjusting the depth of the scan: The penetration of the US beam on a particular transducer can be altered by manipulating the frequency of the probe and adjusting the depth or penetration button/knob on the US machine. 6. Various knobs such as On-Off , Orientation probe – image (markers), Presets, Depth, Focus, Gain, Freeze, Time Gain Compensation, Measurements, Color Doppler, etc.

AH04

Occupational Therapy Work Rehabilitation for Pain Cases Siti Nur Ayishah Bt Basari Hospital Sultanah Aminah, Johor, Malaysia

Occupational therapy propose intrinsic relationship between occupation, health and wellbeing. A holistic view concerned physical, psychosocial and environmental factors that contribute to pain leads impact to daily life activities. It is non-pharmacological approach in managing pain in performance ADL (activity of daily living), IADL (instrument of activity daily living), work, recreational and social participation. A program develop to train coping skills to achieve goal and maximise function for instance, participation in work. Occupational therapy using client-centred perspective, evaluate the impact of pain on work performance by task analysis. Intervention carries out with education with functional goal setting and followed by training, self management program. A strategies for worker with pain carried by systematic approach work conditioning and work hardening. Strong evidence that service should deliver extend to returning to work by coordinating with employer involving onsite intervention, environmental modification or transitional work. During the rehabilitation, occupational therapist should address client’s perception, set a realistic goals and finally recommend an alternative solution. When dealing with chronic pain, occupational therapy aim to promoting optimal independence by adaptation and lifestyle modification.

Global Burden of Disease: The Impact of Pain

Fiona M Blyth

University of Sydney.

Burden of disease studies are used to rank the impact of different conditions on the health of populations, and are widely used in determining priorities for resource allocation by international and national organisations. Burden of disease measures both fatal and non-fatal burden of specific conditions: premature loss of life (Years of Life Lost) and disability (Years of Life Lived with Disability). The combined impact of fatal and non-fatal burden is assessed through the summary measure of Disability-Adjusted Life Years.

The Global Burden of Disease Study, which is the most comprehensive and only international burden of disease study, has demonstrated that pain conditions – notably low back pain – are leading causes of non-fatal health burden globally, and also regionally in South East Asia. We have not yet seen the recognition of this outside the pain community, with the focus still on conditions causing premature mortality rather than disability.

The burden related to pain conditions has been increasing substantially over the last two decades, primarily due to ageing of the population. There are stark differences in the rates at which populations are ageing in different parts of the world, with accelerated rates seen in less developed countries that are less well resourced to manage this significant demographic change. Forward estimates suggest that by 2050 most of the world’s older population will be in Asia.

There are many gaps in current estimates of global pain burden, leading to underestimation of burden. While a clear roadmap can be developed to address this problem, the size of the known burden suggests that the pain community needs to respond in both scientific and policy terms to reduce the current burden and minimize the size of the future burden.

S1.1

Managing Low Back Pain: Practical Tips on Do’s and Don’ts

Dr. Ozlan Izma Bin Muhamed Kamil MD, MS(Orth), FIPP, CIPS

Gleneagles Hospital Kuala Lumpur Princecourt Medical Centre Kuala Lumpur

Low Back Pain is a symptom and not a disease. Most episodes of Low Back Pain are self-limiting with little or no consequence and will often resolve without treatment. All international guidelines recommend triaging low back pain to 1. Possible serious pathology or “Red Flags” – vertebral fractures, malignancy, infection or Cauda Equina Syndrome in about 1-2% of cases. 2. Nerve root pain resulting from herniated disc or spinal stenosis in about 5% of cases. 3. Low back pain with no specific cause in about 85-95% of cases. This triage especially in the first 2 groups will often lead to investigations usually an MRI, a pathological diagnosis and specific treatment. However, a similar approach will not be beneficial in about 85-95% of patients with Non-specific Low Back Pain. Often in this group it will lead to unnecessary MRI’s and unnecessary procedures.

In my lecture, I will highlight how most Health Care Professionals continue to over rely on MRI’s in making a diagnosis. I will also discuss the inherent problems with MRI that we often overlook.

I believe that the mainstay of treatment in Non-specifc Low Back Pain is self- care. This can be achieved through 1. Education 2. Promote usual activities – to hurt does not mean to harm 3. Graduated stretches and exercises

S1.2

Preventing Fear Avoidance in Low Back Pain

Lester Jones

Singapore Institute of Technology, Singapore La Trobe University, Australia

Pain-related avoidance of movement and activity is a natural response to injury. However, pain-related fear avoidance behaviour describes a maladaptive response often associated with catastrophizing. It can be specific to context and reinforced by learning associated with interoceptive and proprioceptive cues. While many patients will present to pain clinics with established fear-avoidant behaviour, there are opportunities in other contexts to prevent the natural response becoming maladaptive. Also there are strategies that can be employed to educate and build resilience to break the pain-avoidance cycle. This presentation will consider the attitudes and beliefs of health professionals and respond to the question posed by Vlaeyen and Linton in a 2006 editorial ‘are we fear avoidant?’ To explore this, research has investigated both explicit and implicit responses by health professionals. The findings suggest that the clinical encounter may lead patients with low back pain to develop more fear towards the performance of activities such as lifting. Also, health professionals with predominantly biomedical attitude and beliefs about pain are likely to lead to reinforcement of avoidant behaviours in their patients. Our recently completed research demonstrated that an education intervention integrating the Pain and Movement Reasoning Model (PMRM) promoted a more person- centred approach amongst physiotherapists and significantly reduced scores on the biomedical subscale of the Pain Attitudes and Beliefs Scale for Physical Therapists. When clinical reasoning incorporates the person’s prior life experiences, her/his cognitions including the elements of catastrophizing, and emotions, such as fear, the resulting formulation is more likely to lead to appropriate treatment aims. For someone with pain-related fear targeted reassurance through education, offering a safe context to explore movement restrictions and normalization of responses to internal cues would be appropriate. A case will be used to illustrate this in physiotherapy practice.

S2.1

Managing Procedural Pain in Children

Tang Swee Ping

Hospital Selayang, Malaysia

Children and infants, both hospitalised and healthy, undergo various painful procedures daily. This pain if inadequately managed can result in not only short but also long-term deleterious consequences which includes permanent neuroanatomic and behavioural abnormalities. Procedural pain should therefore be optimally managed using a multimodal approach adapted to the individual child in a family centered context. Procedural pain is unique in that apart from the anticipation of pain, there is also fear and anxiety. Thus, the key is preparation of the child and caregiver providing age appropriate accurate information focusing on the whole experience and not just whether it hurts.

Whilst pharmacological interventions like topical anaesthetics, nitrous oxide, sucrose, ketamine, nerve blocks or opiods remain the cornerstone of procedural pain management, these are unlikely to be successful in isolation given that pain, fear and anxiety are closely intertwined. Psychological interventions are thus important to address these aspects in children. Distraction is a very simple yet effective technique which can be easily practised by anyone. Minimal restrain with comfort positioning in an upright position either seated or held by the caregiver is advocated to enhance self-control and to lessen fear. Parental presence is useful to promote and direct pain coping behaviours during the procedure. They can also assist the child to recall and form positive memories after the procedure. Other useful techniques include hypnosis and cognitive behavioural therapy. Sucrose coupled with non-nutritive sucking is useful for those under 12 months of age, as is facilitated tucking, breastfeeding and kangaroo care in neonates.

S2.2

Abdominal Pain in Children

Stefan J. Friedrichsdorf, MD, FAAP

Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN (USA); University of Minnesota, Minneapolis, MN (USA);

Primary pain disorders (formerly “functional pain syndromes”) are common, under-diagnosed and under-treated in children and teenagers. This presentation will review key aspects which support understanding the development of centrally mediated abdominal pain syndrome “CAPS” (formally “functional abdominal pain”), addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in children with centrally mediated abdominal pain syndromes. A significant number of pediatric patients with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition “chronic-on-acute pain.” The description of the structure and process of an interdisciplinary, rehabilitative outpatient pain clinic will be discussed in the treatment of chronic pain symptoms that persist beyond the expected time of healing.

An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders such as CAPS, and other medications, with few exceptions, are usually not first-line therapy.

S2.3

Are Parents Perpetuating Pain?

Dr Angela Yeo Siok Hoong

Children’s Pain Management Clinic, Children’s Pain Service Department of Paediatric Anaesthesia, Kandang Kerbau Women’s and Children’s Hospital, Singapore

Professionals working with paediatric patients are acutely aware of the multiple roles a parent plays within the context of a child’s illness. Parenting style, interpersonal dynamics and differing personalities may result in challenging interactions between health-care professionals and parents despite both parties having the best of intentions for the patient. This talk examines helpful and unhelpful parental behaviours in the context of acute, procedural and chronic pain, and the effects of such behaviour. Recognising these will help the practitioner open the conversation on the magnitude of influence a parent has on the patient’s reactions to pain, medication and therapy, as well as guide parents on appropriate and inappropriate reactions to their child’s pain. With the simple skills and readily available resources contained in this session, clinicians will be able to better help parents fulfill their roles as providers, protectors, advocates and life coaches for their children.

S3.3

Cervicogenic Headache

Nuj Tontisirin

Faculty of Medicine Ramathibodi hospital, Bangkok, Thailand

The cervicogenic headache commonly occurred in patients, aged 30-50 years old with the incidence of 1-4% among patients with headache. The pathophysiology is the referred pain from upper cervical spine, C1-3, pathology, for instance, atlantoaxial arthropathy, C2-3 facet arthropathy. There was a convergence of pain signal between C1-3 nucleus and trigeminocervical nucleus. Thus, the trigeminocervical nucleus received a pain signal from trigeminal branches as well as an afferent pain fiber from C1-3 dermatome.

The ICHD-3 (third edition of the international classification of headache disorder) diagnostic criteria of cervicogenic headache included headache 1) developed in the onset/appearance of cervical disorder, 2) improved after treatment of cervical disorder, 3) is worse by provocative maneuver, there was limited range of motion of the cervical spine and 4) abolished following diagnostic blockade of a cervical structure.

The clinical features of typical cervicogenic headache included unilateral pain, pain started in the neck or occipital area, getting worse with cervical movement and associated with decreased range of motion of the cervical spine.

To differentiate from migraine, there was less nausea, vomiting, photo/phonophobia. It is challenging to distinguish from cervical myofascial pain or tension type headache which is usually bilateral headache.

The conservative pain management including physiotherapy and oral analgesics is the first line of treatment. If ineffective, pain procedures such as lateral atlantoaxial joint intra-articular injection, C2-3 facet injection or radiofrequency ablation (RFA) of the third occipital nerve or pulsed RF of C2 dorsal root ganglion might be considered. There was limited evidence for cervical epidural steroid injection.

P03

Signs and Symptoms of Sensitisations Across Chronic Pain Condition

Lars Arendt-Nielsen

Aalborg University, Denmark

It is generally accepted that pain diagnosis and therapy should be mechanism based and hence pain assessment should be sufficiently sensitive and advanced to provide such mechanistic information. Translating clinical observations to mechanisms and vice versa are not trivial, and assessment tools to quantify the different phenomena are mandatory. This approach has provided new insight into how reorganization of the pain system is manifested in different chronic pain conditions. Based on such studies common features across different pain patient populations have been identified. An example could be cutaneous allodynia in neuropathic pain assessed by brush, which corresponds to pain evoked by weak muscle pressure in musculoskeletal pain and to pain provoked by a weak colonic distension in visceral pain. Although assessed differently in specific tissues for various pain conditions, the underlying mechanisms share common underlying features. This is of importance for developing new diagnostic tools and for design of clinical trials, as e.g. drugs developed for neuropathic pain may as well have beneficial effects in also patients with sensitisation associated with chronic musculoskeletal pain. Profiling patients utilizing a platform of specific tools for diagnostic purposes is possible, and the current challenge is to translate this into better management. Some of the current available mechanistic human pain biomarkers translate back to animals, providing new possibilities for bridging findings between pre-clinical and clinical studies. Data on the clinical applicability in different chronic pain conditions are increasingly available. In particular, normative values have been established and reliability has been tested. The lecture will address how we can understand the manifestations of across different chronic pain conditions and what implications it may have on management. The opportunities to develop individualized pain management and develop better drugs are in the horizon.

Brain Imaging of Chronic Pain Karen Davis PhD FCAHS

Krembil Brain Institute and the University of Toronto, Canada

Chronic pain is estimated to impact one in five people world-wide and is poorly managed for many. The inability to adequately manage chronic pain for all those suffering is in part due to the failure of the one-size-fits-all model for treatment. There is now good evidence that individual differences in pain sensitivity, behavioural factors, and brain structure and function, contribute to chronic pain vulnerabilities and treatment outcomes. In this talk I will provide an overview of the spectrum of individual differences in pain sensitivity that is linked to brain structure and function. I will present work to develop a chronic pain treatment prediction tool based on these findings and machine learning approaches. Emphasis will be placed on the importance of dynamic measures of functional connectivity, and both state and trait measures of pain. I will then highlight recent findings of the relationship between pre-treatment functional and structural imaging, and psychophysical metrics on treatment outcome for chronic pain. An understanding of these factors will provide the foundation to develop a personalized approach to pain management.

S4.1

Coxibs/NSAIDs: The Controversies

Kok-Yuen Ho

The Pain Clinic, Mt Alvernia Hospital, Singapore

Non-steroidal Anti-inflammatory Drugs (NSAIDs) are commonly used analgesics for acute and chronic pain. However, as they are non-selective NSAIDs, they can cause various adverse effects due to COX-1 enzyme inhibition. These include platelet dysfunction, impairment of bone healing, renal impairment and gastrointestinal (GI) ulcers and bleeding. COX-2 selective NSAIDs (or Coxibs) are safer alternatives to non-selective NSAIDs as they are associated with a lower incidence of adverse effects related to COX-1 inhibition. However, in 2004, rofecoxib was found to increase cardiovascular (CV) risks leading to a higher incidence of myocardial infarction and stroke. This led FDA to issue a black box warning on the entire class of Coxibs. In addition, data from retrospective studies, observational trials and meta-analyses were conflicting. In the last few years, there is evidence to suggest that Coxibs have differential CV effects. It appears that rofecoxib, as well as some non-selective NSAIDs, may increase the risk of CV side effects more than other NSAIDs.

S4.2

Cannabinoids for Neuropathic Pain: Are They Safe or Effective?

Andrew SC Rice

Imperial College London, United Kingdom

Our understanding of cannabinoid pharmacology and endocannabinoid physiology has advanced considerably since the discovery of CB1 and CB2 cannabinoid receptors and their endogenous ligands. There is now a large body of basic science evidence supporting the hypothesis of cannabinoid-mediated analgesia. However, clinical use of cannabinoid analgesics requires the following to be ascertained:

1. Evidence of clinical efficacy and equivalence or superiority to existing therapies? Meta-analyses of neuropathic pain clinical trials conducted to date clearly demonstrate a lack of efficacy for cannabinoids in neuropathic pain. Furthermore, a number of existing alternative agents are superior to cannabinoids for the treatment of neuropathic pain.

2. Are cannabinoids associated with short and long-term individual harm and societal harm? The clinical trials conduct to date do not reveal alarming short-term adverse effects associated with therapeutic cannabinoids. However, such clinical trials are not designed, and are of insufficient duration and size, to detect serious, but relatively infrequent, adverse effects. Nevertheless, there are consistent epidemiological data which show that cannabis use is associated with a dose-related increased risk of psychosis and cognitive impairment, especially in susceptible individuals – the relevance of this for therapeutic use is unknown. High potency prescribed cannabinoids have diversion/misuse potential and such societal dangers are evident from problems seen with misuse use of prescription opioids.

In summary, the cannabinoids tested in clinical trials to date do not reveal an efficacy signal for the treatment of neuropathic pain. There are potential long- term mental health risks associated with cannabinoid use. There are unknown societal risks from diversion of therapeutic cannabinoids.

The lecture will conclude with a brief description of the ongoing work of the IASP Presidential Taskforce on Cannabis and Cannabinoid Analgesia. A robust and exhaustive review of the basic science and the evidence for clinical efficacy and harm is being undertaken and will be complete by early 2020. The speaker will describe how IASP members can activity engage in the work of the task force and at the same time be trained in systematic review methods.

S5.1

Treatment Waitlists: Patient Impact and Service Considerations

Anne Burke

Royal Adelaide Hospital, Australia

Multidisciplinary treatment is the gold standard for the management of chronic pain, but accessing it often involves very long and indefinite waits which can perpetuate the cycle of disability and suffering. Although these waits are almost universally condemned, exactly when long becomes too long is unclear. In fact, there is a paucity of research directly examining the impact of waiting for chronic pain treatment on patient outcomes and this has restricted advocacy efforts to focus on ethical concerns rather than evidence-based impacts. It is imperative that clinicians and health care decision makers improve their understanding of the impact of these wait-times on patient outcomes and actively work to improve access to evidence-based care.

To this end, data from a large scale prospective longitudinal study will be presented, articulating the impact of being indefinitely waitlisted on individuals living with chronic pain. Next, two opportunities for facilitating more timely access to evidence-based care will be explored, namely staff resourcing and the provision of pre-clinic education. Finally, the implications of these projects for service design and delivery will be discussed, including recommendations for the development of waitlist standards for chronic pain services.

S5.2

Ethical Challenges in a Death-Denying Environment

Hamzah E

Hospis Malaysia

Medicine is seen as the panacea for diseases. Yet the goals of medicine are sometimes at odds with the outcomes required by the patient and their loved ones. As medicine becomes ever more complex with the advent of greater technological advances the challenge facing clinicians with regards to aiding the patient in clinical decision making becomes more challenging.

The alleviation of pain and suffering is a major challenge. Issues of access to medication and care, lack of knowledge and skills as well as healthcare financing are obvious issues. Physicians are often unprepared to deal with communications surrounding death and dying. Perhaps medicine itself questions the concept of death? A fear of dealing with end of life issues may lead to further futile treatments. Gradually, increasing nations are accepting euthanasia and physician assisted suicide as an acceptable option in facing suffering leading to complex ethical challenges.

S5.3

Brain Imaging to Treat or Diagnose Pain: Ethical Issues Karen Davis PhD FCAHS

Krembil Brain Institute and the University of Toronto, Canada

Brain imaging technologies such as functional MRI (fMRI) have been used for over 20 years to visualize and measure brain responses to noxious stimuli and connectivity patterns associated with pain sensitivity. These advancements have led to the concept by some that brain imaging can be used to diagnose chronic pain, and that imaging-based biomarkers may be used to predict treatment outcome in individual patients. Indeed, this type of assessment of pain represents a tremendous advance towards personal pain management. Despite these lofty goals, there are neuroethical issues that must be addressed during such biomarker development including the technical and neurobiological capabilities of brain imaging, individual differences in pain sensitivities and associated brain mechanisms/circuitries, privacy of brain data, financial and access to brain imaging technologies. In this talk, I will review key capabilities of brain imaging to detect chronic pain at the individual level and the neuroethical, societal, and policy issues that need to be considered should such technology be adopted for pain management decisions, insurance and/or legal claims of pain. I will also review the recommendations of the IASP presidential task force that examined the use of brain imaging for the purposes of chronic pain diagnostics (Davis et al., Nature Reviews Neurology 2017).

S6.2

Pathophysiology and Treatment of Fibromyalgia

Eva Kosek

Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Multiple pathological findings have been reported in fibromyalgia including peripheral abnormalities such as muscle ischemia and small fiber pathology, autonomic dysfunction and central abnormalities i.e., functional as well as structural cerebral changes and recently also sings of neuroinflammation. The multitude of abnormalities in fibromyalgia would suggest a systemic disorder with pain caused by complex interactions between peripheral and central mechanisms. Fibromyalgia patients have a dysfunction of endogenous pain inhibitory mechanisms and neuroimaging studies indicate aberrant cerebral pain processing, making fibromyalgia a prototype of a nociplastic pain disorder. Clinically, fibromyalgia is characterized by widespread pain, increased pain sensitivity and other symptoms such as fatigue, disturbed sleep and frequently also depression or anxiety. Pain is typically exacerbated during and following more intense physical work or exercise as well as by stress. Information to the patient is the cornerstone of fibromyalgia treatment. Patients should be informed that the altered nociceptive function results in normally non-painful stimuli being perceived as painful, thus fibromyalgia pain should not be interpreted as a warning signal. Individually tailored, gradually increasing physical exercise should be implemented for all patients, some may benefit from a physiotherapist to get started. Serotonin-noradrenalin-re-uptake inhibitors and anticonvulsants are accepted for the treatment of fibromyalgia in some countries and can be tried, whereas there is a consensus among fibromyalgia experts that opioid drugs should be avoided, possibly with the exception of tramadol. Patients suffering from co-morbidities such as depression/anxiety disorders or having difficulties to cope with their situation may benefit from cognitive behavior therapy. Multimodal rehabilitation programs can help patients to resume their daily activities and return to work.

S6.3

Prevention of Complex Regional Pain Syndrome

Dela Cruz-Odi, Merle F.

Makati Medical Center, Makati City, Metro Manila

The word ‘complex’ describes this pain entity appropriately in that despite many years, and unceasing interest on the subject, there is paucity of evidence on the prevention of Complex Regional Pain Syndrome (CRPS).

The IASP definition of CRPS reads: "CRPS Type I is a syndrome that usually develops after an initiating noxious event, is not limited to the distribution of a single peripheral nerve, and is apparently disproportioned to the inciting event. It is associated at some point with evidence of oedema, changes in skin blood flow, abnormal sudomotor activity in the region of the pain, or allodynia or hyperalgesia"

The Budapest consensus criteria used by the International Association for the Study of Pain (IASP) for the clinical diagnosis of CRPS is found to be equally sensitive and more specific compared to earlier CRPS criteria in differentiating CRPS from other types of neuropathic pain. Continuing pain disproportionate to any inciting event is the first criterion, followed by a specified number of signs and symptoms of sensory, vasomotor, sudomotor/edema and motor/trophic changes. There should also be no other diagnosis that better explains the signs and symptoms.

Prevention of CRPS can be either primary or secondary.

For primary prevention, the administration of daily doses of Vitamin C showed a significant reduction in the prevalence of CRPS among patients with distal wrist fractures in two studies. However a third study found no difference between the vitamin C group and placebo. A meta-analysis of the three trials found a nonsignificant trend towards benefit of vitamin C. A balance between immobilization for healing of fracture and early mobilization to reduce the risk of CRPS is essential.

To prevent relapse, postponing surgery until CRPS signs are minimal seem prudent. Regional anesthetic techniques are preferred. Evidence show that the addition of clonidine to local anesthetic for regional block, utilization of multimodal analgesia and the subcutaneous use of salmon calcitonin are preventive of CRPS relapse.

Pain in Children

Stefan J. Friedrichsdorf, MD, FAAP

Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN (USA); University of Minnesota, Minneapolis, MN (USA)

Pain experiences, including acute and chronic, are common in infants, children, and adolescents. Data from children’s hospitals reveal that pain in pediatric patients is common, under-recognized and under-treated. A recent systematic review showed that neonates admitted to intensive care units frequently suffer through an average of 7 to 17 painful procedures per day, with the most frequent procedures being venipuncture, heel lance, and insertion of a peripheral venous catheter. In the vast majority of infants no analgesic strategies are employed.[33] In addition, children with serious medical conditions are exposed to frequent painful diagnostic and painful procedures (e.g., bone marrow aspirations, lumbar punctures). Furthermore, even healthy children have to undergo significant amounts of painful medical procedures throughout childhood: Vaccinations are the most commonly performed needle procedure in childhood, and pain is a common reason for vaccine hesitancy.

Exposure to severe pain without adequate pain management has negative long- term consequences, including increased morbidity (e.g., intra-ventricular hemorrhage) and mortality. Exposure to pain in premature infants is associated with higher pain self-ratings during venipuncture by school age and poorer cognition and motor function. Research has shown that exposure to pain early in life has long-lasting consequences in terms of increases in the risk for developing problems in adulthood (chronic pain, anxiety and depressive disorders), adequate management of infant and child pain is imperative.

This presentation will discuss evidence-based strategies to assess, prevent and treat pain in hospitalized children.

An Overview of Neuropathic Pain in Infectious Diseases

Andrew SC Rice

Imperial College London, United Kingdom

Neuropathic pain can be a long-term consequence of nervous system infections, even long after the infection has been eliminated with antimicrobial therapy. This lecture will give a rapid, high-level, overview of some infections frequently associated with neuropathic pain, touching on a few “snapshots” of recent developments. The lecture will focus on two prevalent infections: varicella-zoster virus (VZV) and human immunodeficiency virus (HIV).

During primary infection (varicella/chicken pox) VZV invades sensory ganglia where it lies dormant until a decline in cell mediated immunity precipitates reactivation. This presents clinically as the characteristic dermatomal rash of herpes zoster (shingles). About 10% of zoster cases are complicated by post herpetic neuralgia (PHN). In immunocompetent individuals the risk of both zoster and PHN are age related, climbing steeply over the age of 50. PHN is a model condition for neuropathic pain clinical trials and therefore there is a large body of evidence for the analgesic treatment of PHN, which will be reviewed. New data on the health burden of PHN will be discussed, as will evidence from trials of zoster vaccines which have the potential to prevent an important neuropathic pain condition.

United Nations data reveal that there are currently ~37 million people worldwide living with HIV. The good news is that with increasing access to effective antiretroviral therapy (ART) survival and long term living with the infection has become the norm. However, a number of neurological manifestations of HIV persist despite optimal ART. Although there was a slight decline in prevalence following the withdrawal of obsolete neurotoxic ART drugs, about 40% of people living with HIV have a distal symmetrical sensory polyneuropathy, in many cases associated with neuropathic pain. Recent developments in our understanding of the pathogenesis of this neuropathy, and its impact on quality of life, will be described. In contrast with PHN the clinical trials of neuropathic analgesics in HIV-associated sensory neuropathy have been disappointing and no effective therapies have been identified.

Finally, brief mention will be made of two important, but relatively rare, infections associated with neuropathic pain:

Despite worldwide access to mycobacteriologically curative therapy, about 25% of leprosy patients suffer from very long term neuropathic pain, usually associated with characteristic mononeuropathies or late stage immune reactions. The clinical presentations and impact of neuropathic pain in leprosy will be discussed.

Human T-cell leukemia virus-1 (HTLV-1) is a retrovirus for which there is no curative therapy. HTLV-1 infection is rare, but causes a myelopathy associated with neuropathic pain. As HTLV-1 infection can be overlooked in a patient presenting with unexplained neuropathic pain, the epidemiological and clinical features of this condition will be briefly described, primarily to raise awareness of it as a diagnostic possibility.

S7.1

Neuropathic Pain in Advanced Cancer

Henry U. Lu

Asian Hospital Medical Center, Philippines Makati Medical Center, Philippines St. Lukes Medical Center - Global, Philippines

Studies have shown neuropathic component is evident in about 1/3 of cancer pain cases and have a substantial impact on the quality of life. Due to advancement and effectivity in Cancer treatments, cancer patients are now living longer and there are more cancer survivors. However, side-effects, particularly neuropathic pain, have become more problematic. Awareness of several neuropathic pain syndromes in cancer patients and a better understanding of different issues related to assessment and treatment, may lead to better recognition and improved outcomes in neuropathic cancer pain. Despite the lack of relevant high-quality data and the difficulties in performing randomized controlled trials in cancer pain, have justified the acceptance of drugs already known to be effective in benign neuropathic pain. Treatment of neuropathic cancer pain is often challenging and may involve multimodality pharmacological approach. Opioids are used more frequently and standard guidelines for the use of anticonvulsants (e.g. pregabalin), antidepressants (e.g. duloxetine), and topical treatments (e.g. lidocaine) may be applicable. Choice is dictated not just by age, drug interactions, and comorbidities, but also by the coexistence of many symptoms in patients with cancer.

S7.02

Management of Cancer Pain in Pediatric Patients Edi Setiawan Tehuteru National Cancer Center - “Dharmais” Cancer Hospital Jakarta, Indonesia

Pain is the most symptoms that occurred in childhood cancer. The pain can be related with diagnostic procedures, treatment, or palliative. Since pain declared as the fifth vital sign, its mean we have to get rid the pain as soon as possible.

World Health Organization already modified the step ladder into two steps concerning the lack of CYP2D6 gene in children. That is why children need more morphine because there is no place for codein or tramal anymore.

As physicians that take care of children with cancer, we have to know how to use morphine according to the proper way. The goals are so these children will have a good quality of life during treatment or during their remaining life.

Indonesia as one of the country with limited resources, sometimes we have problems with morphine availability, especially morphine immediate. Because of that, we have to make some modification with any kind of opioid that available in our center. The goal is still the same, that is good quality of life.

Key words: cancer, childhood, pain, morphine, quality of life

S7.3

Intrathecal Drugs Delivery For Cancer Pain

Ng Kim Swan

Hospital Selayang, Malaysia

The intra-thecal catheter (ITC) is an important treatment modality for intractable cancer pain. Its use for severe cancer pain is very much dependent on local policies and procedures, the interest and the competence of the interventional pain physician, palliative care physician, nurses and the family physician in this field of care. It is indicated in severe neuropathic pain unresponsive to opioids or wide spread metastatic pain unresponsive to other options. The common routes are epidural or intrathecal analgesia with catheter and pumps that can be temporarily or permanently implanted. The catheter insertion can be cervical or lumbar, the later being easier approach. The catheter insertion may become more challenging when there are spine metastasis with intra-thecal invasion. In such situation, a pre-op MRI may be helpful in determining the insertion techniques. The delivery of drug into the intra-thecal space can be with percutaneous catheter, subcutaneous port/needle or with fully-implanted pump. The advantages of ITC include easier access to locate the space, less catheter obstruction, less pain on injection, lower dose of drugs (eg IT dose of morphine is 1/200 of oral morphine dose), more rapid and intense analgesia and low risk of infection. The catheter infection has been reported within 2.5-9%. The rate of infection is low with close monitoring of signs of meningeal irritation, the ITC allow easy CSF microscopy, use of prophylactic antibiotics and the bacteriostatic properties of bupivacaine. Overall long-term sequelae are usually minimal. In Selayang Hospital, the intra-thecal catheter is the most common intervention performed for palliative patient. In this presentation, there will be sharing of the experience and the outcomes of ITC in Selayang Hospital with special attention on technique of insertion and subsequent management of patient. In summary, ITC provides excellent pain control for cancer pain and a good pain management in these patient has shown to provide good end of life quality and improve the rate of survival.

S8.1

Fragile Cancer Patients

Hamzah E

Hospis Malaysia

Cancer affects people from all spectrums of the community. Despite variations in age, education, resource and support systems, many are vulnerable to the complexities in navigating the healthcare system. Pain is seen as a symptom in cancer and thus its management by different physicians may also be different causing great difficulty to patients attempting to find treatment in alleviating it. The psychological and existential components of pain are often given less consideration by clinicians who may prefer a pharmacological approach to treatment. Pain may also be ignored as clinicians prioritise the management of the presenting disease.

Issues surround communication around pain, access to medicines, consent to treatment, understanding of pain and goals of care of symptom control and treatment of cancer will be discussed.

S8.2

Pain in Older Adults

Roger Goucke

Consultant, Department of Pain Management, Sir Charles Gairdner Hospital, PERTH Western Australia

Globally our population is increasing. This is true also of the percentage of the population aged over eighty years. At the same time the percentage of the population under thirty is either decreasing or remaining static.

Examples of these changing demographics will be demonstrated.

The pharmacokinetics and pharmacodynamics seen in elderly patients are different and require caution with analgesic use. This should encourage us to explore all evidence based non-pharmacological options. A variety of non- pharmacological pain management strategies for the older person will be discussed. These include: movement and physical activity, traditional and complementary approaches and nutrition. The issues of managing pain in those aged individuals with dementia and cognitive impairment will also be briefly discussed.

With the decline in some countries of the nuclear family, traditionally offering care and support for elderly relatives, governments are being required to provide “aged care facilities”. The managers of these facilities need to be aware that good pain management improves care. Our advocacy here will be important.

S8.3

Pain Assessment in Survivors of Torture: a case of resilience versus vulnerability

Lester Jones

Singapore Institute of Technology, Singapore La Trobe University, Australia

This year, 2019, is the ‘IASP Global Year Against Pain in the Most Vulnerable’. One vulnerable group are the people who have been displaced from their home and country and have been, or are looking to, resettle in a new country. For many they have also experienced torture, organised violence or war (TOVW). These ‘survivors’ often present with pain and extreme distress but it is important to also acknowledge the high levels of resilience that have sustained them on their difficult journey. Importantly, in a healthcare encounter the survivor may not ever disclose their torture history and so may not receive appropriate care. Health professionals are encouraged to be vigilant for signs that may indicate a person has been tortured. Person-centred pain assessment is essential but also a major challenge. Apart from communication difficulties there is the complexity of psychological and social issues associated with any refugee experience - including the associated trauma and losses. There is value in focusing on pain as an output of the body’s protection system rather than an indicator of tissue injury or disease. The bidirectional interplay between pain and other protective outputs, like poor sleep, mood disorders and breathing dysfunction is important. A clinical reasoning tool that has been used to capture this complexity is the Pain and Movement Reasoning Model. Additional culturally-responsive strategies have been developed to promote better understanding of pain in this vulnerable group and offer additional assessment information to the clinician as the client unpacks her/his beliefs about contributors to pain. Overall, health professionals working with survivors of TOVW need to have culturally-informed skills and sensitivities to successfully assess and manage the vulnerability associated with the ongoing effects of trauma. At the same time it is essential to preserve the culture, beliefs and behaviours that support resilience.

S9.2

Long-Distance Education Using Web-Based Tools

Michael Nicholas

University of Sydney and Royal North Shore Hospital

Practising clinicians from all health disciplines have long recognised their need to upgrade their knowledge and skills in the fast developing field of modern pain management. The traditional means of delivering such knowledge and skills has been via face to face lectures and weekend workshops. However, for the busy clinician these modalities can necessitate time consuming and expensive travel and accommodation. The advent of the internet has allowed us to develop online modes of teaching this knowledge and skills, thereby minimizing costs in time and money.

This session will describe how our Post-Graduate Pain Education Unit at the University of Sydney Medical School pioneered this mode of teaching and training almost 20 years ago, with our Masters degree course in multidisciplinary pain management being the first to be offered as a fully online course. Since then the course has expanded but remains consistent with the IASP’s Core Interdisciplinary Curriculum on pain management. Over the years other Universities in Europe, East Asia and North America have also offered our courses under license from the University of Sydney.

In addition to our online Masters and Diploma courses, since 2012 we have also developed online courses to train clinicians of all health disciplines in the skills required to teach pain self-management strategies to patients, both individually and in small groups. The aim of these skills-based courses is to enable the participants to achieve competence in delivering this mode of treatment. The outcomes reported so far have been very encouraging, with over 20 programs being developed in Australia and New Zealand via this route.

This session will describe this mode of pain education, its evaluation by participants, and the opportunities it offers to rapidly and cheaply expand the roll- out of brief pain management programs and to upskill individual clinicians.

S9.3

Applying Tech in Delivering Psych Interventions for Chronic Pain: A Study in Singapore

Yang SY

Tan Tock Seng Hospital, Singapore

Chronic pain is a complex condition which requires interdisciplinary treatment delivery as part of a gold standard of care. With the high prevalence rates of chronic pain worldwide, adequate management of chronic pain has been placed as a world health priority. Yet, the low availability of healthcare resources, limited accessibility to psychological treatments and high out of pocket fee for service especially in Asia, appear to have contributed to an inadequate response to pain.

Technology is fast becoming a part of our everyday life. Pain treatment delivered via technologically based modalities such as online or mobile-based treatments seems to be the way forward. Leveraging on technological developments to deliver psychological treatment allows for wider patient reach with the same amount of therapist time. Such modes of treatment delivery has the potential to address issues related to 1) perceived stigma, 2) a poor understanding of psychological treatment for pain in addition to practical barriers such as cost time commitments and transportation challenges.

This session will discuss the current trends, challenges and gaps in applying technology to psychological treatments for pain. A feasibility trial developed for use in a chronic pain population at a tertiary pain clinic in Singapore as well as ongoing research in this area will be discussed.

S10.1

Overview of Pain Management Programs in Asia

Yang SY

Tan Tock Seng Hospital, Singapore

Much of our knowledge of pain management programs, including the treatment design, content and delivery are predominantly contributed by programs established in Europe, North America and Australia. Such programs usually follow a biopsychosocial approach to treatment; with psychological intervention included as a key component.

In many parts of Southeast Asia, it appears that a relatively similar model of pain service delivery is followed. However, unlike Europe, North America and Australia, psychological intervention rarely contributes to standard care. Little is also known about the availability of pain management programs in this part of the world.

This session will present an overview of pain management programs available in East and South-East Asia based on published research to date. The common types of psychological care models used in such programs, quality of the interventions delivered, primary outcomes, current gaps in program delivery and potential future state for pain management programs in South-East Asia will be discussed.

S10.3

From West to East: Addressing Cultural Differences in Pain Management Programmes

Nattha Saisavoey

Department of Psychiatry Faculty of Medicine Siriraj Hospital Mahidol University

Cognitive-behavioral therapy (CBT) is a first-line psychosocial treatment for individuals with chronic pain. CBT not only reduces pain, disability and depressive symptoms but also improves psychological well-being. CBT is based on Western concepts and models. Implementation of CBT into different culture, from Western to Eastern countries, have to pay more attention and modify therapeutic framework and practice. East and West may have various differences based on culture and education. Therapists need to integrate their understanding regarding to ethnic, culture and religious context. For CBT, clients and therapists have to develop mutual collaboration. CBT uses reasoning approaches but this is not consistent with some Eastern Philosophies. Differences in background culture and previous learning experiences between Wester and Eastern culture could create obstacles in the cognitive and behaviour changing process, if the new explanation does not fit in with previous culture models. However, there were some evidence supported benefits of CBT for chronic pain in Asian countries. One from Malaysia and one from Thailand. Both Malaysian and Thai studies aimed to review the result of group-based, CBT for chronic pain patients. The results were consistent with those found in previous studies from Western countries. It appeared possible that self-management program as group CBT may offer benefits in terms of improved pain self-efficacy and decrease in depression and anxiety symptoms in Eastern patients with chronic pain. However, RCT of CBT for specific culture and ethnic groups is still in need.

S11.2

Continuous Regional Analgesic Techniques for Acute Pain Relief

Michael Beh ZY

University of Malaya, Malaysia

Continuous peripheral nerve blocks (cPNB) can be used to provide effective and prolonged analgesia. In the clinical practice guideline on management of postoperative pain by the American Pain Society (APS), American Society of Regional Anaesthesia and Pain Medicine (ASRA) and American Society of Anaesthesiologists (ASA), the committee strongly recommends that clinicians should consider use of surgical site– specific peripheral regional analgesic techniques in adults and children as part of multimodal analgesia, particularly in patients who undergo lower extremity and upper extremity surgical procedures. The use of continuous rather than single-injection peripheral techniques is preferred when the duration of postoperative pain is likely to be more prolonged, because of the limited duration of analgesia expected with a single injection.

Compared with opioid analgesics, cPNB provide superior analgesia with a lower incidence of opioid-induced side effects such as nausea, vomiting, pruritus, and sedation and may offer an improved functional outcome after extremity surgery. Ultrasound is the gold standard nerve localisation tool in performing PNB. Despite numerous advantages of cPNB, there are potential complications that may hinder its efficacy include inaccurate catheter tip location, catheter dislocation, infection at the catheter insertion site, and difficulty removing the catheter. Neurologic injury with continuous blocks is rare and related to multiple risk factors. Other complications that affect single-injection blocks, such as accidental vascular puncture and systemic local anaesthetic toxicity, may also occur with continuous blocks. Complications associated closely with continuous blocks include increased risk of patient falls and problems with the infusion regimen or equipment.

In this presentation, the speaker provides an update of the published evidence for cPNB for acute pain, current trend of utilizing cPNB in the clinical practice, how to make the catheter works and alternative modalities apart from cPNB.

References: 1. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17(2):131-57. 2. Ilfeld BM. Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison with Novel, Alternative Analgesic Modalities. Anesth Analg. 2017 Jan;124(1):308-335. 3. Geert-Jan van Geffen, Jörgen Bruhn. Continuous Peripheral Nerve Blocks Safe Practice and Management. Complications of Regional Anesthesia. Principles of Safe Practice in Local and Regional Anesthesia. Editors: Finucane, Brendan, Tsui, Ban C.H.; Springer, 3rd Edition, 2017; 167-188.

S11.3

Transition of Acute to Chronic Pain – Identifying The Risk Factors

Ahmad Afifi Mohd Arshad

Pain Management Clinic, Department of Anaesthesia & Intensive Care, Hospital Sultanah Bahiyah, Kedah

Chronic pain is now recognized as one of the distinct health priorities by its inclusion in the International Classification of Disease (ICD -11). Many patients describe persistent unresolved pain following surgery or trauma as initial inciting events. The transition of acute persistent pain to chronic pain is a ‘continuum’. This ‘chronification’ process, involved changes in neurohumoral and neurophysiological responses in the nervous system.

Translational sciences have shown that altered pain modulation following peripheral and central sensitization resulting from trauma or surgery, could be the underlying mechanism of chronification. This imprints neuroplastic changes in the ‘neuromatrix’ of pain sensory system.

More importantly is how it resulted in alteration of behaviour and cognitive function leading to dysfunctional and maladjustment state in patients’ lifestyle. Hence, it is paramount to recognize and implement preventive measures in the perioperative period which could have major impacts in preventing chronic pain.

The discussion seeks to identify factors that predispose to chronic pain. A few have been identified such as female gender, younger age group, genetic predisposition, psychological vulnerability, stress, catastrophizing and hypervigilance state. On top of that, multiple animal studies on incisional pain model and clinical evidences suggest preventive strategies such as minimally invasive surgery and perioperative medication or technique (eg ketamine, regional blocks, lidocaine) to reduce peripheral and central sensitization.

It is hoped that with better recognition of at-risk population, appropriate treatment of acute pain and application of scientific guidelines, the chronification process could be halted while in transition, or prevented altogether.

Further reading: 1. Lavand'homme, P. (2017). "Transition from acute to chronic pain after surgery." Pain 158 Suppl 1: S50-S54. 2. Pogatzki-Zahn, E. M., et al. (2017). "Postoperative pain-from mechanisms to treatment." Pain Rep 2(2): e588. 3. Schug, S. A. and J. Bruce (2017). "Risk stratification for the development of chronic postsurgical pain." Pain Rep 2(6): e627. 4. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J. Acute Pain Management: Scientific Evidence. 4th ed. Melbourne: ANZCA & FPM; 2015

S12.1

Knowledge Translation

Fiona M Blyth

University of Sydney.

While the volume of research produced each year rises considerably, the translation of research findings into health policy and practice remains slow and patchy. Increasingly, funders of health and medical research require researchers to demonstrate the impact of their work beyond the traditional measure of publications citations.

The last two decades have seen the development of a new field of research into knowledge translation, which seeks to understand how evidence is translated into policy and practice, the barriers and enablers to successful translation, and research around interventions aimed at improving translation. This new field incorporates a range of academic disciplines that are relatively unknown to health researchers and practitioners, for example policy science.

In this talk I will address two important questions, with illustrative examples: 1. Why does research not get translated into practice? 2. How do we use research findings (or plan research) to influence policy and change in practice?

S12.2

The Role of Sodium Channels in Nerve Injury Pain

Troels S. Jensen

Dept. of Neurology and Danish Pain Research Center, Aarhus University Hospital, DK-8200 Aarhus N, Denmark.

Management of neuropathic pain is still unsatisfactory mainly because of an insufficient understanding of underlying mechanisms. Sodium channel blockers represent an important group of agents used to treat neuropathic pain, but their mechanism of action and where that effect is exerted is still unsettled. Under normal and pathological conditions neuronal firing is tuned by the complement of sodium channels and their localization along injured fibers in these neurons. Animal and human studies have demonstrated dynamic changes in the expression of channels and their subcellular localization after injury which may contribute to the pain behavior. Sodium channels are expressed both in the peripheral and central nervous system and may therefore also exert their effects peripherally as well as centrally.

While drugs such as opioids, tricyclic antidepressants and calcium channel α2δ subunit ligands seem to have somewhat consistent effects across the spectrum of neuropathic pain conditions, new evidence suggests that the response to sodium channel blocking drugs may depend on the mechanisms that leads to nerve injury and to the characteristics of the pain syndrome in an individual patient. It will be demonstrated how sensory profiling can contribute to predict a better treatment response to a sodium channel blocker. The presentation will review the emerging evidence for sodium channel blocking approaches in peripheral and central neuropathic pain, and discuss the conditions and patient populations in whom pharmacological targeting of sodium channels may be particularly beneficial.

S12.3

Overcoming Challenges in Doing Research in ASEAN Countries

Teekayu P. Jorns DDS., PhD.

Orofacial Pain Clinic, Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand

Orofacial pain research and management is within the domain of Dentistry for nearly a century but still is one of the much-debated issues in the field. Currently, the better understanding of orofacial pain’s incidence, etiology, co-morbidities and investigations, which are highly important factors in managing chronic pain cases, suggests a number of new effective medical and dental approaches to safely treat this group of patients. Moreover, the field of orofacial pain is undergoing a major transformation as a result of current research findings about pain in general. As a result, many chronic orofacial pain conditions commonly found in dental practice are currently recognized as a subset of chronic pain conditions, and this requires a medical or psychosocial perspective to understand and manage. This presentation will provide the current topic of orofacial pain research and its management in the multidisciplinary setting.

S13.1

Chemotherapy induced Painful Neuropathies

Troels S. Jensen

Dept. of Neurology and Danish Pain Research Center, Aarhus University Hospital, DK-8200 Aarhus N, Denmark.

Chemotherapy-induced polyneuropathy (CIPN) is a major cause of long-term morbidity and reduced quality of life in cancer survivors. A series of drugs have been shown to cause CIPN. These include is prevalent after treatment with taxanes, taxanes and platin substances, vinca alkaloids, proteasome inhibitors and antiangiogenesis agents, which are used to treat different types of malignant diseases such as breast, gastrointestinal, lung, ovarian, prostate, myeloma and other cancers. Chronic CIPN is a dose-dependent mainly sensory polyneuropathy with a symmetric stocking and glove-like distribution. The most common symptoms are tingling, numbness and loss of position sense.

Neuropathic pain is seen in a subgroup. Symptoms may develop in the acute or subacute phase but can also develop weeks or months after ended treatment and may be associated with reduced quality of life, anxiety, and depression. The diagnosis is based on history, neurological examination supplemented by a series of tests.

The mechanism behind CIPN is complex with multiple modes of action. Some of the chemotherapeutic agents act on microtubule formation, others compromise mitochondrial function and there by axonal transport systems. Other drugs have effects on the nerve terminals or on the dorsal root ganglion itself.

Treatment of CIPN is difficult. There are no causal treatment available so one is left with symptomatic treatment. So far only one study has demonstrated a beneficial effect of SNRI agents. However many of the existing trail suffer from Methodological problems that may explain the failure to find an effect. There is now a need for identifying risk factors for the development of CIPN so that proper preventive strategies can be implemented.

S13.2

Spectrum of Neuropathic Pain in Myanmar Phyu Phyu Lay Professor and Head, Department of Neuro-Medicine, University of Medicine 2, Yangon, Myanmar

Neuropathic pain is one of the common syndromes attending neurology clinics. Although it is increasingly well recognized that neuropathic pain is one of the most important symptoms, it remains under diagnosed and undertreated in developing countries. Myanmar is a large country with total population of 54,133,137 in 2019. In 2018, among 265 patients attending to pain clinic in Yangon, 9% were found to have neuropathic pain. It is significant and clinical data on neuropathic pain in Myanmar is still scarce. So, short cross-sectional survey was carried out at Neurology and Rehabilitation out-patient clinics of two teaching hospitals in Yangon for one month (January 1- 31, 2019). It included 146 patients with neuropathic pain defined by interviewing with DN4 questionnaire. This study described five main clinical symptoms, types, causes and prescribed medications. 25.3% were new cases. The most frequent age group was 41 - 60 years (48.6%) with the mean age of 52.7±14.5 years. The male to female ratio was 1: 1.3. Central and peripheral neuropathic pain constituted 24.7% and 75.3% respectively. The commonest pain problem was radiculopathy (26%) followed by cerebral post stroke pain (11.7%) and diabetic peripheral neuropathy (9.6%). Five main clinical symptoms were tingling (84.4%), numbness (63.9%), pins and needles (40.2%), burning (36.1%) and electric shock like sensation (31.1%). The most commonly prescribed medication was pregabalin (49.3%) followed by gabapentin (28.8%).Maximum dosage of Pregabalin & Gabapentin to achieve pain relief by 80-100% were 300 mg & 900 mg respectively. Conclusion: Spectrum of Myanmar patients with neuropathic pain was not different from that of ASEAN population. It is crucial to recognize and treat the neuropathic pain in our daily clinical practice to improve the patients’ quality of life.

S13.3

Exploring Comprehensive Management of Painful Diabetic Neuropathy

Jimmy Barus

Atma Jaya Neuroscience and Cognitive Center Department of Neurology School of Medicine and Health Science Universitas Katolik Indonesia Atma Jaya Jakarta, Indonesia

Painful Diabetic Neuropathy (PDN) has been recognize as one of the most debilitating condition for those with Diabetes Mellitus which occurs in approximately 30% in those with diabetic neuropathy. This condition significantly interferes the quality of life. Treatment toward underlying disease (Diabetes) and some vascular risk factors are considered to be very important. Beside glucose control, lipids and body mass index also considered to be having important role in diabetic neuropathy and also PDN. Some treatment focused on the pathogenesis process of PDN such as alpha lipoic acid, benfotiamin etc, has been studied with various result. Symptomatic treatment for PDN mainly relies on pharmacological treatment. TCAs, SNRIs, and Gabapentinoids remain the first choices for this purpose. As one of the most difficult pain condition to treat, due to limited response to current treatment, complex underlying process, and psychosocial problems that potentially occur, more effective approach using treatment combinations and multidiscipline approach should be considered.

S14.2

Spinal Sensitization in Pain Rehabilitation Khin Saw Oo Physical Medicine and Rehabilitation Department, University of Medicine 2, Yangon, Myanmar

Classic descriptions of pain typically include four processes: Transduction, transmission, perception, and modulation. In persistent pain, Central Nervous System signals can result in a hypersensitivity or central sensitization response. As sensitization has been defined as an increased response to stimulation, this process may occur from nociceptors in peripheral tissues to brain areas responding to nociceptive inputs. Central sensitization explains changes observed in sensitivity threshold, time and region of pain in clinical situations of acute and chronic pain, Negative changes in the transmission of pain tend to occur through a process of sensitization. The nervous system can become sensitized at peripheral sites as well as centrally at dorsal horn and/or brain. Some clinical syndromes which central sensitization contribute involved rheumatoid arthritis, osteoarthritis, temporomandibular disorders, fibromyalgia, miscellaneous musculoskeletal disorders, complex regional pain syndrome, post surgical pain, and visceral pain hypersensitivity syndromes. Centrally acting drugs are available that specifically target processes known to be involved in Central Sensitization pain. And also use of topical analgesics may be associated with fewer patient systemic side effects. Exercise therapy also has the capacity to activate brain-orchestrated endogenous analgesia in patients with chronic pain. In some patients with chronic pain (including those with chronic low back pain , shoulder myalgia and rheumatoid arthritis), exercise activates powerful top-down pain inhibitory action, typically referred to as exercise-induced endogenous analgesia. There are also some pain neuroscience education which motivates patients for applying cognitive behavioral strategies to cope with their pain. Other options include spinal segmental sensitization and segmental desensitization.

S14.3

Rehabilitation For Cancer Survivors

Sharon Anne Khor KS

Hospital Sultan Ismail, Johor Bahru, Malaysia

Advances in cancer treatment have resulted in larger numbers of long-term cancer survivors. In 2012, approximately 13.7 million cancer survivors were living in the United States. These numbers are projected to increase over the next decade with the largest group of survivors amongst those who are 5 years or more from diagnosis. Women with breast cancer account for 22% of survivors, whereas men with prostate cancer account for 20% of survivors.

Cancer survivors can have an array of effects from the cancer or its treatment such as bone density loss, cardiotoxicity, pulmonary dysfunction, cognitive deficits, distress, fatigue, motor dysfunction, lymphoedema, nerve injury, pain and sexual dysfunction.

Cancer survivors need rehabilitation to improve these early- and late-onset effects. It is very common for survivors to have multiple impairments. Early referral to oncology rehabilitation services can mitigate the suffering from these adverse effects of treatment. Each cancer patient will have a variable degree of physical problems which require attention. The formulation of rehabilitation goals should take into account the patient’s tumour pathology, the anticipated progression of disease, any associated treatments, personal wishes and comorbidities.

Rehabilitation for these patients are crucial to the survivorship and restoration of the patient as a whole. The cancer survivor returns home hoping to resume his activities of daily living but may instead be faced with physical, psychological, social and financial barriers.

Rehabilitation for cancer survivors should be individualized for each patient throughout their care pathway and for some patients may start from the time of diagnosis to completion of treatment. The process of community reintegration for these survivors would be optimized in an interdisciplinary team management approach with the goal of restoring the cancer patient to his/her greatest functional capacity.

S15.1

Promoting Undergraduate Pain Education

Rehatta, N. M.

Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia

Start in 2018 through the title of IASP Global year for Excellence in Pain Education professional education is one of four areas that pain education will focus.

The widespread prevalence of pain demonstrates the need for comprehensive pain education for all health-care professionals although not all require the same type of pain-related knowledge and skills. The outline of curricula should provide a basic overview of suggested topics for interprofessional learning. It does not replace the uni professional curricula that provide additional depth in content required by each individual profession and discipline. It remains uncertain how the field of pain medicine will evolve to meet the needs of our patients, whether it will become a discrete discipline, a distinct residency, or simply grow to one year fellowship within the subspecialty of anesthesiology, but there is a need to review the role of medical education at the medical school including its current status, challenges, and opportunities in the changing field of pain medicine.

Undergraduate pain education is a critical early step in ensuring that health care practitioners entering the workforce are competent in pain management. However, only few medical school could identify designated pain content hours in their undergraduate curricula. While pain teaching was assumed to be ‘integrated’ in other courses, it was not quantifiable and therefore not able to be determined the content hours. However, it is clear that training and education should be structured not only in an interdisciplinary manner but also in which practitioners work together as team for the most valuable and efficient exchange of ideas and treatment modalities. Many experts commented on the need for pain-related curriculum through a interprofessional programme.

Regardless of the way in which the need is met, the future goal of pain medicine curricula should focus on how we can best improve the health and functional outcomes of our patients.

S15.2

Pain Education for Non-Pain Specialists in the Philippines

Maria Salome N. Vios, MD

1. University of the Philippines, Health Service 2. Lung Center of the Philippines

The Philippines is composed of around 7,700 islands with an estimated population in 2018 of 106, 5000,000 million, 52% living in the rural areas. As of the present count there are only ninety-seven (97) recognized pain specialist in the country by the Philippine Board of Pain Medicine. Furthermore there are only three (3) training centers that offer Fellowship in Pain Medicine. These training centers usually graduate 2-3 pain specialists/year. With these statistics, the ratio between the population and the number of pain specialist is roughly one (1) pain specialist for every one million and thirty-six thousand (1.36 M) Filipinos. The accessibility to a pain specialist is worsened by the fact that most of these pain specialists are found in the big cities. The dismal ratio provided the impetus for the Pain Society of the Philippines to launch the Pain Education Program for non-specialists in the Philippines in 2015. This program is in partnership with an industry that provides the logistics.

The pain education program consists of six modules as follows: general concepts of pain, chronic pain, neuropathic pain, central sensitization dysfunctional pain, low back pain and acute pain. As of March 2019, the program has conducted thirty-four (34) workshops in just four (4) regions. There is still much area to be covered by the Pain Society of the Philippines. This presentation shall present the strategies, and lessons learned to further improve the pain education for non- pain specialists in the country.

S15.3

Impact of Cancer Pain Education In Myanmar

Myo Myint Maw.

Medical Oncology Department , Yangon General Hospital

Cancer pain is troublesome and undertreated in individual with malignancy during the disease trajectory. Some implementation projects for cancer pain management had been done in Myanmar. There had been collaboration between Ministry of Health and Sports of Myanmar (MOHS) and Asia Pacific Hospice Network ( APHN) since 2013.Palliative care training program including cancer pain management was started in Yangon General Hospital from 2013 to 2016. This training program was conducted by voluntary faculty members of APHN from Singapore, Australia and Malaysia. By the end of this program, health care professional have wider view of knowledge regarding cancer pain management. There were new development in giving services for cancer pain management by opening of new palliative out-patient clinic in Yangon general hospital and Mandalay general hospital in 2017.The trained health care professional give active total care of pain management to patients, family members and care-givers. Patients and family members are also more reliable to palliative and pain management. Regarding the pain medication, there was breakthrough in pain management. Myanmar Pharmaceutical industry had been successfully manufacturing oral opioids since 2017, that will promote successful pain management. There has been great area for research and generation of educational intervention. Pain medicine and palliative care will be included in future curriculum of both undergraduate and postgraduate students in Medical Universities and Nursing Universities. In conclusion, there has been huge positive impact of cancer pain management in daily practice due to training program of health care professional that was organized by APHN and MOHS of Myanmar and availability of oral morphine. These improvement lead to reduce the suffering of patients, improve the quality of life of patients and reduce the burden of family members and caregivers. However, we are beginning stage in cancer pain education because of limited pain education program in two tertiary hospitals and limited targets due to limited human resources and financial restraint. In future, we are hoping to extend our education activities to other hospitals and public.

The Other Opioid Crisis

Francis O Javier,MD St. Luke’s Medical Center,Philippines

The world is in pain. Poverty, illiteracy and government regulations are factors that increase suffering. A lot of terminally-ill patients in poor countries receive no more than acetaminophen for their pain or none at all.

But six developed countries consume 79% of the global morphine while the remaining 21% is shared by the rest of the world (INCB).

Gram for gram, the United States of America consumes more narcotic medication than any other nation worldwide. This has led to misuse and abuse of opioids that led to the so called “opioid epidemic” or the opioid crisis of the Western world.

The other opioid cirisis is an older problem, perpetuated by governments and world regulatory bodies on top of an already opioid-scared population. This affects many more people around the world, mostly the poor and underprivileged, who continue to suffer pain until they die.

Historically, the International Narcotics Control Board (INCB) has focused on strict regulations focusing on combating drug abuse more than assuring access to pain relief. This led states and governments mostly in Latin America, Asia and Africa in the 1960s to enact restrictive laws and regulations on narcotics use and handling. Most of these countries underestimate the opioid needs of their people. This further promoted opiophobia among the population.

While the WHO and INCB are trying to re-educate people to reverse this problem, too few opioid medications are seen in developing countries. The newer opioid medications driven by large multinational companies that enter their market are mostly expensive and beyond their capacity to procure. The cheapest morphine tablets remain mostly unavailable.

Today, we see two opposing crises- too much opioid and too little opioids; both detrimental, both with social and economic consequences, and both needing complex solutions.

S16.2

Neuromodulation in context of developing country

Nantthasorn Zinboonyahgoon

Division of Pain Medicine, Department of anesthesiology, Siriraj hospital, Mahidol University, Thailand

Strong evidence has been showing that some high cost neuromodulatory technologies such as spinal cord stimulation not only relieve pain, but also improve function and quality of life in many painful and non-painful conditions. As such, the term high-cost is not equivalent to expensive, if the treatment is worthwhile in adding value back to patients’ lives and society.

The obstacles to using neuromodulation in developing countries include lack of knowledge about this technology among patients and the medical community, lack of cost-utility studies in the context of developing countries, and lower willingness to pay, compared to developed countries. The further education of patients and medical professionals, more cost-utility research, and raising the priority of pain management in health policy will enhance the accessibility of this high cost technology to patients.

Nevertheless, neuromodulation includes not only high technology/high cost equipments, but also low-cost modalities such as TENs stimulation, nerve block and neuroablation. These simple treatments together with medical knowledge can also deliver effective neuromodulatory treatment to appropriate patients in limited resource environments.

S17.1

Practical Management of Myofascial Pain

Pradit Prateepavanich

Siriraj Hospital, Bangkok, Thailand

Myofascial pain syndrome (MPS) is a common chronic pain problem in clinical practice.(1) As the etiology and the pathophysiology are exactly not known, the inevitable controversy still persisted though more researches and clinical studies supported the real body of myofascial trigger point (MTrP).(2, 3) MPS can address as a condition that occurs as a primary source of pain (primary MPS) as well as a comorbid with other diseases or a consequence pain from other conditions (secondary MPS).(4) Awareness in certain circumstances is important issue in practicing with MPS. In this presentation will focus on key awareness that more or less benefit for practitioner. Awareness 1. Overlook: In clinical practice MPS is a source of pain that had been overlooked.(1, 5) As other chronic pain; overlooking primary MPS leading to the over- diagnosis of psychological problem is a common situation(6, 7) and overlooking secondary MPS usually leading to the over-estimate of primary disease.(8) Awareness 2: Look-over: Dealing with MPS we have to take a look at both the source of pain (pain generator: MTrP) and more over the cause (primary or secondary) of MTrP, always.(2, 3, 9) Awareness 3: Short-termed therapy (MTrP inactivation) for long-termed change (find out and correct perpetuating factors) is the main principle of MPS management.(2, 3) Awareness 4: MTrP inactivation is just symptomatic treatment, as MTrP is a source of the symptoms.(2, 3, 9) And no single standard of MTrP treatment strategy (10) for example stretch and spray(11), acupuncture(12), dry needling(12), trigger point injection(13), massage(14), ultrasound diathermy(15), laser therapy(16), extracorporeal shockwave therapy(17), repetitive peripheral magnetic stimulation.(18) In practice, when there is doubt about the clinical significance of a particular trigger point, it can be inactivated with either MTrP release strategies, an immediate (with 2–3 minutes) unequivocal decrease in pain is good evidence that the MTrP in question is clinically relevant.(4) Regarding to MTrP inactivation one of the common question is which one should be a strategy of choice? It is depended on individual profile of the patient and combination may benefit in certain cases.(10, 19, 20) Also how long does the symptom relieve last after one time of the MTrP treatment? Definitely no one can tell as depended on individual PPF so rarely study reported.(21) And the number of the local MTrP treatment in clinical study was vary from few to 10 sessions within few weeks to few months.(3) Immediate and short-term relief is common finding but long-term not.(2, 3, 5) Awareness 5: Long-termed prognosis is to find out and correct the cause of the MTrP (comorbid or PPF).(2, 3, 9) In case of secondary MPS, comorbid may be one disease S17.1 but in case of primary MPS, PPF common to be multifactor. Awareness 6: Do all of the multifactor need to be corrected? By theory is yes but in practice may be not. Multifactor is not sole agent to activate MTrP, corrected one or some factors may attenuate the active MTrP to latent MTrP. So mix & match, set priority and evaluate the feasibility of each and which PPF to correct is important. Awareness 7: Does all the symptoms will gone after the comorbid was cured or all the PPF were corrected? In practice not all is found. Possible explanation might be regarding to self-sustaining positive feed-forward process of MTrP pathophysiology.(2, 3) At this moment any local MTrP treatment strategy obtained usually promise a magic result.

Reference

1. Skootsky S, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med. 1989;151(2):157-60. 2. Dommerholt J, Bron C, Franssen J. Myofascial trigger points: an evidence- informed review. JMMT. 2006;14(4):203-21. 3. Simons DG, Travell JG, Simons LS. General overview. In: Johnson E, editor. Travell & Simons’ myofascial pain and dysfunction: the trigger point manual. Vol. 1. Upper half of body. 2nd ed., Baltimore: Williams & Wilkins; 1998. p. 11-93. 4. Gerwin RD. Diagnosis of Myofascial Pain Syndrome. Phys Med Rehabil Clin N Am. 2014;341–55. 5. Gerwin RD. Classification, epidemiology, and natural history of myofascial pain syndrome. Curr Pain Headache Rep. 2001;5:412-20. 6. Pilowsky I, Barrow CG. A controlled study of psychotherapy and amitriptyline used individually and in combination in the treatment of chronic intractable, psychogenic pain. Pain. 1990;40:3-19. 7. Fischer AA. Diagnosis and management of chronic pain. In: Ruskin AP, editor. Current therapy in physiatrist: physical medicine and rehabilitation. Philadelphia: Saunders; 1984. p. 123-49. 8. Flax HJ. Myofascial pain syndrome: the great mimicker. Bol Assoc Med PR. 1995;87:167-70. 9. Rachlin ES. Trigger points. In: Rachlin ES, editor. Myofascial pain and fibromyalgia: trigger point management. St. Louis: Mosby; 1994. p. 145-57. 10. Desai MJ, Saini V, Saini S. Myofascial pain syndrome: a treatment review. Pain Ther. 2013;2:21-36. 11. Simons DG, Travell JG, Simons LS. Apropos of all muscles. In: Johnson E, editor. Travell & Simons’ Myofascial pain and dysfunction: the trigger point manual. Vol. 1. Upper half of body. 2nd ed. Baltimore: Williams & Wilkins; 1998. p. 94-177. S17.1

12. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009;13(1):3-10. 13. Hong C-Z. Myofascial trigger point injection. Crit Rev Phys Rehabil Med. 1993;5:203-17. 14. Fernández-de-las-Peñas C, Alonso-Blanco C, Fernández-Carnero J, Miangolarra-Page JC. The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study. J Bodyw Mov Ther. 2006;10(1):3-9. 15. Weber DC, Hoppe KM. Physical agent modalities. In: Braddom RL, editor. Physical medicine & rehabilitation. 4th ed. Philadelphia: Elsevier Saunders; 2011. p. 449-68. 16. Carrasco TG, Guerisoli LD, Guerisoli DM, Mazzetto MO. Evaluation of low intensity laser therapy in myofascial pain syndrome. Cranio. 2009;27(4):243-247. 17. S. Ramon et al. Review Update on the efficacy of extracorporeal shockwave treatment for myofascial pain syndrome and fibromyalgia Int J Sur. (2015) 1-6. 18. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. IJOM. 2006; vol. 9(4):120- 136. 19. Borg-Stein J, Simons DG. Myofascial pain. Arch Phys Med Rehabil. 2002;vol 83(1);40-47. 20. Gulick DT. Evidence-based interventions for myofascial trigger points. Phys Med Rehabil Res. 2016;vol 1(3):41-47. 21. Dhadwal N, Hangan MF, Dyro FM, Zeman R, Li J (2013) Tolerability and Efficacy of Long-Term Lidocaine Trigger Point Injections in Patients with Chronic Myofascial Pain. Int J Phys Med Rehabil S1:004. doi: 10.4172/2329-9096.S1-004

S17.2

Acupuncture, Complementary & Integrative Medicine: Evidence in Pain Management

Yap Sau Hsien

Ng Teng Fong General Hospital (NUHS), Singapore

Complementary and Integrative Medicine (CIM) is growing in popularity for various reasons, especially so for patients having chronic pain. Many of us do not understand and accept concepts of CIM and is heavily influenced by preconceptions. Thus, we find it difficult to acknowledge the evidence and potential benefits for chronic pain patients. Evidence for CIM is appearing slowly, but criticism are aplenty. Is placebo controlled, randomised trial the only way to look at evidence? Should we dismiss and deny CIM for chronic pain patients? Would dismissing CIM short-change our patients? As Confucius quoted: “Everything has its beauty, but not everyone sees it”. So, let’s try to understand and explore CIM together!

S17.3

The Evaluation of Pain Complicating Disabling Conditions

Angela BM Tulaar

Examples of the most debilitating diseases with pain complicating disability are the neuromusculoskeletal conditions, such as Rheumatoid Arthritis, Ankylosing Spondylitis, etc. Pain as ‘the fifth vital sign’ has resulted in mandated routine assessment and treatment of pain in hospital settings in all populations across the life cycle. Pain may have several etiologies that warrant a thorough examination in order to give proper management. Nociceptive, Neuropathic or combined pain whether acute or chronic should be well understood, as well as their pain pathways.

A comprehensive examination should start with the history of the pain, followed by a detailed physical examination that consists of observation, palpation, movement, including special tests. These will provide at least 90% of the diagnosis and additional information from the supportive examination will conclude the diagnosis. Functions should be of importance in order to preserve or possibly to improve it foe a better quality of life. Presentation will include the comprehensive examination of pain from the physical medicine and rehabilitation standpoint.

S18.1

Pain Diagnoses in ICD 11: Implications for Pain Practitioners

Michael Nicholas

University of Sydney and Royal North Shore Hospital

The diagnosis of chronic pain conditions has had a long and often contentious history. Opinions about chronic pain have ranged from it being a primarily mental health problem (e.g. masked depression) to it being a disease in its own right. The net effect has been to render chronic pain almost invisible in public health and hospital records and metrics. In most countries pain is often only mentioned in these records as a symptom of something else (e.g. arthritis, cancer, etc). Yet, the Global Burden of Disease project has identified chronic pain conditions amongst the most disabling conditions in terms of years lived with a disability – in all countries included in the survey, including South East Asian countries.

Over the last 5 years a taskforce of the International Association for the Study of Pain (IASP), in conjunction with the World Health Organization (WHO), has developed and now published the new International Classification of Diseases (ICD-11) with a new section devoted to chronic pain conditions. Unlike the previous version (ICD-10), ICD-11 makes it much clearer and simpler to diagnose chronic pain conditions, especially those where there is no obvious cause. Such patients were often told they had ‘medically unexplained symptoms’ and, quite understandably, often felt stigmatized as they didn’t have a ’real’ medical condition. Accordingly, it is hoped that when countries start using ICD-11 we will start to see, for the first time, the presence of chronic pain conditions, whether primary or secondary, being represented in medical/hospital records and public health statistics. It is also hoped that these patients will no longer be left feeling stigmatized.

This paper will discuss some of the main implications the new way of representing chronic pain conditions will have for pain practitioners and their patients.

S18.2

Nociplastic Pain: Do We Need a 3rd Descriptor?

Eva Kosek

Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden

Pain has traditionally been regarded as a symptom of tissue injury or disease/lesion in the nervous system, i.e., nociceptive or neuropathic pain. However, certain forms of chronic pain are best regarded as a disease in their own right, i.e. primary pain. In October 2017 the International Association for the Study of Pain (IASP) decided to revise the classification system of chronic pain by adding a third mechanistic descriptor, nociplastic pain, in addition to the terms nociceptive and neuropathic. The third mechanistic descriptor, nociplastic pain, defined as pain that arises from altered nociception, permits the mechanistic classification of “primary” pain. The new matrix of IASP mechanistic terms, nociceptive, neuropathic, nociplastic and pain of unknown origin will be presented along with a discussion how these terms should be used in the clinic. The presentation will provide an overview of the variety of pain conditions associated with nociplastic pain and the potential clinical and scientific usefulness of the new term. The underlying pathophysiological mechanisms as well as clinical signs and symptoms in nociplastic pain will be presented. The transition from nociceptive to nociplastic musculoskeletal pain, how it can be recognized, and the relevance for treatment will be discussed.

PD04

Opioids, Getting the Balance Right

Maria Lilybeth R. Tanchoco

MCU Hospital, Philippines

The World Health Organization reported that the global cancer burden is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018. One in 5 men and one in 6 women worldwide develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease. Worldwide, the total number of people who are alive within 5 years of a cancer diagnosis, called the 5-year prevalence, is estimated to be 43.8 million. These reported in the developing part of the world, including Asia, Africa, Central and South America. Cancer survival rate is poorer in developing countries due to diagnosis at late stage and limited access to timely treatment. Since the disease per se cannot be treated even with the best available treatment modalities, what remains important is symptom management and providing comfort care to these patients. The incidence of pain in advanced stages of cancer approaches 70–80%. Lack of preventive strategies, poverty, illiteracy, and social stigma are the biggest cause of pain suffering and patient presenting in advance stage of their disease. The need for palliative care is expanding due to aging of world's population and increase in the rate of cancer in developed and developing countries. A huge gap remains between demand and current palliative care services. Overcoming barriers to palliative care is a major global health agenda that need immediate attention. Main causes of inadequate pain relief remain lack of knowledge among physician and patients, lack of adequate supply of opioids and other drugs for pain relief, strong bureaucracy involved in terms of procurement, and dispensing of opioids. Beside this, poverty and illiteracy remain the most important factors of increased suffering

PD06

Opioids-Getting the Balance Right in Thailand

Supranee Niruthisard

Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thailand

It has been known for centuries the remarkable beneficial effects particularly analgesia and the toxic side effects and addictive potential of opioids. Since establishment of Thai Chapter of IASP in 1990, several movement of Thai Chapter has been done to promote pain education, setting different clinical pain guidelines, and improvement of effective and safe pain management including opioid availability and accessibility in the country.

In 1997, the Thai Food and Drugs Administration (Thai FDA), by request of Thai Chapter, increased the opioids quota to be used in the hospitals and relaxed the legitimation of the report on opioid usage resulting in being easier to access medical use of opioids. By the supportive policy of Ministry of Public health, policies implemented by the Thai FDA, the National Health Security Office and the Government Pharmaceutical Organization, the annual Morphine Equivalence consumption in Thailand rose from 3.96 mg per capita in 2010 to 5.85 mg per capita in 2015. However, there was still a long way to go towards equitable level of usage for the whole country and pain remained underassessed and undertreated in the majority of pain patients.

The epidemic of prescription opioid overdose death happened in the United States and some developed countries has called attention to properly use of opioids in different types of pain patients (acute pain and chronic non-cancer pain VS cancer pain and pain in palliative care) according to IASP Opioid Statement. The WHO-2P safety focusing in patient safety with opioid prescription has been implemented in the hospital accreditation program by the Healthcare Accreditation Institute (Public Organization). Continuing education regarding optimized opioid usage and narcotic laws for physicians and related health care personnel, and setting up conferences for policy makers/regulators are needed.

Evaluation Of Pre-emptive Intravenous Parecoxib On Analgesic Sparing Effect In Patients With Total Abdominal Hysterectomy

Mohd Erham Mat Hassan1, Nik Abdullah Nik Mohamad 1, Mohd Faeiz Pauzi1, Siti Norazlina Juhari1

1 Universiti Sultan Zainal Abidin, Malaysia

AIM OF INVESTIGATION: Many studies suggest pre-emptive administration of analgesics has postoperative opioid sparing analgesia. This study was designed to evaluate the effects of pre-emptive intravenous parecoxib on intraoperative anaesthetic and analgesic sparing potential in patients undergoing total abdominal hysterectomy.

MATERIALS AND METHODS: Sixty eight ASA I and II patients were studied in a double blind, randomized placebo controlled trial. Patients were randomly divided to receive either 2 ml of intravenous parecoxib or 2 ml of normal saline 30 minutes before induction of anaesthesia. Sevoflurane concentration was adjusted according to BIS value to maintain depth of anaesthesia. Intraoperative end tidal sevoflurane concentrations and haemodynamics were recorded every 10 minutes during the surgery. Total intraoperative rescue analgesic consumption, extubation time, time to first postoperative analgesia requirement and postoperative pain score, sedation score, nausea and vomiting score were recorded.

RESULTS: Pre-emptive intravenous parecoxib was significantly reduced the intraoperative anaesthetic requirement of sevoflurane and analgesic requirement of opioids (all P < 0.001). In addition, postoperative recovery condition of parecoxib group was much better than control group in term of significantly shorter extubation time, longer time to first postoperative analgesia requirement, less morphine consumption, good pain score and sedation score (all P < 0.05). However the incidence of postoperative nausea and vomiting and postoperative complications were found to be equivocal (P value = 1.0).

CONCLUSION: Pre-emptive intravenous parecoxib provided an intraoperative anaesthetic and analgesic sparing effects that improved postoperative recovery and analgesia without increasing the incidence of side-effects and complications. complications.necessary social and psychological support to these patients.

Effects Of Intravenous Magnesium Infusion For Total Knee Replacement Surgery Under Spinal Anesthesia: A Randomized Double-Blinded Prospective Study

Liew Sat Lin*1, Alvin Oliver Payus1, Jony Sieman1, Khor Foo Kiang1, Raman S. Rm1, Dharmalingam Tk1, Muniandy Rk1, Thong Fu Yuen1, Tan Chen Vui1, Symeon Mandrinos2

1 Universiti Malaysia Sabah, Malaysia 2 Swinburne University, Sarawak Campus

AIM OF INVESTIGATION: Residual pain at rest or during daily physical activity is a major cause of patients’ dissatisfaction after total knee replacement (TKR) surgery. A high quality of perioperative analgesia should be warranted to optimize patients’ rehabilitation and satisfaction. The aim of this study is to look into the effectiveness of magnesium sulphate (MgSo4) in acute pain management post-TKR.

MATERIALS AND METHODS: It involved patients scheduled for elective TKR surgery under spinal anaesthesia in Hospital Queen Elizabeth, Sabah. Ethical approval and registered under National Medical Research Registry, Malaysia. After obtaining informed written consent, the patients were randomly assigned to two groups. Post spinal anaesthesia, the placebo group (Group A; n=40) received IV infusion of 50 mls of isotonic saline. The magnesium group (Group B; n=40) received MgSo4 2.47g in 50 mls isotonic saline. Postoperative visual analogue scale (VAS), PCA consumption and incidences of side effects evaluated immediately after operation, at 12 and 24-hour post-surgery. Descriptive and inferential statistics were used to analyse the data.

RESULTS: Mean score of VAS is lower in Group B than Group A at immediate post-operative and 24 hours post operation. (p=0.003). The mean morphine use in the placebo group (Group A), 23.90 ± 14.10 mg which was higher than the magnesium group (Group B), 17.08 ± 13.09 mg (which was 28.9% reduction in magnesium group), p=0.028.

CONCLUSION: Intravenous magnesium sulphate infusion is effective to reduce postoperative morphine consumption and lower VAS score in the first 24-hour period among our patients, without causing adverse effects.

Intrathecal Morphine For Post-Cesarean Analgesia: Duration of Analgesia, Side effects and Patient satisfaction

Dr T Prabha1, Dr Shivali Shamsher1, Boo Jian An1, Charlene Chew Shao Lynn1, Yeh Kuan Yau1, Dr Bina Rai1

1 AIMST (Asian Institute Of Medical Science And Technology)/ Malaysia

AIM OF INVESTIGATION: To evaluate the postoperative duration of analgesia, side effects and patient satisfaction of intrathecal morphine (ITM) in women who underwent caesarean section under spinal anesthesia.

MATERIALS AND METHODS: For this prospective study 50 full term healthy parturient (ASA 2) were interviewed (regarding duration, side effects and patient satisfaction towards pain relief) after the first 24 hours of lower segment caesarean section under spinal anesthesia with intrathecal morphine for postoperative analgesia.

RESULTS: From total, 3(6%) patients had pain relief lasting 24 hours and for 31(62%) pain relief lasted for 6hours or less. Total 45 (90%) had side effects, the most common being sedation (28.6%), Pruritus (25.9%), followed by Nausea and vomiting (17%). Irrespective of the results 88% were satisfied with the pain relief obtained.

CONCLUSION: ITM provides good patient satisfaction as a mode of postoperative analgesia though the duration is short and side effects are common. More studies with larger sample size need to be done to find the prolonged efficacy of ITM as a sole postoperative analgesic.

PCA Ketamine-Morphine versus PCA Morphine As Analgesia In Postoperative Colorectal Surgery Patients

Nurul Akasya Adnan1, Nita Salina Abdullah2

1 Hospital Sultanah Aminah/ Malaysia

AIM OF INVESTIGATION: Ketamine, an NMDA receptor antagonist has undergone a recent resurgence of interest amongst acute care providers as an opioid sparing agent in management of acute pain. In this study, we evaluated the effectiveness of PCA ketamine-morphine in comparison to conventional PCA morphine as postoperative analgesia in colorectal surgery patients.

MATERIALS AND METHODS: In this double blind, randomized controlled study, 59 patients who underwent elective colorectal surgery were studied. They were randomly assigned into two groups. Group A received PCA ketamine-morphine 0.5mg/ml in 1:1 ratio while Group B received PCA morphine 1mg/ml as postoperative analgesia. These patients were followed up until 48 hours post operation, and their pain scores at rest and on movement, cumulative morphine consumption, side effects including nausea and vomiting, pruritus, dizziness, respiratory depression and hallucinations and also patients’ overall satisfaction score were recorded and analyzed.

RESULTS: There were 29 and 30 patients allocated into group A and B respectively. Overall, there was no significant difference in pain score at rest and on movement in both groups. Cumulative morphine consumption however were significantly lower in group A at all intervals with 24.7±15.2 vs 48.9±30.4 mg (p <0.05) at 24 hours and 38.3±22.4 vs 77.8 ± 46.3 mg (p<0.05) at 48 hours. There was no significant difference in incidence of side effects and overall satisfaction score in both groups.

CONCLUSION: PCA ketamine-morphine is as effective as PCA morphine as postoperative analgesia, with comparable pain scores and side effects and significant reduction in morphine consumption.

Pain Free Hospital Program Effort How to Maintain Pain Score 4 in Post- Operative Patients

Ungku Kamariah Ungku Ahmad1, Nur Hazalina Md Salleh2

1 Hospital Sultan Ismail Johor Bahru/ Malaysia

AIM OF INVESTIGATION: To study effectiveness of pain score on movement as indicator to determine the type of oral drugs to be used after discontinuation of specific modality in order to maintain pain score < 4 in post-operative patients.

MATERIALS AND METHODS: This cross-sectional study involved all adult postoperative patients on specific modality (PCA, epidural infusion and subcutaneous drugs) managed by Acute Pain Service (APS) team from January to Jun 2016. Data collected were pain score on movement post 24 hours after conversion to oral drugs following a standard protocol where patients with pain score ≤1 on movement while on specific modality will be converted to weak opioids and patients with pain score ≥2 on movement will be converted to strong opioids.

RESULTS: Of 677 patients chart reviewed, 497 were eligible for analysis. Pain assessment at 24 hours after converted to oral drugs from specific modality found that 460 patients (92.6%) were able to maintain pain score of <4 on movement. Out of the 460 patients, 260 patients were converted to oral drugs from PCA, 167 from epidural infusion and 33 from subcutaneous drugs.

CONCLUSION: Pain score on movement proven to be useful and effective indicator to determine appropriate oral drug to start after conversion from specific modality in order to maintain pain score <4 in post-operative patient.

Pain Out Aspire phase 1 project Preliminary Acute Postoperative Pain Baseline Data in an University Hospital

Lim Siu Min1, Beh Zhi Yuen1, Lim Woon Lai1, Marzida Binti Mansor1, Ramani Vijayan Sannasi1

1 University Malaya/ Malaysia

AIM OF INVESTIGATION: Pain Out Aspire is a collaboration network project carrying out in 7 South-East Asia countries, aiming at improving postoperative pain management by collecting baseline data, analyzing them, introducing improvements and assessing these improvements' effect in a second phase of data collection. We are reporting our center preliminary baseline data on acute postoperative pain in orthopaedic department.

MATERIALS AND METHODS: Adult patients who underwent major orthopaedic surgery were recruited on their post operation day 1. Basic demographic data, medical and surgical data, perioperative pain management practices, and patients reported outcomes (PROs) were collected for analysis. Most PROs used 11-point numerical rating scales (0=null, 10=worst possible).

RESULTS: 78 patients were recruited over 4months duration. The worst pain score they reported were 5.59 ({SD+/-} 2.67), and they experienced severe pain in 41.15% (23.02) of the time since operation. Pain had interfered or prevented them from sleeping by the scale of 3.37 (2.81). 55% of patients received information about pain treatment options preoperatively. They are allowed to participate in decision of pain treatment as much as they wanted to in a scale of 5.06 (3.70). The percentage of pain relief they received overall was 56.23% (23.49), and 49% of the patients actually wishes for more treatment to be given to them. Common side effects reported were: nausea 1.62(2.61), drowsiness 3.06(3.02), itchiness 1.17(2.02), and dizziness 2.36(2,.91). Overall satisfaction score was 6.78(2.50).

CONCLUSION: Acute postoperative pain management remains a real challenge and more work to be done to identify the gaps and possible changes.

External Validation of a Predictive Model for Acute Postoperative Severe Pain after In- and Outpatient Surgery

Lum Phooi Si1

1 Hospital Raja Permaisuri Bainun/ Malaysia

AIM OF INVESTIGATION: Objective of this study was to externally validate and update a previously developed and internally validated predictive model for postoperative severe pain in surgical inpatients and outpatients in a tertiary hospital in Malaysia.

MATERIALS AND METHODS: Study was conducted as prospective convenient sampling cohort. Analysis was performed using logistic regression. Model discrimination was quantified using area under the receiver operating characteristic curve (ROC AUC). Model calibration was assessed by visualisation of calibration plot, and analysed using Hosmer–Lemeshow (HL) χ2 statistic. The model was updated by recalibrating to the difference in outcome incidence.

RESULTS: A total of 138 patients were included. Incidence of severe pain was 15.2%, compared to that in development cohort (62%). The model systematically overestimated the probability of severe pain, with mean (SD) predicted probability of 0.603 (0.175) compared to observed probability = 0.152 (0.096). The model showed acceptable discrimination with ROC (95% CI) of 0.701 (0.62- 0.79). Model calibration plot showed poor calibration with HL goodness of fit test showed poor fitting: X2 (df) = 23.625 (8), P=0.003. The updated model showed slight improvement in discrimination, ROC 0.704 (95% CI 0.62-0.79), with unchanged calibration.

CONCLUSION: The prediction model showed poor calibration and acceptable discrimination. Though, the predictive performance of the model was not conclusive as the small sample size may have limited it's validation accuracy. Findings from this study could serve as preliminary data for future study with adequate sample size to validate and improve the model’s performance in local setting.

Acute vs Chronic Pain Is There Any Difference in Quality Of Life

Farida Niken Astari1, Tika Prasetiawati1, Hermawan Hanjaya1

1 Universitas Gadjah Mada/ Indonesia

AIM OF INVESTIGATION: This study aims to determine the relationship between the onset of pain and the decreased of quality of life, in the outpatient clinic of Universitas Gadjah Mada Academic Hospital.

MATERIALS AND METHODS: This cross sectional study was conducted between March – July 2018. This study determines the acute pain cut-off point is less than 3 months, so criteria of chronic pain is 4 months or more. This study used Visual Analog Scale (VAS) and The Short Form 36 Health Survey (SF-36)

RESULTS: From 151 eligible subjects, most of them (71 %) suffered from chronic pain with the mean of VAS was 39.9 ± 15.7 mm. The remaining 43 subjects have acute pain with the mean of VAS was 40.36 ± 19.2 mm. This study compare mean SF-36 score between acute and chronic pain subjects using Mann-Whitney analysis. The results show no significant correlation of total SF score (p=0,765), physical functioning ( p = 0.761), limitation due physical (p = 0.947), limitation due emotional (p = 0.659), fatigue (p=0.263), emotional wellbeing ( p=0.764), social functioning ( p=0.261), pain (p=0.878) and general health (p = 0.409) between acute and chronic pain.

CONCLUSION: There was no significant relationship between onset of pain and decreased of quality of life

The Analgesic Effects of Pentadecapeptide BPC 157 studied on Incisional Pain Model in Rats

Rushin Maria Dass1, Kim Eunsoo2, Kim Haekyu2

1 Hospital Selayang/ Malaysia 2 Pusan National University Hospital/ Korea

AIM OF INVESTIGATION: BPC 157 is a partial sequence of the natural peptide which is isolated from human gastric fluid. It consists of 15 amino acids and has shown to be anti-inflammatory and accelerates wound healing. In this study, we intend to demonstrate that BPC 157 may have some antinociceptive function along with accelerated wound healing effect in rats subjected to an incisional pain model.

MATERIALS AND METHODS: Rats (average weight of 210-230g) were randomly grouped into 3 groups (Control, Morphine, BPC 10mcg) with 4 rats in each group. All rats were subjected to incisional pain model and all medications were administrated via intraperitoneal injection. The control group received no medications, morphine group received morphine at 5mg/kg, and BPC groups were given BPC 157 at 10mcg/kg. A twice daily dosing was given daily for 6 days for both morphine and BPC groups. Mechanical testing was done every morning prior to receiving their usual doses of the day from postoperative day 2-7.

RESULTS: Rats that were in BPC 157 compound showed higher mechanical threshold. Mean values were higher in the BPC group from postoperative day 2 till day 7 and was statistically significant especially from postoperative day 5 till day 7 with p values less than 0.05 (two-way ANOVA with Tukey post-hoc test).

CONCLUSION: Rats given BPC 157 shows better analgesic effect with a quicker return to baseline mechanical threshold compared to rats in morphine and control group.

Fracture Reduction – Analgesia Is the Most Important Not Sedation

Ungku Kamariah Binti Ungku Ahmad1, Mohd. Aizat Bin Mansor1, Nuur Nisarin Binti Talib1

1 Sultan Ismail Hospital, Johor Bahru/ Malaysia

AIM OF INVESTIGATION: To survey the adequacy of multi-modal analgesia in pain relief during performance of manual fracture reduction in the hospital.

MATERIALS AND METHODS: All patient with ASA 1-2 who had pain relief given to performed ‘Closed Manipulative Fracture Reduction’ (CMR) in year 2016-2017 by Pain Unit Team was included in the survey. Pain assessment by pressing over the fracture site are use as a monitoring indicated. All patients are fasted following fasting guidelines and they received multi-modal analgesia which includes intravenous paracetamol, NSAIDs (parecoxibe for adult or ibuprofen for children) at least 1 hour prior to intravenous oxynorm protocol. Oxynorm are titrated till pain score on assessment are 1-2 before CMR is performed. Rescue dose of oxynorm are given if pain score are more then 3. Sedation with intravenous midazolam titrated dose are given if patient had anxiety or request.

RESULTS: Total of 395 patients received pain relief for Closed Manipulative Fracture Reduction by Pain Team. Lowest pain score was 0 and highest was 4. The mean pain score was 3. Seventy percent were successful reduction with thirty percent failures. Less then 1 percent of patients requires sedation with midazolam.

CONCLUSION: Multi-modal analgesia are able to provide sufficient pain relief for closed manual reduction of fracture for most of the patients without or minimal needs of sedation.

Intravenous Ketamine-Lignocaine Infusion for Pain Management in Wound Care

Muhammad Rahmat Ali Hassan1, Ungku Kamariah Ungku Ahmad1

1 Hospital Sultan Ismail/ Malaysia

AIM OF INVESTIGATION: While IV ketamine and IV lignocaine infusion is used separately to treat acute pain in common practice, we In Hospital Sultan Ismail practices concurrent infusion of both drugs as a supplement to analgesia prior to wound dressing. Our aim is to evaluate the effectiveness of ketamine-lignocaine infusion in patient with a wound which required wound dressing in ward.

MATERIALS AND METHODS: Database of 76 patients who received ketamine 4 mg/hour and lignocaine 20 mg/hour infusion for wound debridement in the year 2017 was reviewed retrospectively. Only patients who received continuous infusion of both medications between 72 to 120 hours were studied for pain score upon first opening of dressing. Side effect of ketamine-lignocaine and incidence of neuropathic pain during dressing opening were reviewed.

RESULTS: Out of 76 patients, 5 patients were excluded. Lignocaine infusion was stopped less than 72 hours in 3 patients for possible toxicity, while ketamine infusion dose was reduced in 2 patients as they experienced visual and auditory hallucination. From 71 patients that were studied, 68.8 % have pain score of 2 or less during opening of wound dressing. Only 3 patients have pain score of more than 6. Incidence of sedation scores more than 1, giddiness, and neuropathic pain was 0.0 %, 20.8 % and 4.2 % respectively.

CONCLUSION: Concurrent ketamine-lignocaine infusion provides effective analgesia during wound dressing opening with minimal significant side effects.

A Meta-analysis on the Efficacy and Safety of Epidural Oxycodone versus Epidural Morphine for Postoperative Pain Relief in Adults

Chris Bryan Sembrana1, Nina Bella1

1 University Of The Philippines College Of Medicine, Manila/ Philippines

AIM OF INVESTIGATION: Oxycodone is rarely used in epidural anesthesia despite having advantages over morphine such as greater potency, less side effects, and faster onset of action. We assessed the efficacy and safety of epidural oxycodone (EO) versus epidural morphine (EM) for acute postoperative pain relief in adults.

MATERIALS AND METHODS: CENTRAL and MEDLINE databases were searched until April 2018. Randomized controlled trials in the English language comparing EO to EM in adults who underwent surgery were included. Two authors independently selected studies, assessed risk of bias, and extracted data. Mean differences (MD) of numeric rating scale and visual analogue scale pain scores and relative risk ratios of opioid side effects were calculated.

RESULTS: Four studies with 244 patients met our inclusion criteria. EM was statistically superior to EO in postoperative pain on movement at 12 (MD 2.0; 95% CI 0.35 to 3.65), 24 (MD 0.77; 95% CI 0.01 to 1.52), and 48 hours (MD 1.27; 95% CI 0.05 to 2.50) postoperatively. There was no statistically significant difference between EO and EM in postoperative pain at rest (0, 3, 12, 24, and 48 hours postoperatively) and on movement (0, 3, and 6 hours postoperatively). There was no statistically significant difference in relative risks of opioid side effects.

CONCLUSION: EO has no clinically significant advantage over EM in postoperative pain control and incidence of opioid side effects. The high certainty of evidence and low risk of bias of our included studies do not support future clinical trials comparing EO and EM.

Sphenopalatine Ganglion Block Transnasal Approach: Post Spinal Anesthesia with Headache.

KB Ibrahim1, NI Bahar1

1 Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan.

Abstract

A 19 -year- old girl, was scheduled for a diagnostic arthroscopic of left knee and meniscus repair under subarachnoid block. Post-operatively, an oral analgesics (Paracetomol, Celecoxib) was started. However on post-operative Day 1, she complaint of persistent frontal-parietal headache upon waking up and associated with nausea and vomiting. Headache was not relieved even on supine position. There was no problem with neck pain and movement. She was referred to Acute Pain Service (APS) team on Day 3. As headache was severe (PS = 7/10) and disabled patient from doing routine activity, APS team did a sphenopalatine ganglion (SPG) block transnasal approach. It was a blind procedure, performed on supine position, soaking a 7 inches wooden cuticle (Orange stick) with lignocaine 2%, and 0.5mls. The stick was inserted via left nostril, 90 degree, and slowly pushed and twisted posteriorly until resistance felt. Another 0.5mls of lignocaine 2% was dropped on the stick as it flowed posteriorly and the stick was left for 10 minutes. There was no immediate complication occurred. Surprisingly Pain Score at 0H,1H was 3 and 4H,12H,24H was 0 (no pain) with subsided nausea and vomiting. Simultaneously an intravenous analgesics (Paracetomol,Parecoxib) was served at 5H post SPG block. In conclusion, SPG block showed desirable pain relieve with no side effect. Thus, it can be an alternative modality to treat post spinal anesthesia headache.

It Was an Epidural Block; Or Was It A Subdural Block? Possible Transient Ischemic Attack (TIA)?

SN Amani A1, A Hazwan MN1, W Rohaidah WA1

1 Hospital Sultanah Nur Zahirah

AIM OF INVESTIGATION: Lumbar epidural is a common procedure done in anaesthesia field. Subdural block is a known complication. The clinical presentation often attributed to other causes and it can present as high sensory block. On the other hand, transient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.

REPORT: We recently experienced a case of 57yo lady, weight 55kg and BMI 23.5kg/m. She was diagnosed as having ovarian carcinoma stage IV with underlying hypertension on 3 antihypertensive agents and IHD. She underwent a debulking surgery under GA and epidural. The lumbar epidural insertion at L1L2 was successful at first attempt. Induction was started at BP 109/70mmHg and HR 95bpm. Induction used drugs included fentanyl, lignocaine, propofol and subsequently rocuronium. She then required boluses of phenylephrine as to keep MAP more than 70mmHg without ECG changed seen. Total 16mls of epidural ropivacaine 0.375% + 2mcg/ml Fentanyl was given. Post extubation, she was monitored in recovery bay. Epidural cocktail commenced at 8ml/hr without pre bolus. However after 30 minutes, she was unresponsive at GCS 3/15, her pulse was palpable with HR of 105bpm and normotensive. She had a shallow breathing. Hence she was intubated for airway protection. Her conscious level improved post intubation however all muscles power were remained zero. After a few hours in ICU, the GCS was 10T/15 and started to move all 4-limbs with muscle power of 5/5. The extubation was done on the same day and then she was transferred out from ICU.

CONCLUSION: Subdural block from an epidural catheter is a known complication that may lead to life-threatening consequences. However, it is difficult to detect due to the variability of symptoms and signs. In this case, we treated her as likelihood subdural block with TIA needed to be excluded first. .

Benefits Of Early Intervention Using The Combination Of Gasserian And Sphenopalatine Ganglion Block On Trigeminal Neuralgia At St. Lukes Medical Center Global City, Taguig City, Philippines

Rainier Tanalgo11, Emmanuel Q. Villano1, Jocelyn C. Que1

1 Pain Center St. Lukes Medical Center Global City, Taguig City, Philippines/ Philippines

INTRODUCTION: The International Association for the Study of Pain (IASP) defines Trigeminal Neuralgia (TN) as ‘a unilateral painful disorder that is characterized by brief, electric shock like pains, is abrupt in onset and termination, and is limited to the distribution of one or more divisions of the trigeminal nerve’. Worldwide prevalence varies from 10 to 300/100 000. The peak age of onset is between 50 and 60 years old with a male-to-female ratio of 1:2. We don’t have the local data but it is often underdiagnosed and thus, undertreated.

REPORT: We reported a case of 40-year-old woman, presented with right lower jaw pain for 2 weeks which was intermittent, electric like sensation, NRS 3-8/10, triggered or aggravated by talking, chewing, and tooth brushing. She was started on Carbamazepine and Tramadol. MRI of the Brain showed no significant findings. There was still recurrence of severe pain. We did the combination Gasserian ganglion and Sphenopalatine ganglion (SPG) block to abort the pain and to prevent the pain becoming chronic. The pain was relieved thereafter. Carbamazepine and Tramadol were continued for few days. The patient is pain free for 2 months now.

Many patients responded well to medication while some might be refractory to medical treatment. Also some patient’s pain condition may become chronic. For immediate pain relief, “Sphenopalatine”, “Gasserian” ganglion block, or the combination thereof would be an effective treatment modality for these difficult- to-treat patients.

CONCLUSION: Early combination of Gasserian ganglion and SPG block in Trigeminal Neuralgia can give early pain relief.

Neutrophil-to-Lymphocite Ratio in Primary Brain Tumor Patients Presenting With Versus Without Headache

1 Rissito Centricia Darumurti , Kusumo Dananjoyo1, Ahmad Asmedi1

1 Universitas Gadjah Mada/ Indonesia

AIM OF INVESTIGATION: To learn if there is a difference between the neutrophil-to-lymphocite ratio (NLR) in primary brain tumor patients presenting with headache and in those without headache.

MATERIALS AND METHODS: This study used cross-sectional design. Data were obtained from medical records of patients with primary brain tumor in the Neurological Ward of Dr. Sardjito General Hospital Yogyakarta during the period of January-December 2017 that met the inclusion and exclusion criteria. NLR was calculated from the differential white blood cell (WBC) count. The difference between NLR in primary brain tumor patients presenting with headache and in those without headache was analysed using Mann-Whitney test.

RESULTS: From 37 data included in this study, we found a significant difference (p = 0.008) between the NLR in primary brain tumor patients presenting with headache and in those without headache. The results also showed that the NLR in brain tumor patients presenting without headache (Mean ± SD = 12.34 ± 7.30) was greater than the NLR in those presenting with headache (Mean ± SD = 6.07 ± 3.77).

CONCLUSION: There is a significant difference between the NLR in primary brain tumor patients presenting with headache and in those without headache. The NLR in brain tumor patients presenting without headache is greater than in those with headache.

Hygroma Post Intrathecal Catheter Insertion: A Case Report

Kiung Sze Ting1, Mazlila Meor Ahmad Shah1, Mary Suma Cardosa1, Sushila Sivasubramaniam1

1 Hospital Selayang, Malaysia

INTRODUCTION: Intrathecal drug administration for cancer pain is well established and is effective in controlling pain, reducing systemic opioid requirements and minimizing analgesic related side effects. Documented procedure related complications include infection and cerebrospinal fluid leak causing post dural puncture headache and, rarely, hygroma.

REPORT: We present a 25-year-old female with advanced cervical carcinoma who underwent intrathecal catheter insertion for cancer pain control. The level L2/L3 was punctured twice, for a trial catheter; followed by a permanent catheter insertion 1 week later, at the same level.

After 2 months, she developed fluid leakage from catheter tunneling puncture site and a fluctuant swelling at the insertion level. Further clinical examination and ultrasound concluded that she had developed a hygroma from persistent cerebrospinal fluid (CSF) leak at the insertion site. She was treated conservatively with compression bandages. Both swelling and leakage resolved completely after 10 days without further complications.

CONCLUSION: Commonest procedure related complications are from implantation technique. In this case repeated punctures at the same site may have contributed to dural defect and persistent CSF leakage. Despite being self- limiting, this complication can lead to intracranial hypotension and subdural hematoma if severe. Focus must be given at insertion technique and diligent surveillance for potential complications.

Aromatase Inhibitor Induced Arthralgia - Management Approach from A Rehabilitation Perspective

1 Tan Yeow Leng , Mothi Babu Ramalingam1

1 Singapore General Hospital/ Singapore

INTRODUCTION: Up to 50% of patients on Aromatase Inhibitor for receptor positive breast cancer report arthralgia and musculoskeletal discomfort leading to premature discontinuation of therapy, poor functional performance and quality of life. There is a need to increase awareness of AI induced arthralgia to facilitate prompt treatment strategies for these survivors. We present a case of AI induced arthralgia in a lady with breast cancer and management of her symptoms from a rehabilitation perspective.

REPORT: A 64 year old Chinese lady was diagnosed with right sided receptor positive breast cancer in July 2015. She underwent surgical treatment in July 2015 followed by chemotherapy and radiotherapy. Oncologist recommended her to be on endocrine treatment in January 2016 and was seen at the rehabilitation medicine clinic for AI induced arthralgia in May 2018. The multi modal treatment included physical therapy for posture education, aerobic and stretching exercises. She was prescribed home based exercises including yoga to improve flexibility .Her pain symptoms improved with acupuncture to shoulder , neck a& elbow region followed by dry needling of myofascial trigger points involving the neck and shoulder muscles. Patient responded well to these treatment strategies and was able to return to her office work and sport activities such as jogging and swimming.

CONCLUSION: This case highlights the need for early recognition and appropriate treatment strategies including a prescribed individualized rehabilitation program aiming to improve AI-related symptoms, function and quality of life.

Identifying Predictors of Postoperative Persistent Pain in Women with Breast Cancer in Malaysia

Che Gon Hashim1 Nur Aishah Taib2 Hwan-Jin Yoon3 David Larkin4 Desmond Yip5 and Violeta Lopez6

1 ANU Medical School, Australian National University, ACT, Australia 2 Faculty of Medicine, Department of Surgery, University of Malaya, Malaysia 3 Statistical Consulting Unit, Australian National University, ACT, Australia 4 Canberra Region Cancer Centre, Canberra Hospital, Australia, and University of Canberra, ACT, Australia 5 Department of Medical Oncology, Canberra Hospital, ACT, Australia, and ANU Medical School, Australian National University, Act, Australia 6 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine , National University of Singapore, and Australian National University, ACT Australia

AIM OF INVESTIGATION: Pain is experienced by 25 to 60% women with breast cancer after surgery. Persistent pain has significant impact on those survivors. However, it is not known how many of those women experience persistent pain after breast surgery due to cancer. The study sought to answer: What is the prevalence of pain? And, Is the women’s age, stage of cancer, type of surgery or other factors, good predictors for persistent pain?

MATERIALS AND METHODS: This was a prospective, cross sectional, and a record review design study (N=119). SPSS version 24 was used for analysis. Descriptive statistics was used to describe the demographic data, linear regression to investigate interaction between pain intensity and pain interference, and stepwise regression method was employed to identify predictors of persistent pain.

RESULTS: A sample of 119 participants met the inclusion criteria. Median duration after surgery was 6 months (ranged 6 months to 12 months). A total of 43% of the participants had persistent pain (n=51), Data were analysed to determine predictors, of which three were found: distress, B=-.911, resilience, B=-.444, and pain interference, B=.309. The model was found statistically significant [F (3, 41) =13.827, R 2 = .503, Adjusted R 2 = .467, P = .001]. Confident intervals were 95% and significant P values were ≤ .005. Pain prevalence was 43% in this Malaysia population.

CONCLUSION: Pain prevalence was high in this Malaysian population. Interventions to prevent pain, improve resilience, and reduce distress are required to improve life satisfaction among breast cancer survivors in Malaysia.

Spinal Cord Stimulation Therapy for Patients with Post-Surgical Spine Syndrome

Kwan Ho Park1, Tae Wan Kim1, Ju Chul Yang1, Do Hyun Kim1

1 VHS Medical Center/ Korea

INTRODUCTION: Post-surgical spine syndrome (PSSS) is defined as persistent or recurrent pain, mainly in the back and/or legs after spine surgery. Multiple modalities includes medications and interventional techniques, resulting in moderate improvement, leaving a few patients in intractable pain. Surgery benefits a limited number of conditions, mainly root compression and instability. Spinal cord stimulation (SCS) techniques are applied to manage severe pain. We evaluated the effectiveness of SCS in PSSS.

REPORT: Twenty five patients had chronic back and/or leg pain with a diagnosis of PSSS. All patients who underwent SCS implantation were retrospectively reviewed. Preoperative mean Visual Analogue Scale (VAS) score for leg was 7.6. SCS trial was performed to evaluate patient’s response to SCS procedure. We placed percutaneous or paddle leads depending on symptoms. SCS system was implanted in patients with favorable responses. The mean follow-up was 32 months. Twenty two patients were male and three were female. The mean age was 57 years. The patients with leg pain responded favorably to SCS. Back pain did not respond well. SCS was less effective in patients with neural compressive lesions. Preoperative mean VAS score for leg was 7.6 and postoperative VAS score was 3.4.

CONCLUSION: Although the SCS therapy does not work for everyone, it can be an alternative treatment for patients with PSSS, mainly leg pain and no compressive lesion.

Effectiveness of Intrathecal Morphine Pump Procedure in Patients with Post-laminectomy Syndrome

Kwan Ho Park1, Ju Chul Yang1, Tae Wan Kim1, Do Hyun Kim1

1 VHS Medical Center/ Korea

INTRODUCTION: Some patients continue to have persistent back/leg pain after spinal operation. Medications, pain interventions, and spinal cord stimulation (SCS) therapy may provide some benefit. A few cases are resistant to these treatments. We present three cases of post-surgical spine syndrome (PSSS) treated with intrathecal morphine pump (ITMP) implantation.

REPORT: Case 1: A 37-year old man complained of severe back/ leg pain. He had a past history of lumbar discectomy. He had received pain interventions. The patient showed allodynia, discolorization, and dystrophic change in left leg and foot. He was diagnosed as complex regional pain syndrome (CRPS) type 2. He underwent SCS implantation. He suffered from intractable leg and foot pain. ITMP was implanted. Case 2: A 38-year old man complained of back/left leg pain. He had a past history of lumbar discectomy. He received pain therapies. He underwent SCS implantation. The pain had deteriorated. ITMP was implanted. Case 3: A 39-year old man complained of severe back/ left leg pain. He had a past history of lumbar discectomy. He already had performed SCS implantation. No pain procedures were effective. ITMP was implanted. Case 1: He was able to walk. Case 2: Daily activity have been possible. Case 3: Daily activity have been possible.

CONCLUSION: ITMP implantation can be considered as an additional option to improve intractable pain.

Effects of Acupuncture on Quality of Life and Pain in Patients with Chronic Pain

Rajesh Kumar Muniandy1

1 Universiti Malaysia Sabah, Malaysia

AIM OF INVESTIGATION: The purpose of this study was to examine the effect of acupuncture on the quality of life in patients who suffered chronic pain.

MATERIALS AND METHODS: Sixty-two patients who suffered from chronic pain were enrolled in this study. They were randomly allocated to either AC group (acupuncture treatment) or control group (conservative treatment). Quality of Life (QOL) and Pain were assessed at inclusion and after treatment. The AC group went through acupuncture for 10 sessions, once a week.

RESULTS: Patients treated with acupuncture experienced reduction in pain from baseline and better quality of life than controls after 10 weeks of therapy.

CONCLUSION: Acupuncture is effective in improving the pain and quality of life of patients with chronic pain.

The Use of Low Level Laser Therapy (LLLT) in Complex Regional Pain Sydrome (CRPS).

Rushin Maria Dass1, Dr Jon Yong Hoon1, Dr Kim Eunsoo1, Dr Kim Haekyu1

1 Pusan National University Hospital, Korea

INTRODUCTION: LLLT has been used as a method for treating various kinds of pain syndromes and promoting tissue repair. Although, its mechanism of action is not well understood and tend to be very broad, it is considered to be non- invasive, safe, easy to use, lack side effects compared to pharmacological treatments and has minimal complications as compared to other more invasive methods of pain relief.

REPORT: Case 1: 37 years old male, diagnosed with Type 1 CRPS of his left hand after a fall. He had poor response to oral medications including antineuropathics, opioids and bisphosphonates and had poor results after sympathetic blocks. LLLT was given to the left hand and left stellate ganglion which significantly improved his outcome. NRS scores reduced more than 50% and is now on low dose oral medications. Case 2: 9 years old female who was diagnosed to have Type 1 CRPS of her left ankle two months after an ankle sprain. She was not able to walk and has stopped going to school. Upon diagnosis, she was started on LLLT directed to her left ankle three times a week for 4 weeks. After one month, she was taken off all analgesics and was discharged. NRS scores improved significantly and patient was able to walk home.

CONCLUSION: LLLT is a safe and effective technique to manage pain in patients with CRPS. However, there are insufficient amount of trials or study on its use particularly in CRPS patients and further studies are required.

Acupuncture-Assisted Anaesthesia in Breast Lump Excision A Case Series from Malaysia

Ju-Ying Ang1, Kavita M. Bhojwani1, Huan-Keat Chan2

1 Hospital Raja Permaisuri Bainun/ Malaysia 2 Hospital Sultanah Bahiyah/ Malaysia

INTRODUCTION: While excessive drug use during surgery is of concern, acupuncture-assisted anaesthesia (AAA) is increasingly practiced. This case series describes the experience of a public tertiary hospital in using AAA during breast lump excision.

REPORT: The information of 17 female patients, who underwent breast lump excision and consented for the use of AAA, was obtained from their medical records. The patients were aged between 20 and 83 years, with 5 of them having at least one comorbidity. All patients received electrostimulated(2-4Hz), single- needle, bilateral acupuncture at Hegu(L14) and Neiguan(Pc6). They also received electrostimulated(30Hz), four-needle, parallel acupuncture at the lump site. Electrostimulation was initiated approximately 60 minutes before the surgery, and continued until the end of the surgery. The sizes of lumps excised ranged from 1cmx1.5cm to 4cmx4cm, and the duration of surgery was less than 2 hours. Thirteen patients received both intravenous fentanyl(25-100µg) and midazolam(2-5mg) during the surgery, while three received either one. Lignocaine 1% (1-6mL) was used for all the patients as local anesthesia, except for one who received 10mL of bupivacaine 0.5% with adrenaline 1:200,000. All patients reported no or mild pain (pain score ≤2/10) at 1h, 2h and 4h following the surgery, except for one who reported a pain score of 4/10 at 4h. No major adverse events were documented during hospitalization, except for drowsiness in one case.

CONCLUSION: AAA was found to be generally safe and effective in providing a better pain control in breast lump excision. However, a large-scale study is required to verify the findings.

Acupuncture Assisted Anaesthesia for High Risk Parathyroid Surgery

Dr Peggy Cheang Peak Chee1, Dr Kavita Bhojwani1

1 Hospital Raja Permaisuri Bainun Ipoh/ Malaysia

INTRODUCTION: General anaesthesia and peri-operative pain management are challenging in surgical patients with multiple co-morbidities and drug allergies. This is further complicated by limited intensive care facilities (ICU) available. This case series reports use of acupuncture-assisted anaesthesia (AAA) during parathyroid surgery among high risk patients, at a public tertiary care centre in Northern Malaysia.

REPORT: Data was retrieved from medical records of three patients who underwent parathyroid surgery under AAA. Patients are ASA Class III to IV, with end-stage renal failure, multiple co-morbidities like cardiomyopathy, difficult airway and multiple drug allergies. They received single-needle, electrostimulated (2-4Hz) acupuncture at bilateral Neiguan (Pc6) and Hegu (L14). They also received single-needle, electrostimulated (30Hz) at bilateral Futu (St32) and parallel to Futu. Electrostimulation commenced 30 to 40 minutes prior to surgery and continued throughout the surgery. All patients received titrated doses of intravenous fentanyl and midazolam during surgery. Local aneasthesia infiltration was given to supplement AAA. All patients underwent surgery uneventfully, without requiring intensive care. Throughout post-operative hospitalization, they were hemodynamically stable with minimal analgesics used. They reported no or mild pain (pain score 0 - 2), without any incidence of postoperative nausea and vomiting (PONV).

CONCLUSION: AAA is an alternative approach in peri-operative pain management during parathyroid surgery. It potentially reduces postoperative pain and intensive care monitoring of the patients. Study of a larger scale is required to confirm these findings.

Oral Health-Related Quality Of Life Patients With and Without Temporomandibular Disorders in A Regional Referral Hospital.

Zafirah Hani Binti Mohamad1, Khamisah Binti Awang Kechik1, Yuen Kar Mun1

1 Hospital Raja Permaisuri Bainun, Ipoh/ Malaysia

AIM OF INVESTIGATION: The aim of this cross-sectional study was to compare the oral health-related quality of life (OHRQoL) between individuals with and without temporomandibular disorder (TMD) see in the Oral Medicine and Oral Surgery clinic in Hospital Raja Permaisuri Bainun, Ipoh, Perak. The specific objective is to assess the seven domains of negative impact on OHRQoL in TMD patients and compare it with those without TMD.

MATERIALS AND METHODS: A total of 58 adult subjects were recruited by convenience sampling, consisting of 29 subjects each in the group of those with and without TMD. The subjects without TMD conist of patients reviewed in the clinic with other diseases. The data was collected using the Malaysian short version of the Oral Health Impact Profile S-OHIP(M) questionnaire or its translated English version. The level of OHRQoL was indicated by the overall S- OHIP(M) score median and IQR using Mann-Whitney test. Comparison of the total score and each individual domains were made between the two groups where a higher score indicates a poorer OHRQoL.

RESULTS: The median age of TMD patients was 45.0(15.58). Most of them are female (82.8%) and belong to the Malay ethnicity (48.3%). Patients with TMD has significantly poorer OHRQoL compared to patients without TMD (21.0 vs 16.0). The domains which reported significant difference were functional limitation and psychological disability (4.0 vs 2.0 and 3.0 vs 1.0, respectively).

CONCLUSION: TMD has an overall negative impact on OHRQoL. The specific domain with negative impact are functional limitation and psychological disability.

Hydrotherapy for Chronic Neck Pain

Michael Warburton1

1 Gateway Physiotherapy/ Australia

INTRODUCTION: Functional status and mental well-being are important elements in the management of chronic neck pain, and hydrotherapy may be a suitable and effective environment to safely undertake functional exercises and physical activity, especially when land-based activities are unfeasible or too painful. Buoyancy, warmth, pressure, viscosity and turbulence are elements of hydrotherapy that can offer the chronic neck pain population a unique hydro- therapeutic environment to execute a functional exercise and physical activity program, and to provide pain management

REPORT: Hydrotherapy was provided for 4-weeks, 2 x week, 45-minute session duration Pool temperature 33 degrees centigrade. Pool length 20-metres, pool depth 1.2 metres Sessions included a warm up/cool down, pool mobility, neck and shoulder range of movement (ROM) exercises, neck stretching exercises, suspended pool neck traction, and upper limb strength exercises. Outcomes were completed weeks 0 and 4 via the neck disability index (NDI) & the Warwick Edinburgh wellbeing scale (WEWBS). Results: NDI baseline score: 22/50; Final score: 15/50 WEWBS baseline score: 46/50; Final score 56/70

CONCLUSION: Hydrotherapy can be a beneficial hydro-therapeutic option for the chronic neck pain population when land-based exercises or gym activities are unfeasible or too painful. It provides a relatively safe environment for mobility, neck ROM exercises, traction, general exercises and stretches to be undertaken – important for the chronic neck pain population.

Trigeminal Neuralgia Serial Case Report

Devi Ariani Sudibyo1, Isti Suharjanti1

1 Medical Faculty Airlangga University / Indonesia

INTRODUCTION: Trigeminal neuralgia (TN) is a disorder characterized by recurrent unilateral brief electric shock-like pains, limited to the distribution of one or more divisions of the trigeminal nerve and triggered by innocuous stimuli as defined in International Classification of Headache Disorders (ICHD 3). We present serial case of trigeminal neuralgia along with clinical history, MRI (Magnetic Resonance Imaging) findings and treatment approach.

REPORT: We present three cases of TN, 55-year-old, 43-year-old and 60-year- old women presented with severe unilateral electric shock-like and sharp facial pain along maxillary (V2) and mandibular (V3) division of trigeminal nerve. The pain was triggered by eating, swallowing, and even on touching. MRI showed neurovascular contact trigeminal nerve with left posterior cerebral artery from the first case, and solid mass lesion in splenium with neurovascular conflict within left trigeminal nerve from the second case, and neurovascular contact of root entry zone trigeminal nerve with right anterior cerebellar artery from the third case. Pain intensity were reduced from severe to mild, measured by Numeric Pain Rating Scale (NPRS), when oral carbamazepine was given as the first line treatment for TN. The third patient suffered from drug allergy during carbamazepine treatment, so the combination of gabapentin and amitriptyline were given.

CONCLUSION: Trigeminal neuralgia (TN) is characterized by unilateral, intense, touch-evoked, stabbing paroxysmal pain. TN can be either classical, secondary and idiopathic. Carbamazepin as the first line treatment is useful for any type of TN. Gabapentin and amitriptyline can be chosen as an alternative treatment for TN.

The Validation of Sonograph-Guided Medial Branch Blocks As Confirmed By Flouroscopy In Chronic Lumbar Facet Joint Pain

Farid Yudoyono1

1 Santosa International Hospital Kopo, Indonesia

INTRODUCTION: Sonograph-guided allows us to visualize in “real time” of intervention in the management of chronic pain. This study investigate sonograph-guided validation by flouroscopy during lumbar medial branch block.

METHOD: Sonograph-guided medial branch block was done in 12 segments for 5 patients with chronic back pain by facet origin. After the surface landmarks of the spinous process, lamina and iliac crest line were confirmed, longitudinal facet views were obtained by a curved array transducer to identify the different spinal segments. The spinous process and facet joint with transverse process were delineated by transverse sonograms at each level and the target point for the block was defined as lying on the upper edge of the transverse process. The needle was inserted toward the target point. After a contrast injection, the placement of the needle and contrast was validate by fluoroscopy.

RESULTS: Twelve segments could be guided successfully to Lumbar MBB by using ultrasound. After fluoroscopic control, three needles had to be corrected because of problems with other segments (2 cases) and lamina placements (1 cases). However, the mean visual analogue score for back pain was improved from 7.1 ± 0.9 before the block to 3.70 ± 1.0 after the block (p = 0.001).

CONCLUSION: Sonograph-guided allows longitudinal facet view and the other spine surface landmarks and validation by fluoroscopy increasing accuracy during lumbar MBB procedure.

Effectiveness and Safety of Ablation Radiofrequency in Trigeminal Patients in Sardjito Hospital, Indonesia: Case Series

Fauziah Lidya Jayanti1, Whisnu Nalendra Tama2, Yudiyanta3, Mahmud4

1 Universitas Gadjah Mada/ Indonesia

AIM OF INVESTIGATION: Trigeminal Neuralgia (TN) is a painful neuropatic pain affecting the face causing severe morbidity. Drugs therapy proved ineffective in some cases. Minimally invasive interventional therapy such as pulsed radiofrequency is considered as option when drug therapy fails. This study aims to determine the effectiveness and safety of ablation radiofrequency in TN patients.

MATERIALS AND METHODS: Descriptive, retrospective, one year follow up study of patients with TN who underwent ablation radiofrequency guided C-arm, between January 2017 until September 2017 in Sardjito Hospital,Yogyakarta, Indonesia.

RESULTS: Five patients were participated in this study with mean age was 57,6 years old (ranged from 42 to 77 years old) with right vs left sided as much 3:2, and all involve third branch of trigeminal nerve. After the intervention, four patient went from severe pain to mild pain, but one patient still complained moderate pain. The average Visual Analogue Scale (VAS) before intervention was 82 (ranged from 70 to 90), the reduction pain score on a month, second months, third months, six months and a year follow up as much 36,5%, 48,8%, 58,5%, 63,4%, and 68,2%, respectively. In four patients, medication was reduced gradually at a year follow up. There was no side effect on the patients intervened.

CONCLUSION: Ablation radiofrequency proved effective and safe, and this procedure could be the option for treatment in TN.

Ultrasound Guided Steroid Injection for Piriformis Syndrome in Sardjito Hospital: Case Series

Hana Amatillah1, Indarwati Setyaningsih1, Cempaka Thursina Srie Setyaningrum1

1 Universitas Gadjah Mada/ Indonesia

AIM OF INVESTIGATION: To determine the efficacy and safety of ultrasound guided steroid injection in patients with piriformis syndrome in Sardjito Hospital

MATERIALS AND METHODS: Descriptive retrospective study of patients with Piriformis Syndrome between January 2017 until July 2018 who underwent ultrasound guided steroid injection in Sardjito Hospital. The patients given ultrasound guided piriformis injection of 4 mg Triamnicolone acetonide, 2 ml 2% Lidocaine, and 1 ml of 0,9% NaCl.

RESULTS: There were fourteen patients (Female: 11; Male: 3; mean age: 54.9 years) with left-side (64.2%), right-side (28.57%), and bilateral (7.1%) piriformis syndrome. The average reduction of numeric pain scale within a week, a month, and third month after injection were 59.29%, 84.96%, 100% respectively. Patients who still need analgesic drugs in a week, a month, and third month after injection were 78.57%, 28.57%, 0% respectively. No side effects were observed.

CONCLUSION: Ultrasound guided piriformis injection is effective and safe to treat intractable piriformis syndrome. Further research with clinical trial is necessary.

Case Series: Ultrasound Guided Triamcinolone Acetonide Injection for Frozen Shoulder in Sardjito Hospital

Siti Zulaikhah1, Whisnu Nalendra Tama1, Subagya1

1 University Gadjah Mada/ Indonesia

AIM OF INVESTIGATION: This study review seven cases of ultrasound guided triamcinolone acetonide injection in patients with frozen shoulder in Sardjito Hospital

MATERIALS AND METHODS: This was a descriptive retrospective study of seven patients with frozen shoulder in Sardjito Hospital between January 2016- July 2018. All patients were treated with ultrasound guided steroid injection: 10- 20 mg of triamcinolone acetonide and 2cc of lidocaine 2%. Numeric Pain Scale (NPS) was measured before and after injection.

RESULTS: There were seven patients in this study, two males and five females, average age was 56, 4 years old, predominantly left side frozen shoulder (57%). Before the injection, seven patients went moderate to severe pain, average NPS was 8. We did follow up on 6th and 12th week, and there was improvement in NPS. At 6th week, average NPS was 4 and at 12th week, average NPS was 2. There was no side effect found.

CONCLUSION: A good outcome follows an injection of triamcinolone acetonide in patients with primary frozen shoulder. Further work in the form of controlled studies are needed to compare this approach with other methods of treatment.

Unanticipated Improved Appetite after Diagnostic Celiac Plexus Block in Gallbladder Adenocarcinoma

Chris Bryan Sembrana1, Emmanuell Villano1

1 St. Luke's Medical Center - Global City, Taguig/ Philippines

INTRODUCTION: Epidemiologic data on celiac plexus blocks (CPB) in Asia is scarce. CPB is rare in the Philippines because of lack of interventional pain specialists trained in the procedure, and poor awareness of its availability among clinicians. CPB is indicated in patients with cancer pain from upper abdominal malignancies that is refractory to opioid therapy, or with intolerable side effects. We report a case of recurrent gallbladder adenocarcinoma with an unanticipated beneficial response of improved appetite after diagnostic CPB.

REPORT: Our patient is a 66 year-old male with stage 4 gallbladder adenocarcinoma with lung metastases and tumor recurrence in the pancreatic head and porta hepatis despite surgery, chemotherapy, and radiotherapy. He had chronic malignant mixed neuropathic and nociceptive visceral pain in the right upper abdominal quadrant that was unrelieved by high dose opioids. He also had opioid-induced constipation. Diagnostic CPB done resulted in transient pain relief and significantly decreased opioid requirement. Unexpectedly there was improved appetite immediately after the CPB until 4 weeks post-procedure. To date there have been only a handful of published reports on appetite improvement after CPB. These previous cases attributed the increased appetite after CPB to lower post-procedure opioid requirements leading to decreased opioid-induced nausea, vomiting, and constipation. Our patient never had nausea or vomiting. His opioid-induced constipation persisted after CPB.

CONCLUSION: Our case supports the role of early CPB in improving quality of life of terminally ill gallbladder adenocarcinoma patients. Further research on the biologic and psychosocial effects of CPB is necessary.

Ultrasound Guided of Stellate Ganglion Block for Primary Hyperhidrosis

Wan Rohaidah Wan Ahmad1

1 Hospital Sultanah Nur Zahirah, Terengganu/ Malaysia

INTRODUCTION: Hyperhydrosis is defined as excessive sweating beyond what is necessary to maintain thermal regulation. It could be primary or secondary hyperhidrosis due to drug intake, endocrinopathies and malignancies. It may result in social embarrassment, workplace impairment and emotional problems. Although a number of treatment options available, the outcome is still less than satisfactory. In some cases, treatment can be more invasive with higher risk of complications such as surgical sympathectomy

REPORT: We report a case of a 32 year old gentleman with underlying temporal lobe epilepsy who had been complaining of bilateral excessive sweating involving both upper limbs and faces especially over the palms and axillary area since 15 years ago. He had to stop working outside and now doing online business from home. He underwent right Stellate Ganglion block under ultrasound guidance and received 3 mls of 0.25 % levobupivacaine. He reported immediate reduction of about 80% in sweating over his right side of the face and right palm. He only complained of congested right eye, otherwise there was no other complications or signs and symptoms of Horner’s Syndrome such as partial ptosis or miosis. At 1 month follow up, he is still satisfied with the outcome.

CONCLUSION: Stellate Ganglion Block using local anaesthetic can be used as part of multidisciplinary treatment of hyperhydrosis. The use of ultrasound makes this procedure safer and the amount of local anaesthetic used is much smaller, hence less side effect of Horner’s Syndrome.

Pneumothorax Post Stellate Ganglion Block, Unrecognized Complication or Merely Coincidence

Ikhwan Wan Mohd Rubi1, Dr Wan Rohaida Wan Ahmad1

1 Hospital Sultanah Nur Zahirah Hsnz Kt/ Malaysia

INTRODUCTION: Hyperhidrosis is a clinical condition where body produces excessive sweating either focal or general. Also known as polyhydrosis or sudorrhea, it causes discomfort and uneasiness towards patient. Some may feel embarrass and have psychological sequelae. Treatments can be nonsurgical or surgical approach. The latter is reserved for debilitating condition not responding to normal therapy.

REPORT: A 32 years old male was referred to us for having hyperhidrosis since past 15 years. He has been experiencing increase sweating of whole body especially palm, sole and axilla. It has been affecting his job as a self-employer especially when meeting clients. He had to work in an air conditioned environment to reduce the severity of sweating. Apart from the temporal lobe epilepsy and allergic rhinitis, he is otherwise well and healthy. Looking at the severity of his condition, we suggested for him to undergo Stellate ganglion block. Right hand was chosen first as he is right handed and he was listed in day care procedure. Stellate ganglion block was performed using ultrasound guidance and in plane approach. A total of 3mls Levobupivacaince 0.25% was given. Procedure was successful without any complication

CONCLUSION: Steallate ganglion block is a pain intervention technique which plays some roles in managing hyperhydrosis. Amount of local anaesthetic used will influence the incidence of complication from the procedure. This technique gives more option for patient to choose apart from surgical intervention and it can be done as outpatient procedure giving more flexibility to patient.

Prevalence Study of The Relationship Of Chronic Back Pain And Depression Symptoms At Hospital Tuanku Jaafar, Seremban

Chanell Fong Zishan1, Chen Yunn Kai1, Jasmin Ng Can Wei1, Sinthia A/P Ramani1, Prof Philip George1, Ng Saw Yeong1

1 International Medical University/ Malaysia

AIM OF INVESTIGATION: Chronic back pain has been shown to be linked to depression. Depression can interfere with recovery in chronic back pain and similarly, chronic back pain can induce depression. Often if patients with depression are not managed, their back pain morbidity may be prolonged.

MATERIALS AND METHODS: A cross sectional study of 100 chronic lower back pain patients of the Orthopedics Clinic in Hospital Tuanku Jaafar, Seremban was performed. The patients were chosen through convenient sampling and the Ministry of Health (MOH) pain scale and Patient Health Questionnaire (PHQ-9) questionnaire was used as instruments to identify the severity of their pain and severity of their depressive symptoms. Statistical analysis was done to identify the relationship between pain and depressive symptoms.

RESULTS: 100 patients with chronic lower back pain were recruited comprising of 71 females and 29 males. 68% scored positively on the PHQ-9 with 40% having moderate to severe rating scores. It appeared that Malays were less likely to suffer depression symptoms compared to other races studied. The risk of depression increased with severity of pain and 77.8% of the studied population with severe chronic lower back pain experienced depressive symptoms.

CONCLUSION: This study shows that depression is common among those with chronic back pain. None of the population studied were on treatment for depression and this could only serve to prolong their medical condition. It is important that consideration of depression co-existing be part of the holistic management of chronic back pain.

Comparison of Clinical Outcome Low Versus High Fatty Infiltration Of Posterior Muscle In Chronic Low Back Pain Following Medial Branch Block 1 Years Follow Up

Farid Yudoyono1

1 Santosa International Hospital, Bandung, Jawa Barat/ Indonesia

INTRODUCTION: Fatty infiltration in posterior lumbar muscle is a common in chronic low back pain (CLBP). It is hypothesized that’s might compromise spinal pain. This study investigate whether there is a correlation between lumbar medial branch block (LMBB) on different lumbar fatty infiltration in CLBP patients.

METHOD: In this retrospective study, 76 patients with CLBP performed MBB have 6 months follow up was recruited. They were classified by MRI findings for fatty infiltration : Grade 0 (0–10%) as Group A, Grade 1 (10–50%) as Group B and Grade 2 (>50%) as Group C. Clinical outcome evaluated according to Visual Analogue Scale (VAS) pre ,1,-3 and 6 month follow up.

RESULTS: Patients had a mean VAS score of 7.6, 7.2 and 8.4 in Group A, B and C before the procedure. Significant pain relief after the procedure of 87%, 72% and 76% at at 1, 3 and 6 months in Group A an 77%, 82% and 66% at at 1, 3 and 6 months in Group B. No major complication was noted except local pain in all patients and numbness of the back in 9 patients after the procedure.

CONCLUSION: A MBB can be an effective pain intervention in CLBP patients. The MBB seemed lowered clinical outcome for the patients who had high grade fatty infiltration, careful selection of the patients is necessary to provide a higher success rate of pain relief. Further study and longer time follow up are warranted.

Correlates of Low Back Pain among Filipino Caregivers of Children with Disability

Maybelle Anne L. Zamora1; Hernan C. Labao2

1 Our Lady Of Fatima University, Philippines 2 Inti International University, Malaysia

AIM OF INVESTIGATION: The caregiver’s role in the rearing a child with disability requires huge physical demands that may lead to development of musculoskeletal disorders such as low back pain (LBP). This study aims to determine the factors related low back pain among caregivers of children with disability.

MATERIALS AND METHODS: A quantitative, correlational research design was used. Data were gathered among caregivers of children with disability enrolled on a specialized educational and pediatric rehabilitation unit. A personal information sheet was used to gather relevant demographic data while Oswestry Disability Index (ODI) was used to measure low back pain and disability. Chi square was used to determine the relationship among the factors and low back pain.

RESULTS: Majority of the respondents were mothers (13%) caring for children with autism spectrum disorder (31.8%), married (68.2%) and living in an extended family (36.4%). Chi squared revealed a statistically significant association between caregivers’ gender (p=0.003), relationship to child (p=0.000) and marital status (p=0.000) to low back pain and disability. Married mothers are prone to develop low back pain and disability.

CONCLUSION: Physical therapists should create preventive and restorative physical intervention to mothers who are primary caregivers of children with disability. Caring rotation between mothers and other potential caregivers may be recommended to reduce the burden of low back pain and disability. Future studies should focus on other factors such as psychosocial and emotional aspects of low back pain and disability among caregivers of children with disability.

The Modified Prasit Thai (Maneevej) Upper Extremities Stretching Exercise combined with Ergonomic recommendations on Neck & Shoulder pain in Nongkhai Hospital workers

Wanrattha Tangkitwanitch1

1 Nongkhai Hospital, Ministry Of Public Health Thailand, Thailand

AIM OF INVESTIGATION: Neck and Shoulder pain are the most common musculoskeletal problem that is often chronic or recurrent.Multimodal or combine treatment that acceptable.The aim of this study was access to The Modified Prasit Thai (Maneevej) Upper extremities Stretching Exercise due to easy to stretching and remember because 4 posture step look like simple activity daily living (1.Wai Sawasdee 2.Grind into powder 3.Take off T-shirt 4. Unleash on Superpower) and combine with Ergonomic recommendation which to bring to good posture in hospital workers.

MATERIALS AND METHODS: Descriptive study A total of 41subjects which work in staff of the hospital has neck and shoulder pain NRS>3 for more than a month. Subjects were include to study had to Pretest about pain status.All subjects had to lecture learning about Modified Prasit Thai( Maneevej) stretching exercise and Ergonomic recommendation.After 6weeks they had to Post test assessed about pain status and how to they management about pain in hospital.

RESULTS: Most of subject were female(75.7%) .The average age are 41 years.All had neck and shoulder pain due to myofascial pain syndrome, the mean of maximum pain score week0 and6 were 4.95and 3.24 respectively. In post test 35persons (85.37%)Decrease pain group were Modified Prasit Thai stretching(Maneevej) 68.3%, adjust Ergonomics 75.6% and combine 2 method 61%

CONCLUSION: The Modified Prasit Thai stretching (Maneevej) could reduce neck and shoulder pain.The Ergonomics recommendation could reduce neck and shoulder pain too, combine 2 method are effectiveness.

Correlates of Coping Among Filipino Migrant Workers in Malaysia with Musculoskeletal Pain

Hernan Cortez Labao1

1 Inti International University/ Philippines

AIM OF INVESTIGATION: Musculoskeletal pain is associated with anxiety and depression which is correlated with severe pain behavior. Therefore, this study aims to determine the factors related with coping among Filipino migrant workers in Malaysia with musculoskeletal pain.

MATERIALS AND METHODS: This study utilized a quantitative, non- experimental, correlational research design. A total of 90 subjects were randomly selected who were asked to answer Nordic Musculoskeletal Questionnaire (NMQ) to determine various regions in the body having musculoskeletal pain. Coping Strategies Questionnaire (CSQ) - 24 was used to gather the subject’s coping strategies and overall coping.

RESULTS: Filipino migrant workers mostly complain of pain in the Shoulders (63.3%) and Low Back region (55.6%) in the last 12 months. Majority of the subjects use strategies such as Diversion (51.26 ± 27.44) and Cognitive Coping (48.92 ± 30.40), with moderate overall Coping Score (57.22 ± 21.93). A statistically significant strong positive correlation is noted between Cognitive Coping Strategy (r=0.704, p-value=0.000) and Diversion Strategy (r=0.654, p- value=0.000) to Overall Coping Score.

CONCLUSION: Results imply that there is high prevalence of shoulder and lower back pain in the last 12 months. Those who utilized Diversion and Cognitive Coping strategies have better coping over pain. Interventions focusing on positive coping and education about early recognition of musculoskeletal disorders is recommended. Further studies should consider psychosocial aspects pain among migrant workers.

Review of Sonoelastography in the Assessment of Myofascial Pain Syndrome: A Novel Technique

Jing Chen1, Tze Chao Wee2

1 Changi General Hospital/ Singapore

AIM OF INVESTIGATION: In recent years, sonoelastography has been using in the diagnosis of myofascial pain syndrome (MPS). This review aimed to summarize current knowledge regarding the application of sonoelastography in diagnosing MPS.

MATERIALS AND METHODS: A search for studies of sonoelastography, MPS and fibromyalgia was carried out in PubMed Electronic databases from inception to November 2018. Total 43 articles matched. Abstracts of those articles were reviewed and irrelevant articles were excluded. Total 15 studies were included and full articles were reviewed. Results were summarized using descriptive statistics.

RESULTS: Among the total 15 studies identified, one is randomized control trial, majority of other studies are descriptive or case control studies. The study sample size ranges from 4 to 50 subjects. The sonoelastography technique applied in the studies include vibration sonoelastography (VSE), shear wave elastography (SWE), and elastography strain ratio. The most common muscle groups investigated in the studies are upper trapezius muscles (10 out of the 15 studies), followed by lumbar erector spinae, multifidus muscles, biceps brachii, quadratus lumborum, longissimus thoracis, piriformis, gluteus medius muscles, and Masseter muscle. The studies showed promising results in identifying MTrPs in MPS. However, sonoelastagrphy failed to identify tender point in fibromyalgia.

CONCLUSION: Sonoelastography is a useful tool to assess MPS, to differentiate active and latent MTrPs, and to monitor treatment effect. However, sonoelastography may not be able to discriminate tender points in fibromyalgia. Further studies are required to establish the best type of sonoelastography technique, and to validate its sensitivity and specificity.

The Difference of Depression Incidence in Osteoarthritis Patient with Oral NSAIDs and Intraarticular Injection of Hyaluronic Acid in Dr Moewardi Hospital Central Java

Anisa Naziha1, Mohammad Fanani1, Nurhasan Agung Prabowo1

1 University Of Sebelas Maret/ Indonesia

AIM OF INVESTIGATION: Investigate the differences of depression incidence in osteoarthritis patients with oral NSAIDs therapy and intraarticular injection of hyaluronic acid in Dr Moewardi Hospital Central Java.

MATERIALS AND METHODS: This was an observational study with cross sectional design. The subjects were moderate to severe osteoarthritis patients who treat by oral NSAIDs or intraarticular injection hyaluronic acid in ≥ 3 weeks. Each group consists of 33 subjects. This number is based on categorical unpaired sample formula. This research used purposive sampling technique. The depression incidence was measured by Beck Depression Inventory II. The comparative analysis used chi-square and multivariate analysis used logistic regression test.

RESULTS: Comparative test by chi-square found p < 0,05 (p=0,000); CI=95%. There are 89,5% patients with oral NSAIDs got depression. In this research, sex, age, physical disease, marital status, and educational attainment are not the predictor factor for depression. Oral NSAIDs has more risks to cause depression than Intraarticular Injection of Hyaluronic Acid (p= 0,001; OR= 13,902).

CONCLUSION: There is a higher incidence of depression in osteoarthritis patients with oral NSAIDs than intraarticular injection of hyaluronic acid therapy in Dr Moewardi Hospital Central Java.

Hip or Spine, Which One To Treat? A Case of Complex Hip Spine Syndrome in Body Builder

Mohamad Azwan Aziz1, Redzal Abu Hanifah1, Mariam George Mathew1

1 Queen Elizabeth Hospital, Malaysia

Introduction: Hip Spine Syndrome (HSS) is a condition of concurrent hip arthrosis and degenerative spine affecting the elderly. However, younger people may present with similar presentation as they participate in high impact sports. The diagnosis is challenging and may delay in delivering appropriate treatment. This case report is of a complex HSS in a young athlete, and emphasis of systematic approach in management.

Report: A 32 year old body builder who was treated conservatively for 5 years with herniated disc of L3/L4 and L4/L5 with radiculopathy radiating to the foot, presented with acute pain of the anterior left hip. The pain significantly affects his daily activities. Clinical presentation of the C sign and examination of reduced hip motion, positive hip provocation test, and X-rays points to the diagnosis of Left Femoral Acetabular Impingement (FAI). MRI showed acute labral tear. Conservative treatment was decided and case was referred to Sports Medicine team. The exercise treatment prescribed by the Sports Medicine Specialist helps to alleviate the pain; however it only last for a short period. Thus, the Orthopaedic Surgeon decided for intra-articular anaesthetic hip injection for symptomatic relief. However, the pain was still intractable. The surgeon then decided to counselled the patient for L3, L4, L5 laminectomy as the pain does not seem to arise from the hip. Patient’s condition drastically improved after the operation.

Conclusion: A systematic approach is discussed as a guide in managing complex HSS , where diagnosis is uncertain and surgical intervention is required to improve patient’s outcome

The Role of Transdermal Buprenorphine In The Treatment In Elderly With Arthritis

Bavani Sandrakasan1, Mohamad Aswad Abu1

1 Hospital Tunku Jaafar Seremban/ Malaysia

INTRODUCTION: Chronic pain increases with age due to increase in the incidence of diseases such as arthritis, diabetes mellitus (DM) and neurological diseases. Many elderly patients suffer cognitive impairment, this can lead to problems of compliance of taking medicine, describing pain or side effect. The transdermal buprenorphine is suited for the elderly as it provides ease of use for the patient and the care-taker, providing greater adherence to prescribed regimens and has less side effect.

REPORT: A 69 years old lady with underlying DM, Hypertension suffering of bilateral knee osteoarthritis and neuropathic pain. She was started on Transdermal Buprenorphine 5-10 mcg/h for few months and able to reduce her analgesics. She developed localized skin reaction with 10mcg/h. Once reduced to 5mcg/h, she was able to sleep at night with tolerable pain score thus improves her quality of life. Buprenorphine is a partial agonist on the mu-opioid receptors while also acting as an antagonist at the kappa-opioid receptors. The transdermal formulation provides continuous delivery, resulting in relatively consistent plasma drug concentrations throughout 7 days interval. Few side effects reported with buprenorphine patch include nausea, application site reactions, dizziness and dry mouth. In addition the long-acting analgesic property and relative safety profile makes it a suitable choice for the treatment of chronic pain in the elderly.

CONCLUSION: Chronic pain represents a significant challenge to the elderly and physician. Transdermal buprenorphine is effective in treating chronic pain and safe analgesic for the elderly, most convenience of once weekly administration and no need for dosage adjustments in the elderly with renal and liver impairment. Further studies are needed on the effectiveness of transdermal buprenorphine for chronic pain.

A Rare Case of Chronic Tophaceous Gout with Disseminated Cutaneous Tophi And Renal Impairment Pain Management Considerations

Faisal Parlindungan1

1 Faculty Of Medicine Universitas Indonesia-Rumah Sakit Umum Pusat Nasional Cipto Mangunkusumo, Jakarta, Indonesia/ Indonesia

INTRODUCTION: Gout is a metabolic disease that is characterized by the deposition of urate crystals. There are rare occasions where urate deposition occur extensively in the skin, called disseminated cutaneous gout. This type of gout is accompanied with chronic pain that can affect quality of life.

REPORT: A 46-year-old male presented with acute pain in multiple joints. He had a history of gouty arthritis with multiple nodules all over his body. Laboratory value showed elevated uric acid and creatinine. Skin biopsy confirmed tophi formation. We diagnosed the patient with acute flare of chronic tophaceous gout with disseminated cutaneous tophi and renal impairment. Disseminated cutaneous gout is a rare and relatively new entitiy. Considering kidney safety, the initial aim of treatment is to settle the symptoms of an acute attack with steroid, while options for prevention include allopurinol and colchicine. The long term management is to reach and maintain serum uric acid at subsaturating levels without further damaging the kidney. We gave methylprednisolone, colchicine and allopurinol and the patient showed dramatic improvement.

CONCLUSION: This case is a rare presentation of gout that involve cutaneous, joint and renal manifestations. Treating pain in this patient should be done very carefully as to not worsen his renal function while controlling the urate deposition and minimize acute pain episodes.

Depression Among Non-cancer Chronic Pain Patients at Pain Clinic, Queen Elizabeth Hospital, Sabah, Malaysia

T.Kumaravadivel Dharmalingam1, Rajesh Kumar Muniandy2

1 Hospital Teluk Intan, Malaysia 2 Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia

AIM OF INVESTIGATION: World Health Organization (WHO) recognizes pain as an important public health concern. Depression is the most frequent emotional condition seen in chronic pain patients, and need to be treated in order to improve the outcome and quality of life. This study was aimed to analyze the depression rate among chronic pain patients attending the Pain Clinic (PC),.

MATERIALS AND METHODS: This is a retrospective study involving all non- cancer chronic pain patients who visited the PC from the year 2013 till 2017. All the patients were required to self-administer Pain Detect and fill up the Patient Health Questionnaire-9 (PHQ-9) questionnaire during their first visit to our PC. Data from this questionnaire were extracted and analyzed.

RESULTS: A total of 254 patient’s case notes were analyzed. This study shows that 29.6 % patients had mild depression, and 34.4% of patients had moderate to severe depression. 37% of our patients did not have neuropathic pain, while 29.1 % had possible neuropathic pain, and 33.9% patient is high likely to be at risk of neuropathic pain. Results showed that there was a significant correlation between "depression and pain scores" and between "depression and the pain Detect scores". Gender, religion, marital status, or pain characteristic did not affect the depression score in our patients

CONCLUSION: The high rate of depression among chronic pain patients in Sabah, Malaysia is alarming. This study further strengthens the need for psychological treatments for chronic pain patients.

Effectivity of Vitamin B Combination on Diabetic Neuropathy Patients: An Observational Study

Rosa De Lima Renita Sanyasi1, Rizaldy Taslim Pinzon2

1 Duta Wacana Christian University, Indonesia

AIM OF INVESTIGATION: This study measures the effectivity of vitamin B combination to reducing diabetic neuropathy (DN) symptoms and improving quality of life (QoL).

MATERIALS AND METHODS: This study was an observational study on DM patients with DN. Each subject was given vitamin B combination consists of: vitamin B1, vitamin B6, dan vitamin B12, with dosage 100 mg, 100 mg, and 5000 mcg respectively. DN symptoms were measured by using Total Symptom Score (TSS). QoL was measured by using SF-8 questionnaire with 2 components: physical component summary (PCS) and mental component summary (MCS). Follow-up was performed 5 times, with the total duration of study was 3 months.

RESULTS: There were 104 subjects. Subjects was dominated by male (61.5%), age >65 year (94.2%). Seven subjects were not following the study completely, thus it was remained 97 (93.3%) subjects. Improvement in four DN symptoms (stabbing pain, burning pain, parasthesia, and numbness) showed in this study, compared from the baseline to fifth follow-up. The improvement was significant (p <0.0001). QoL score was increasing after 3 months medication using vitamin B combination. Physical problem was more common than mental problem among DN subjects, indicate by a lower PCS score. The differences between baseline score to fifth follow-up score were statistically significant (PCS: p <0.0001 and MCS: p =0.0001).

CONCLUSION: DN is a common complication among diabetic patients. Combination of vitamin B is effective to improve symptoms and QoL in DN patients.

The Comorbidities Profile in Geriatric Patient With Neuropathic Pain

Patrick Nalla Nunsio1, Rizaldy Taslim Pinzon1

1 Duta Wacana Chrsitian University/ Indonesia

AIM OF INVESTIGATION: The elderly population in Indonesia reaches 20.24 million people, equivalent to 8.03% of all Indonesians in 2014, this number will continue to grow due to increasing life expectancy rate and quality of health services. The common complaint in the elderly is pain and pain management in the elderly will be increasingly complex because the elderly have experienced decreased organ function, increased susceptibility to drug side effects adverse, and multiple comorbidities In Indonesia, related research on neuropathic pain is still very rarely done, especially research on neuropathic pain related to the elderly. The purpose of this study is to determine the comorbidities that occur in elderly patients with neuropathic pain.

MATERIALS AND METHODS: Cross sectional study was performed systematically from 100 subjects that have been randomized before. All of the subject was over 60 years old and had been examined and diagnosed with neuropathic pain. From the subject, comorbid data will be collected to for further study.

RESULTS: From 100 patients, consist of 61 male and 39 female, the mean age are 66, 35 patients had hypertension as comorbidities, 22 patients had diabetes, 3 patients had cardiovascular disease, 4 patients had other comorbidities beside hypertension, diabetes and cardiovascular disease and the remaining 33 have no comorbidities.

CONCLUSION: Majority of elderly patient with neuropathic pain experiencing hypertension. This result provides an overview of the health condition of the elderly with neuropathic pain which will later be related to the pain management and the effectiveness of its treatment.

Clinical Outcome of Percutaneous Epidural Neuroplasty in Lumbar Disc Herniation at Hardjolukito Air Force Central Hospital, Yogyakarta

Clara Novena Bittikaka1

1 Gadjah Mada University/ Indonesia

AIM OF INVESTIGATION: To figure out the clinical outcome of percutaneous epidural neuroplasty in treating lumbar disc herniation

MATERIALS AND METHODS: A retrospective cohort study. The research subjects are patients who had been diagnosed with lumbar disc herniation during January-June 2018 and has undergone percutaneous epidural neuroplasty. Clinical outcome was assessed using Visual Analog Scale (VAS) and ID Pain.

RESULTS: There were 76 samples consisting of 37 (49%) were male and 39

were 34 samples (44.7%) were DM and 42 samples (55.3%) were not DM. Fourty eight samples (63.16%) had BMI overweight. Measurement of pain scale using VAS and neuropathic pain using ID pain scale. Compared to the value before the PEN intervention, the results of a significant improvement in the PEN procedure were obtained with a significance of P value <0.01, where the VAS value before the PEN procedure had a mean of dure was 2.61 p value <0.001.

CONCLUSION: Percutaneous epidural neuroplasty shows a better clinical outcome in the treatment of the lumbar disc herniation. And it can be considered that this pain procedure as a treatment option for cases of lumbar disc herniation which is have no improvement with conservative therapy.

The Comparison of Symptom of Diabetic Neuropathy and Other Type of Neuropathy

Jesisca Jesisca1, Rizaldy Taslim Pinzon1

1 Duta Wacana Christian University School Of Medicine/ Indonesia

AIM OF INVESTIGATION: Neuropathic pain is considered to be an international health problem because impairs the quality of life for millions of individuals. It presents as a symptom of several diseases with various characteristics. An accurate pain assessment is required to make the correct diagnosis and determine the most efficient strategy of pain treatment. This study aimed to determine the comparison of characteristic and scale of pain patient with diabetic neuropathy and other type of neuropathy.

MATERIALS AND METHODS: This is a cross-sectional multicentre study.In total of 414 patients were screened and 411 patients (99,3%) were enrolled consecutively. Patients were interviewed using the Michigan Neuropathy Screening Instrument (MNSI) or Toronto Clinical Neuropathy Score (TCNS) questionnaire and pain scale is measured by the Visual Analog Scale for pain (VAS).

RESULTS: From 411 patients, 114 (27,7%) were male and 297 (72,3%) were female. Etiology of neuropathy was diabetic in 117 subjects (28,5%), Carpal Tunnel Syndrome (CTS) in 165 subjects (44,0%) and idiopathic in 194 subjects (47,2%).Painful symptoms of diabetic neuropathy characterised by numbness (48,1%) with mean VAS 4,07±1,637;tingling (42,3%) mean VAS 4,05±1,666;pain (38,5%) mean VAS 4,05±1,563 and burning (17,3%) mean VAS 3,55±1,678.Idiopathic neuropathy and CTS majority described the pain as tingling (84,1% and 79,5%) with CTS mean VAS 4,56±1,388 and idiopathic neuropathy mean VAS was 4,52±1,428.

CONCLUSION: Numbness was the most common type of painful diabetic neuropathy in this study and tingling was the most common type of CTS and idiopathic neuropathy. Most of the subjects with neuropathies of various etiologies, pain was of moderate severity (4-6,9).

Effects of Cardamonin on Nitric Oxide Using Neuroinflammation Lps- Induced Sh-Sy5y Human Neuroblastoma Cell Model

Nurul Syazwani Mohd Suhaimi1, Mohd Roslan Sulaiman1, Enoch Kumar Perimal1

1 Universiti Putra Malaysia, Malaysia

AIM OF INVESTIGATION: This study aims to investigate the effect of cardamonin on nitric oxide synthesis on LPS-induced SH-SY5Y human neuroblastoma cells.

MATERIALS AND METHODS: Differentiated SH-SY5Y cells were induced with 1µg/ml of LPS for 12 hours. The induced cells were then treated with cardamonin in 3 different doses (2.5 μg/mL, 5 μg/mL and 10 μg/mL) for 24 hours. Nitric oxide concentration was measured using Griess’ reagent at 540 nm.

RESULTS: The concentration of nitric oxide in SH-SY5Y cells treated with 2.5 μg/mL, 5 μg/mL and 10 μg/mL cardamonin is 69. 38 ± 15.026 μM, 74.38 μM ± 38.007 and 24.38 μM ± 7.955 respectively. All the three doses of cardamonin show significant different with p<0.05, when compared with non-treated groups, consisting of LPS only, with nitric oxide concentration 913.125 μM ± 0.8839.

CONCLUSION: Cardamonin is able to reduce the nitric oxide concentration in LPS-induced SH-SY5Y human neuroblastoma cells.

Role of Nitric Oxide Synthase Inhibitor in Alleviating Hyperalgesia and Allodynia in CCI-Induced Neuropathic Pain Mice.

Nur Khalisah Binti Kaswan1

1 Universiti Putra Malaysia/ Malaysia

AIM OF INVESTIGATION: To investigated the effect of L-NAME in the alleviating allodynia and hyperalgesia in single and repeated administration in CCI-induced neuropathic pain mice.

MATERIALS AND METHODS: L-NAME in the alleviating allodynia and hyperalgesia in single and repeated administration. CCI-induced neuropathic pain mice model. ICR male mice had undergone CCI-surgery of sciatic nerve. The response on withdrawal latency and number of paw lifting towards thermal hyperalgesia and cold allodynia were analysed using hargreaves plantar test and cold plate on day 14 and 21 post-surgery. The animals were divided into 6 treatment groups including sham-operated, vehicle (0.9% NaCl), three dosages of L-NAME (3 mg/kg, 10 mg/kg, and 30 mg/kg), and Amitriptyline (20 mg/kg). All treatments were administered intraperitoneally on day 14 and continued daily for 7 days until day 21.

RESULTS: This finding shows that single and repeated dose of intraperitoneally administration of L-NAME (3, 10 and 30 mg/kg) significantly inhibited (p <0.05) cold allodynia in CCI-induced neuropathic pain mice. L-NAME at 30 mg/kg in single and repeated treatment shows that there is significant difference (p<0.01; p<0.001) in thermal hyperalgesia when compared to vehicle. No significant difference was found in single and repeated treatment of L-NAME in both tests.

CONCLUSION: These findings inhibiting the nitric oxide production in the mice able to attenuate the hyperalgesia and allodynia in CCI-induced neuropathic pain mice.

Pain Control in Chronic, Refractory CRPS by Continuous Brachial Plexus Analgesia

Andrzej Zyluk1, Piotr Puchalski1

1 Pomeranian Medical University In Szczecin/ Poland

AIM OF INVESTIGATION: The objective of this study was to evaluate the effectiveness of continuous brachial plexus analgesia with bupivacaine for pain control in chronic, refractory CRPS.

MATERIALS AND METHODS: 10 female patients with an average age of 35 (range 24-44) years, suffering from long-lasting, refractory CRPS were treated by continuous brachial plexus analgesia. The assessment of outcomes of the treatment included: the period between first and last operation, number of operations performed, grade of pain relief and duration of recovery.

RESULTS: Rapid and strong analgesic effect was obtained immediately after beginning of injection of bupivacaine solution: pain decreased from a mean of 8.3 to 1.6. Duration of maintaining the catheter in the brachial plexus and effective analgesia was 5.3 months (range 2-12). After removal of the catheter the pain returned to baseline. No patient obtained permanent or at least partial reduction of her pain after completion of this therapy.

CONCLUSION: We believe that presenting this study will contribute to current knowledge about treatment options for the most severe, “hopeless” cases of CRPS.

Results of the Treatment of Chronic, Refractory CRPS with Ketamine Infusions

Andrzej Zyluk1, Piotr Puchalski1, Zbigniew Szlosser1

1 Pomeranian Medical University In Szczecin/ Poland

AIM OF INVESTIGATION: Chronic, refractory complex regional pain syndrome remains very difficult to treat. A sub-anaesthetic low-dose ketamine has shown promise in advanced CRPS. We investigated the efficacy of ketamine in anaesthetic dosage in chronic, refractory CRPS patients that had failed available standard therapies.

MATERIALS AND METHODS: Five female patients, aged a mean of 34 years with long-standing, a mean of 8 years’, CRPS received ketamine in anaesthetic dosage over 10 days. The patients received 1-5 ketamine courses. The following variables were recorde: intensity of pain on a VAS scale, presence of allodynia and active range of motion of the digits.. After dismissal, the patients were monitored once a week by phone interview.

RESULTS: The effect of gradual pain reduction began on the 4th-5th day of treatment, resulting in desistance from taking any analgesic drugs they previously used was observed. At the completion of the therapy, all but one patients reported significant reduction of pain to a level of 2-5 in VAS scale, but not to zero. No improvement of function of the involved hand was noted.

CONCLUSION: Our results show a short-term analgesic effect of this therapy, with no effect on movement and function of the affected limb, but this beneficial effect was confined to about two weeks and at one month both pain and disability relapsed to the baseline level. Nevertheless, this method brings hope to the most severely ill patients who cannot be offered any other reasonable treatment option.

5% Lignocaine Patch on Chronic Low Back Pain

Dr Kevin Ooi Zi Kai1, Dr Mohamad Aswad Abu2

1 Hospital Tuanku Ja'afar Seremban, Negeri Sembilan, Malaysia

INTRODUCTION: Low back pain (LBP) is defined as pain and discomfort localised below the costal margins and above the inferior gluteal folds. 2010 Global Burden of Disease Study showed LBP to be the commonest cause of years living with disability (YLDs) and the cause of disability-adjusted life years (DALYs) worldwide. Chronic LBP comprises both nociceptive and neuropathic components but the neuropathic component appears under-recognised and underrated. Lignocaine patch 5% medicated plaster contains 5% lignocaine. It acts by stabilisation of neuronal membranes, which is thought to cause down regulation of sodium channels resulting in pain reduction.

CASE REPORTS: Case 1 Mr. C was referred to us for degenerative spine disease of L4-S1 with a history of previous spinal operation (laminectomy) 17 years ago. He is on multiple analgesias. Patient was introduced with 5% lignocaine. Pain was greatly reduced from an initial pain score of 9/10 to 4/10. Case 2 Miss D was diagnosed with L4/L5 disc protrusion causing bilateral L5 nerve roots impingement and spinal stenosis. Despite being on multiple medications, patient still complains of worsening pain with ambulation. Lignocaine patch 5% was introduced with dramatic improvement of pain on Day1. Case 3 Mdm R with MRI spine revealing L4/L5, L5/S1 spondylosis with annular tear was given 5% lignocaine patch claims improvement of pain and her function was achieved with great satisfaction.

CONCLUSION: Chronic LBP is a debilitating condition. It is not well managed despite of novel therapy. After application of these patches, patients with chronic LBP showed improvement in pain and functions.

Role of Intravenous Ketamine Infusions in Alleviating Pain for Fibromyalgia Patient

Hadri Bin Kamarrudin1, Mohamad Aswad Bin Abu1

1 Hospital Tuanku Ja'afar, Seremban, Negeri Sembilan, Malaysia

INTRODUCTION: Fibromyalgia is a complex chronic pain disorder that causes widespread pain and increased sensitivity to pain, fatigue, difficulty sleeping and depression. In chronic pain states prolonged nociceptive stimulation causes activation and upregulation of the NMDAR at dorsal horn synapses resulting in enhanced and amplified trafficking of pain signals to the brain (central sensitization).

REPORT: A 54 years old woman diagnosed as Fibromyalgia, Cervical Spondylosis and Degenerative Lumbar Disc Disease with co-morbid of Major Depressive Disorder under our pain clinic follow up since 2011. She reported having diffuse muscular and joint pain which disturbed her sleep and reduced her quality of life significantly. Several treatment options including physical therapy, relaxation technique and conventional medications did not achieve adequate pain control. She was on IV Ketamine infusion 100 - 150mg over 6 hours in per day and repeated every week for 1 month. The only side effect she had is visual and auditory hallucination during IV Ketamine infusion. Upon completion, she has reported that the pain had alleviated for longer time without any further medication and improved her daily function.

CONCLUSION: Low dose of ketamine produces strong analgesia in neuropathic pain states, presumably by inhibiting of the N-methyl-D-aspartate receptor (NMDAR) although other mechanisms are possibly involved, including enhancement of descending inhibition and anti-inflammatory effects at central sites. The usage of ketamine intravenous infusion should be explored as it was shown to benefit therapy-resistant chronic pain patient with Fibromyalgia.

Neuropathic Pain Secondary to Complete Transection of the Sciatic Nerve

Maria Fe Rosario A. Esguerra1, Edwin John Cruz2

1 Adventist Medical Center Manila/ Philippines

INTRODUCTION: Neuropathic pain is caused primarily by injuries of the nervous system resulting to neuroplastic changes. The damage to the nerve causes typical pain symptoms. Neuropathic pain is caused by neural plasticity, which can cause sensitization of the nervous system (Barash, 2017). It cannot be relieved by common OTC drugs (Baron, 2006). However, the role of opioids in the treatment of neuropathic pain remains controversial (Gilron, 2006).

This case report presents the treatment of neuropathic pain due to complete transection of the right sciatic nerve.

REPORT: This is a case of a 20 year-old male complaining of right leg pain secondary to a complete transection of his right sciatic nerve. Pain management was started with Pregabalin and Tramadol for 3 days. Pain scores were decreasing. Rehabilitation activities were started. He was shifted to Fentanyl patch. However, pain scores were increasing. Tramadol was shifted to Morphine until consumption was decreased with decreasing pain scores on the twelfth hospital day. He was discharged with minimal pain on the fifteenth hospital day.

He underwent sural nerve grafting. He continued on with Fentanyl patch for a year.

CONCLUSION: Currently, no guidelines are available for the management of neuropathic pain secondary to transected sciatic nerves. In this case, guidelines on the treatment of postherpetic neuralgia and diabetic neuropathy were used, and was shown to be equally effective.

Surgical repair of the severed nerve that has to be addressed to pain management.

Pregabalin as an Adjuvant to Diagnose and Manage Atypical Optic Neuritis, a Case Report

Muralitharan Perumal1, Gaayathri Nadarajah1, Subhashini Subramaniam2

1 Hospital Tengku Ampuan Rahimah, Klang/ Malaysia 2 National Clinical Research Centre/ Malaysia

INTRODUCTION: Optic nerves sometimes acquire inflammation, demyelination or degeneration leading to optic neuritis. We report a difficult-to-diagnose and manage case of bilateral optic neuritis with severe pain. Initially it was a case of conjunctivitis that progressed to sclerites and finally atypical optic neuritis. Various imaging, blood tests and medications were important as diagnostic tools as well as served in atypical optic neuritis management. We describe the role of pregabalin, an analgesic adjuvant, in diagnosis and management in this case.

REPORT: A 36 years old woman who presented with conjunctivitis symptoms and severe ophthalmic pain was initially seen and managed at a primary health care centre. She was then referred to the ophthalmologist for further investigation and management as there was no improvement in symptoms. Various investigations were done, and her diagnosis was revised multiple times to ensure appropriate management. Other pain-relieving drugs prescribed from the initial stages of treatment did not improve her symptoms and her pain score. Upon referral to a pain medicine consultant, pregabalin was prescribed for neuropathic symptoms that was not documented in the preceding month, pain scores tremendously improved. She also had better sleep at night.

CONCLUSION: Prescription of pregabalin in this case has contributed towards the diagnosis of atypical optic neuritis and has effectively controlled the severe ophthalmic neuropathic pain.

Deafferentation Pain in a Patient with Trigeminal Neuralgia Following Multiple Radiofrequency Ablations a Case Report

Nicole S. Tañedo-Trinidad1, Emmanuell Q. Villano, Md1

1 St. Luke's Medical Center - Global City, Taguig/ Philippines

INTRODUCTION: Deafferentation pain is characterized by episodes of severe pain often delayed in onset and resistant to conventional treatment. The underlying mechanisms remain poorly understood although there are evidences for widespread changes within both the peripheral and central somatosensory nervous system. Management remains a challenge to physicians and a heavy burden to patients as it is often under reported, assessed and managed.

REPORT: We are presented with a 41 year-old male with a 6-year history of right sided facial pain described as intermittent, lacerating, aggravated by talking, eating and drinking. He rated his pain at 7-8/10 on the numerical rating scale at rest and 9/10 during flares. The patient sought consult and a brain MRI was done which showed a slightly tortuous right vertebral artery and the impression given was Trigeminal Neuralgia. Medical management was initially done but symptoms remained unrelieved. He underwent radiofrequency ablation thereafter which temporarily resolved the symptoms. The ablation was repeated for the second time a year later. Unfortunately, patient still had persistent pain and suffered five years before seeking another consult. On examination, allodynia to light touch was elicited on the right V2-distribution of the trigeminal nerve. A diagnostic fluoroscopic guided gasserian ganglion and sphenopalatine block was done which provided near complete resolution of pain.

CONCLUSION: Deafferentation pain may still be poorly understood at present but it is proven to have a significant impact on the quality of life of patients. Proper monitoring is vital for early diagnosis and management.

Successful Treatment of Paediatric Lower Limb CRPS by Continuous Epidural Anaesthesia A Report of 2 Cases

Andrzej Zyluk1

1 Pomeranian Medical University In Szczecin/ Poland

INTRODUCTION: CRPS occurs in children less frequently than in adults, but in the last two decades it has become a well-established entity in children and adolescents. The symptomatology, course, responsiveness to treatment and prognosis of the paediatric disease is also different from the “adult” form.

REPORT: The paper presents the successful treatment of two cases of paediatric CRPS involving the lower limb, by continuous epidural anaesthesia with bupivacaine. Both patients developed the condition after minor trauma or overuse. CRPS diagnosis was based on clinical grounds. Both patients presented a history of psychological distress, due to familial problems. Results. In one patient, the initial treatment was lumbar sympathetic block, resulting in immediate and complete recovery. After relapse of the disease at four months, the next intervention included continuous epidural infusion of bupivacaine, with an excellent and rapid response. In the 2nd case, continuous epidural infusion was used primarily with the same, excellent and fast result. Clinical peculiarities, treatment modalities and other aspects of paediatric CRPS are discussed. Poor awareness of the condition in the paediatric community is emphasized.

CONCLUSION: Both cases reported in this article show the effectiveness of the proposed method (insertion of the epidural catheter, infusion of bupivacaine) in the management of paediatric CRPS.

Retrospective Study: Comparison Between Effect of Epidural Infusion and Epidural Morphine on Pain Score 48 hours Post-Operatively Among Caesarean Patient with Underlying Heart Disease.

Nur Liyana Binti Hanapi1, Afaf Azlin Binti Aziz1, Husni Zaeem Abd Hadi1, Nanthini Pulevendren1

1 Hospital Serdang/ Malaysia

AIM OF INVESTIGATION: To compare the effect between epidural infusion and epidural morphine on pain score 48 hours post-operative for Lower Segment Cesarean Section (LSCS) among patient with underlying heart disease.

MATERIALS AND METHODS: All patients underwent LSCS with established diagnosis of heart disease requiring critical care back up post-operatively starting from November 2016 till November 2018 were reviewed. Cases which met the inclusion criteria were selected. Pain score at rest and on movement 48 hours post-operatively were then analysed and compared. Visual Analogue Scoring were used in the pain reporting. Data retrieved was later analysed using SPSS.

RESULTS: Overall, results suggested good pain control achieved in both modalities with mean pain score 1.25 on rest and 1.75 on movement 48 hours post-operatively. However, it was discovered that patient which received epidural infusion achieved better pain control 48 hours post cesarean compared to epidural morphine with mean pain score on both rest and movement of 0.89 and 1.11 respectively. There was a significant difference found between epidural infusion and epidural morphine with regards to the pain score on movement (p= 0.049) however was not statistically significant with pain score at rest 48 hours post operatively (P=0.103).

CONCLUSION: Patient on epidural infusion prior appears to have better pain control 48 hours post LSCS. Despite significant difference found between epidural infusion and epidural morphine with regards to the pain score on movement 48 hours post operatively, a much larger sample size is required before concluding it is statistically significant.

Evaluation on the Effectiveness of Post Caesarean Pain Management and Patient's Awareness of Pain

Lu Enhong1, Cheng Shang Ming1

1 Kk Women's And Children's Hospital Sinapore/ Singapore

AIM OF INVESTIGATION: To improve post caesarean pain management through multidisciplinary approach based on patient’s perspectives.

MATERIALS AND METHODS: Consecutive samples of 50 women were surveyed on post-operative day 1 using modified American Pain Society/ Patient Outcome Questionnaire. Participants aged from 21 to 39 years old completed a voluntary anonymous questionnaire, consisting of 6 multiple questions pertaining to their age, race, pain score, knowledge and attitude on pain management.

RESULTS: 66% of patients rated pain score 5-10/ 10 in first 24 hours post caesarean section (0 = no pain, 10 = worst pain ever), and 22% of them experienced severe pain more than half of the time. However, 36% of patients were not comfortable taking analgesics even though all analgesics prescribed were safe for breastfeeding. In this group, there were 61% Malay, 33% Chinese and 5% Indian.

22% of patients believed it was normal to have pain and just to tolerate the pain. Within this group, there were 45% Chinese, 36% Malay and 18% Indian.

10% of patient believed it was not necessary to treat dynamic pain and 4% wanted only to take stronger analgesics before ambulation.

42% of patients did not know any complications of pain.

CONCLUSION: The findings suggest that pain was under managed for patients who had post caesarean delivery. There are multiple knowledge gaps identified and much influence from culture. There is a need to involve multidisciplinary team, like pharmacist and physiotherapist, to provide more professional information and feedbacks to improve post caesarean pain management.

Incidence of Neonatal Abstinence Syndrome (NAS) Among Infants with Prenatal Exposure to Transdermal Buprenorphine for Maternal Pain Management

Mohd Aiman1, Wan Rohaidah Wan Ahmad2

1 Hospital Sultanah Nur Zahirah/ Malaysia

INTRODUCTION: Buprenorphine is a partial mu-opioid agonist and kappa-opioid antagonist. Its low intrinsic receptor results in a less-then-maximal effect and diminished risk of overdose. The effects of abrupt withdrawal of buprenorphine are minimal compared to full mu-opioid agonists. These pharmacologic advantages led to its use in prenatal treatment for chronic pain. Norbuprenorphine, the primary metabolite has opioid receptor activity similar to its parent compound and has been found in biological matrices associated with reproduction (e.g., umbilical cord, placenta, maternal and neonatal urine and breast milk).

Neonatal Abstinence Syndrome (NAS) is characterized by hyperirritability of the central nervous system and dysfunction in the autonomic nervous system, gastrointestinal tract, and respiratory system following antenatal exposure to strong opioid. When left untreated, can result in serious illness (e.g., diarrhoea, feeding difficulties, weight loss, and seizures) and death.

REPORT: We described five cases of parturient receiving transdermal buprenorphine as a substitute to other strong opioid (morphine and oxycodone) for chronic pain management. All mothers were explained regarding the risk of NAS. All babies had good APGAR score. However, one neonate developed NAS and required infusion of morphine at special care nursery (SCN). The baby belonged to the mother who required high dose of strong opioid and longest duration of exposure antenatally. All of them were discharged home well.

CONCLUSION: From our limited data, we concluded that buprenorphine is safe to be used in pregnant mother. The risk for developing NAS is related to dose and duration of exposure to the drug.

Knowledge, Attitude and Practice of Critical Care Nurses’ (CNS) towards Critical Care Pain Observation Tool (CPOT)

Natrah Binti Abdullah1, Norimah Said1, Maniza Mohamad1, Siti Aslina Nordin1

1 Universiti Teknologi Mara (UITM), Malaysia

AIM OF INVESTIGATION: This study was designed to identity the demographic data and the level of knowledge, practice and attitude on CPOT assessment by Critical Care Nurse (CCN).

MATERIALS AND METHODS: This study employ cross sectional study with the total of 126 nurses has participated. The instrument that was used for this study is self-administered questionnaire that has been adapted and modified from Ferrell et al, 2012, Puntillo et al, 2002, Stites 2013, Souza et al, 2015 and Victorian Quality Council (VQC) Acute Pain Management Measurement Audit Tool Guidelines.

RESULTS: The majority of respondents were female of 94.4%. Majority of the nurses had experience working in ICU and CCU for between one to five years and between 6-10 years for both by 38.7%. Among the nurses with good knowledge show good practice by 76.4%. It shows significant relationship between knowledge on CPOT and practice with p-value <0.001. Among the nurses with poor knowledge on CPOT had moderate attitude on CPOT by 71.4%. It shows significant relationship between knowledge on CPOT and attitude with p-value 0.003. Among the nurses with good attitude show good practice by 56.4%. It shows significant relationship between practice on CPOT and attitude with p-value 0.001.

CONCLUSION: Pain assessment in the critically ill patients should be practiced and educational intervention is essential in improving compliance with pain assessment and management practices in adult CCA. Therefore this research support that importance of education in ensuring appropriate pain assessment and management.

Nurses Knowledge and Attitudes Towards Pain Management in Malaysia.

Woo Geik Keow1

1 Sultan Bin Abdulazi Humanitarian City, Malaysia

AIM OF INVESTIGATION: 1. To study the level of pain knowledge and attitudes of Malaysian nurses. 2. To compare the level of pain knowledge and attitudes before and after pain education. 3.To determine Malaysia nursing education syllabus and standard towards pain management

MATERIALS AND METHODS: A cross-sectional study was conducted at Penang Allied Healthcare training corporation on 30/6/18 and 1/7/18. Convenience sample of 17 Malaysia trained registered nurses from 5 private hospitals in Penang completed the demographics and “Knowledge and Attitudes Survey Regarding Pain (KASRP)” questionnaire before and after the pain management course.

RESULTS: The mean percentage score in Pre pain education was 52% and 68% for Post education, an overall increase of 16%. Pharmacology questionnaires had the least score. However, there are negative correlations between the respondents’ score and level of nursing education (e.g. Degree, diploma, post-basic) and years of working experiences.

CONCLUSION: The pre-education knowledge level (52%) reflected the quality of care provided by nurses and the study supported the universal concern of inadequate pain knowledge among healthcare provider. Collaboration of Malaysian Nursing Board and Malaysian Association Study of Pain to revise the nursing education curriculum towards pain management and initiate more pain education opportunities may perhaps improve nurse's pain knowledge. Currently, Malaysia do not have structural pain management certification course for nurses. With the rapid growth of pain medicine and patients needs, it would be beneficial if Ministry of Health would initiate "Post-Basic In Pain Management" course for Malaysian nurses.

A Survey on Health Care Worker’s Perception towards a Pain Free Hospital

Usha Rajah1, Li En Ng1, Eng Ching Guok1, Syahanim Salleh1, Maleni Maialagan1, Nurhidayah Zulkifli1, Jahizah Hassan1

1 Hospital Pulau Pinang/ Malaysia

AIM OF INVESTIGATION: The objective of the study is to assess the perception of health care worker (HCW) in Penang General Hospital towards a pain free hospital to assist in deciding the needs for further training.

MATERIALS AND METHODS: The survey was conducted through questionnaires distributed to HCW during Pain Awareness Week in Penang General Hospital. Five questions were asked: What is Pain Free Hospital? Is pain score a vital sign? Who treats pain? What are the components of Pain Free Hospital and the targeted post op pain score? Results were calculated and interpreted as percentage (%) of response.

RESULTS: Total 237 HCW were recruited; 36(15%) specialists or medical officers, 82(35%) house officers, 100(42%) staff nurses or medical assistants. 19(8%) did not state their designation. 74% HCW correctly defined Pain Free Hospital as a hospital with standardized protocols to treat pain, while 26% defined it as a hospital without pain or a hospital that gives free pain. Most (99%) correctly answered that pain score is included as a vital sign. 79% HCW feels that everyone are involved in pain management. As for the components of pain free hospital, 197(83%) HCW felt that it consists of anaesthesia, analgesia, together with traditional and complementary medicine. Most HCW (93%) were aware that post-op pain score should be less than 4.

CONCLUSION: This survey indicates that HCW in Penang General Hospital have adequate knowledge on Pain Free Program. However, awareness and training must be continued to ensure that they comply with the pain free guidelines.

Pain Service in East Timor

Dr Flavio Brandao de Araujo

1 National Hospital Guido Valadares

After the end of Indonesian occupation of East Timor (2000), the health service relied entirely on International Staff to fill the human resource gap. These were personnel provided by Australian, Cuban and Chinese Goverment and other Non-Govermental organizations.

In 2002 there was a handful of Timorense doctors, but non of them was aspecialist, over the last 10 years the number of Doctors has steadly increassed and for the last 5 years there are also a few Timores specialists including Anaesthetist return from training abroad.

The Pain Care in Timor is dependent on the attending doctor and the direct nursing staff. There is no existing policy to address Pain in its many forms, such as Acute Pain from Surgery or Trauma; Chronic pain, compounding issues due to experiences of persons during the conflict and its manifestation as somatic pain. Now it is time to develop an aproach to optimize patient care and safety and improve quality including good Pain Care; so improving patient satisfaction with the health care system in East Timor.

In the absence of any policy or clinical pathways to address Pain Care, it has become Anesthesia’s role to provide this in Timor Leste. We have several chalenges such as:

1. Improving communication and understanding between members of Hospital staff on Pain management,

2. how to provide a common platform for doctors; because we have staff who come from different countries, different training backgrounds, and varying perceptions of pain and Pain Care.

We have recently started to address Pain Care by raising awareness of pain and its importance in patient care.

For example, we have introduced in October 2018 “ Introducing Pain as a Fifth Vital sign in Dili National hospital”; and Regular Pain Audit for post-op Caesarian Section and intervention accordingly; and Empowering Physiotherapy’s role in Pain Care, Develop pre-operation anaesthesia consultation in Dili National Hospital

There several factors that are challenging building Pain Care in East Timor :

1. Manpower : Anasthetist still as main role in Pain Care.

2. Education and Training :Inadequate Political and financial support for Continued medical education from the goverment leading to stagnation in profecional development

3. There is Pain from socioeconomic impact as a country develop and as a concequence of Post Conflic where there is lack of understanding of how psychological trauma impacts on the manifestations of pain. The Role of Pharmacist in Pain-Free Hospital

Nadia Hani Binti Ghazali1

1 Hospital Raja Permaisuri Bainun, Ipoh Perak/ Malaysia

INTRODUCTION: Pain medicine is a branch of medicine which employs a multidisciplinary approach for ease the suffering and improving the quality of life of those patients living with pain. The typical pain management includes anaesthesiologists, occupational therapists, physiotherapists, clinical psychologists, pain nurses including pharmacists. In Ministry of Health hospitals, to date not less than 16 chronic pain clinics have been established while acute pain services are provided in 84 hospitals but not many hospitals have full-time pharmacist in the pain-free services. Currently, Hospital Raja Permaisuri Bainun Ipoh, Perak (HRPB) have full-time pharmacist involve in the multidiscipilinary team

REPORT: This report was done to summarize patients that have been seen and counselled by the pharmacist during pre-operative assessment and chronic pain clinic. Data were collected from HRPB anaesthetic clinic and pain clinic record. In 2016, a total of 5200 patients were registered under anaesthetic clinic for preoperative assessment. Out of this, 1962 (37.7%) patients had been counselled by the pharmacist. In 2017, a total of 5247 patients registered. 1262 (24%) patients had been given pre-op medication counselling. For chronic pain clinic, in year 2016, 726 patients have been seen by pharmacist and were counselled regarding their pain medication therapy. Out of this number, 70 patients are new patients and 656 patients is a follow-up patients.

CONCLUSION: Pharmacotherapy and pharmacokinetics expertise are essential in pain management. In the future, hopefully pharmacist should be involve in a pain-free program and play an important role in many aspects in pain management

The Knowledge of Flacc Tool in the Management of Post-Operative Paediatric Pain Among Anaesthetic Nurses

Khairunnisa Binti Samsudin1, Amaliana Binti Shaharin Shabasa1, Asmahani Binti Abd Shukor1, Izzaty Nadiah Binti Adnan1, Devanandhini Krisnan1, Ahmad Kamarul Zaman Bin Abdul Rahaman1, Malini A/P Morris1, Mohd Azrul Bin Izhak1

1 Institut Latihan Kementerian Kesihatan Malaysia Sultan Azlan Shah/ Malaysia

AIM OF INVESTIGATION: Postoperative pain affects movement and delays the healing process. Acute pain is an individual and subjective experience. Children frequently lack verbal and cognitive skills to express physical discomfort and pain intensity. Hence, nursing observation and documentation plays an important role in pain management after surgery. Proper assessment and subsequent documentation ensures proper pain management which is in line with optimal patient care. The objective of this study was to evaluate the level of nurse's knowledge in pain management after surgery. In addition, it was also intended to assess the level of nurse's knowledge in methods used to assess the level of postoperative pain among paediatric patient.

MATERIALS AND METHODS: This was a descriptive study which is the respondents of this study consisted of 30 anaesthetic assistant nurses from both the General Operation Theatre (GOT) and Ambulatory Care Centre Operation Theatre (ACC OT) of Hospital Raja Permaisuri Bainun, Ipoh . Questionnaire was a method used as a means of data collection.

RESULTS: Result showed varying levels of knowledge among the respondents regarding postoperative pain documentation as well as methods for evaluating pain after surgery.

CONCLUSION: Constant education and awareness is important in ensuring optimal knowledge and practice of pain assessment among anaesthetic assistant nurses in particular with regard to the Faces, Leg, Activity, Crying, Consobility (FLACC) behavioral scale tool. It is without doubt that pain education plays an important segment of the training curriculum of these perianesthesia nurses.

EMLATMCream 5% Exploring the Usage of Eutectic Mixture of Local Anaesthesia (EMLA) in Paediatric Departments in Malaysia

Sindhu Viswanathan1, Premaa Supramaniam1, Devanandhini Krisnan1, Amar-Singh Hss1, Netia Jeganathan1, Jeyaseelan Nachiappan1

1 Hospital Raja Permaisuri Bainun, Ipoh/ Malaysia

AIM OF INVESTIGATION: We explored the prevalence of EMLATM 5% cream in paediatric departments in public hospitals to :- a) determine its average usage for various paediatric procedures, b) assess the impact of written policies , manpower and staff training on pain assessment and management on availability and usage of EMLATM, c) identify the barriers and facilitators towards its ubiquitous use

MATERIALS AND METHODS: This was a cross-sectional, multi-centred telephone interview study which was conducted between January to December 2017 in consenting government hospitals with paediatricians in Malaysia using a self-developed structured questionnaire.

RESULTS: 38 /43 surveyed hospitals had EMLATM available. Hospitals without EMLATM were district hospitals with less than half the median number of paediatricians in comparison. EMLATM was utilised for a variety of paediatric procedures in varying frequencies depending on the procedure.No statistical correlation was noted with regards of frequency of EMLATM usage for the various procedures to the size of the department, the number of paediatricians per department, the presence of Pain Free Hospital rounds or availability of training for staff in pain assessment and management.Multiple factors were identified as barriers towards EMLATM usage with lack of awareness being most frequently cited.

CONCLUSION: Improving peri-procedural pain management in paediatric population across the nation still has a role and efforts need to be made in streamlining this as a priority in managing children. A written guideline at national level may help address administrative issues and improve peri-procedural pain management amongst children requiring procedures in public hospitals.

Surgical Treatment of the Pain of Chronic Pancreatitis in Adolescents A Report Of 2 Cases

Beh Zhi Yuen1, Lim Siu Min1, Nuraeiniza Binti Ismail1, Lim Woon Lai1, Marzida Binti Mansor1, Ng Ruey Terng1, Yik Yee Ian1

1 University Of Malaya/ Malaysia

INTRODUCTION: Chronic pancreatitis is unusual in children and much more common in adults. Pain is the predominant symptom in chronic pancreatitis which >80% of patients present with pain as the primary symptom either at the first attack of acute pancreatitis or as the main reason for hospital readmissions in the following months and years, as the disease progresses to what defined as chronic pancreatitis.

REPORT: We report 2 adolescents suffered from severe chronic abdominal pain due to chronic pancreatitis. They had multiple hospital admissions for severe abdominal pain which worsened and became intractable to medical therapies – multimodal analgesics with high dose strong opioids, antidepressants, gabapentinoids, ketamine plus endoscopic therapies with drainage and stenting. They improved tremendously following surgical decompression/drainage procedure (modified Peustow). Strong opioids were weaned off and they took minimal simple analgesics (paracetamol and tramadol) at home during follow up. Case A is a 13-year-old boy who has chronic pancreatitis since the age of ten. His abdominal pain was poorly controlled despite opioid rotation between PCA Fentanyl to Morphine (highest consumption 60mg per day), ketamine infusion (0.15mg/kg/hour) for days, regular paracetamol, tramadol, celecoxib, amitriptyline and pregabalin. Case B is a 17-year-old girl who has hereditary pancreatitis with pancreatic dilatation and calculus. She suffered similar pain experience like case A and refractory to medical therapies.

CONCLUSION: The pain of chronic pancreatitis remains a major challenge to pain specialists, gastroenterologists and surgeons. Surgical treatment is a viable option for those who suffered from intractable abdominal pain.

Prescribing Patterns of Pain Treatment in Elderly with Chronic Pain

Rizaldy Taslim Pinzon1, Fransiscus Buwana1

1 Duta Wacana Christian University School Of Medicine/ Indonesia

AIM OF INVESTIGATION: Aging has the risk of certain health disorders that can cause to chronic pain. It becomes big problem since it often leads to serious health problems such as increased depression and decreased the quality of life. Stemming from these issues, there is a need to provide effective and safe treatments for elderly patients with chronic pain. To measure the prescribing pattern of pain treatment in elderly with chronic pain.

MATERIALS AND METHODS: In this retrospective descriptive study, the data were obtained through electronic medical records of Bethesda Hospital. The subjects were patients ≥ 60 years of age who were diagnosed with Chronic Pain from January to November 2018. Univariate analysis is used to describe the proportion of the subjects in the frequency distribution.

RESULTS: From 98 patients, 36.73% were males and 63.26% were females, include the participation of 81,63% patients aged between 60-74 years old. Of all patients, 66.2% had inflammatory pain and 82.64% had mid-moderate pain. For the treatment, the most patients get single therapy 85.71%. For the prescribing patterns of drugs, NSAIDs (34.52%) found to be the most common used, followed by Acetamenofen (23.80%), Adjuvant analgesics (20.23%), Vitamin B12 (12.24%), Vitamin B complex (4.08%), Corticosteroids (2.38%) and the use of drug combinations (14.28%). For the most common drug combination therapy used in this study was Acetaminofen + NSAID +Adjuvant analgesic (35.71%).

CONCLUSION: Our study showed that single therapy in accordance with the guideline is being the most common found among elderly patients with chronic pain.

The Clinical Pattern of Pain and Comorbidity in Geriatric Patients with Various Pain Condition

Vincent Ongko Wijaya1, Rizaldy Taslim Pinzon1

1 Duta Wacana Christian University School Of Medicine/ Indonesia

AIM OF INVESTIGATION: The aim of this study was to explore the clinical pattern of pain and its relationship with comorbidity in geriatric patients./ Introduction: Pain is an unpleasant sensory and emotional experience associated with actual and potential tissue damage. Geriatric patients are more likely to have chronic disorders associated with pain, leading to disability and impaired quality of life.

MATERIALS AND METHODS: This was an observational analytic study with cross sectional design. 111 geriatric patients with pain complaints were recruited from Neurology Department in Bethesda Hospital, Yogyakarta. Data obtained by interviewing patients that completed questionnaires to determine the clinical pattern of pain (intensity, type, properties, and location) and medical records for the comorbidity. Data were analyzed with univariate test and Chi-square test.

RESULTS: There were 111 subjects consist of 40 (36%) males and 71 (64%) females. There were 79 patients with comorbidity (71.2%). The most common comorbidity in subjects was hypertension (63.3%), whereas the rarest was chronic kidney disease (2.5%). Mixed pain (85.6%) was the most common type of pain, multiple side pain (60.4%) was the most common location of pain, moderate pain (46.8%) was the most common pain intensity, and chronic pain (60.4%) was the most common properties of pain. Location of pain (p:0.642), type of pain (p:0.925), pain intensity (p:0.450), and properties of pain (p:0.573) were not significant with patient comorbidity.

CONCLUSION: The comorbidity prevalence in geriatric patients is 71.2%, there are no significant clinical pattern of pain that influence the comorbidity in geriatric patients.

The Characteristic of Pain in Elderly Patient with Hypertension in Indonesia

Patrick Nalla Nunsio1, Rizaldy Taslim Pinzon 2

1 Duta Wacana Chrsitian University/ Indonesia

AIM OF INVESTIGATION: The most common disease in the elderly population in Indonesia is hypertension with a prevalence of 45.9% at the age of 55-64 years, 57.6% at the age of 65.74% and 63.8% at the age of ≥ 75 years. Beside hypertension, Pain is the common complaint of the elderly. As the number of individuals older than 65 years (60 years old in Indonesia) continues to rise, frailty and chronic diseases associated with pain will likely increase. The study was conducted to describe what types of pain commonly occur in elderly patients with hypertension

MATERIALS AND METHODS: A hundred geriatric patients who experienced pain and hypertension were randomly selected and studied the type of pain. The data about pain characteristic is measured systematically with standardized instrument.

RESULTS: From 100 geriatric patients with hypertension that consist of 44 male and 56 female, with an average age of 69 years old ,the results obtained were 21 patients experienced neuropathic pain, 27 patients experienced nociceptive pain and 52 patients experienced mixed type pain.

CONCLUSION: From the study, It is apparent that mixed type pain is the most common type of pain in geriatric patients with hypertension. This result will affect the treatment of pain, as each type of pain will have a different treatment by also considering the comorbidities of the elderly

Pain Characteristic in Geriatric Patient with Sleep Disturbance

Ranbebasa Bijak Buana1, Rizaldy Taslim Pinzon1

1 Duta Wacana Christian University/ Indonesia

AIM OF INVESTIGATION: Sleep is a vital function of human for maintain homeostasis and optimize function of physiologic system. Sleep disturbance commonly happen in geriatric patient and related to various factors, one of these factors is pain. However the study about characteristic of pain in Indonesia is still limited. This study is aim to review the characteristic of pain in geriatric patient with sleep disturbance.

MATERIALS AND METHODS: Cross-sectional design was use in this study. Subjects that meet inclusion criteria were recruited using consecutive sampling. Subjects then fill the pain essay sheet about pain characteristic. The data that obtain from the pain essay was evaluated to categorize the subjects with sleep disturbance and without sleep disturbance.

RESULTS: The data consist of 152 geriatric patients. Eighty eight subject were female and 64 were male with age range between 60-90 years old, 68 subjects (44,74%) were experience sleep disturbance. From 68 subjects with sleep disturbance, moderate pain intensity (45,59%), mixed type of pain (72,06%), Chronic pain (60,29%), multiple side pain location (55,88%) and uncertain time pain exacerbation (58,82%) were the most found pain characteristic.

CONCLUSION: The Characteristic of pain that mostly found in patient with sleep disturbance were mixed type of pain and Chronic pain. The Characteristic of pain should be considered in therapy for geriatric patient with sleep disturbance.

Importance of Pain Management in Elderly

Jesisca Jesisca1, Rizaldy Taslim Pinzon1

1 Duta Wacana Christian University School Of Medicine/ Indonesia

AIM OF INVESTIGATION: The world’s older population has been growing more numerous for centuries. Prevalence rates for pain are expected to increase as populations with advancing age. One of the greatest tools exacted by pain is on satisfaction and quality of daily life which is increasingly being recognized as one of the most important parameters to be measured in the evaluation of medical therapies, including those for pain management. This study aimed to determine patient satisfaction with pain management and its impact on daily life of elderly patients with pain.

MATERIALS AND METHODS: This is a cross-sectional study. Patients were selected by consecutive sampling. Patients were surveyed on questions assessing pain treatment satisfaction, pain severity, and disruption of daily life regarding to sleep, activity, and emotion.

RESULTS: A total of 159 subjects, primarily with chronic pain. 61 subjects (38,4%) were male and 98 (61,6%) were female. The average (SD) age was 69,03 (6,12) years. It was found that the pain severity was associated with activity disruption (p = 0,04). Significant pain improvement from all pain treatment was reported (p = 0,00). Patients who had experienced pain improvement, expressed a high level of satisfaction and this result were statistically significant (p = 0,00).

CONCLUSION: Health care professionals should recognize that a complaint of pain in elderly is a significant problem moreover it has an impact on physical function or quality of life. A holistic management is recommended to assess regularly the needs of elderly to get a goals of pain therapy.

The Correlation Between The Amount of Painkiller and The Risk of Gastrointestinal Bleeding in Elderly Patients

Abraham Al Jody1, Rizaldy Taslim Pinzon2

1 Duta Wacana Christian University/ Indonesia 2 Bethesda Hospital, Yogyakarta, Indonesia/ Indonesia

AIM OF INVESTIGATION: Pain is one of health burdens that affects everyday living. Pain also can be occurred in elderly population. Many elders are thriving to relieve pain symptom, but it doesn’t guarantee if it is side effects-free, including gastrointestinal (GI) bleeding. The purpose of this study is to find the correlation between GI bleeding risk and quantity of painkiller taken.

MATERIALS AND METHODS: This observational analytic study was conducted using cross-sectional design. 128 subjects, who had fulfilled the inclusion and exclusion criteria, were recruited and sampled by using consecutive sampling. The data was collected by interview and matching the result with medical record. The data was processed using Fisher test, to determine the correlation between the amount of painkiller and the risk of GI bleeding.

RESULTS: From 128 subjects, 85 subjects (66.41%) have GI bleeding risk, and 43 subjects (33.59%) are without GI bleeding risk. The most selected painkiller is paracetamol (27.34%), while the least selected drug is pregabalin and potassium diclofenac (0.78%). 115 subjects (89.84%) are treated with monotherapy, with 13 other subjects (10.16%) are treated with more than one painkiller. There was no correlation between the amount of painkiller and the risk of GI bleeding (p=0.095).

CONCLUSION: The prevalence of GI bleeding risk is 66.41%. Paracetamol is the most selected painkiller among the total subject, with 27.43%. 89.84% subjects are taking monotherapy treatment, while others (10.16%) are treated with more than one painkiller. No correlation was found between quantity of painkiller and risk of GI bleeding.

The Characteristics of Pain in Elderly

Rosa De Lima Renita Sanyasi1, Rizaldy Taslim Pinzon1

1 Duta Wacana Christian University, Indonesia

AIM OF INVESTIGATION: The main objective of this study is to describe the characteristics of pain among elderly patients.

MATERIALS AND METHODS: This study was a cross sectional study conducted at Bethesda Hospital, Yogyakarta, Indonesia. The inclusion criteria including: age >60 years, male or female, has a pain as the main complain, and willing to be interviewed. The data obtained in this study i.e.: age, gender, pain severity, pain type, pain duration, pain location, medication. We also assessed the impact of pain on sleep, activity, and emotion state.

RESULTS: The total of subjects were 128. The mean age was 69.03 years and dominated by female (61.6%). About 45.3% subjects had a moderate pain intensity. More than 50% of subjects had a mixed pain type and suffered from a chronic pain. The most common pain location was back (15.6%). All of subjects had an analgetic. Paracetamol (17.9%), gabapentin (16.4%), and vitamin B12 (13.3%) were the most common medication among subjects. Based on the assessment in this study, the pain was not impact on sleep and emotion state, but it did impact on activity. Seventy four subjects stated that the pain interfere their activity, 18.8% among them claimed the pain sometimes impair their activity and the other 39.1% claimed the pain was really impair their activity.

CONCLUSION: The prevalence of pain in elderly is high. Pain in elderly tend to be chronic and interfere their activity. Pain management is important to improve their quality of life.

Is Sacro-Iliac Joint Dysfunction Succesfully Managed by Pulse Radiofrequency Ablation in Elderly within Long term Follow Up?

Farid Yudoyono1, Deasybherminawaty2

1 Santosa International Hospital, Bandung, Jawa Barat/ Indonesia

INTRODUCTION: Chronic refractory low back pain (CLBP) is the leading cause of disability, an estimated 15–25 % of low back pain may have sacroiliac joint (SI) joint pain in the United States. Pulse Radiofrequency ablation (PFA) has become an option for those with chronic or refractory sacroiliac (SI) joint pain.

REPORT: This PRFA using an alternating current with an oscillating frequency, allowing the heat to dissipate, thus avoiding temperature increases. Case 1, Female, 57 yo, right buttock pain, VAS 8-9, ODI 30 %, no radiating pain, no neurological deficit. Physical examination provoke SI joint pain. Case 2, Female, 82 yo, right buttock pain, VAS 8-9, ODI 20%, no radiating pain, no neurological deficit. Physical examination provoke SI joint pain. Both plain X ray pelvis revealed grade III sclerosis on right SI joint, MRI T2 bony osteochondrosis and sclerosis on right SI joint. Our study reveals that Cooled RFA of Si Joint innervation might ensure substantial pain relief and decrease analgesic need in patients suffering from refractory SI joint pain. At 1-, 3-.6-and 12-months post-RFA intervention, 73%, 60%, 53% and 35% of patients, respectively, gained >50% pain relief.

CONCLUSION: Pulsed RFA may provide effective and longer pain relief in properly screened elderly patients with painful sacroiliac joint dysfunction.

Utilization of Intravenous Paracetamol in the Intraoperative Setting and Its Effect on Hemodynamic Changes

Munira Mohammad Izat1, Marhanis Salihah Omar1

1 Universiti Kebangsaan Malaysia, Malaysia

AIM OF INVESTIGATION: This study provides an insight on the utilization of intravenous paracetamol (IV PCM) in the intraoperative setting, with the aim to assess the incidence of hypotension following its infusion and identify factors that are associated with it.

MATERIALS AND METHODS: This study was conducted in Hospital Kuala Lumpur. The medical records of patients who underwent general/orthopedic surgery and received intraoperative IV PCM between August 2017 and October 2017 were retrospectively reviewed

RESULTS: A total of 80 patients were included in this study. All patients received a single dose of 1 g IV PCM with a mean duration of infusion of 18 ± 8.5 minutes. A significant reduction in mean arterial pressure (MAP) of at least 15% from baseline was observed in 23 (28.8%) patients. Patients who experienced hypotension had significantly higher pre-infusion systolic blood pressure (SBP), diastolic blood pressure (DBP) and MAP values compared to those in the non- hypotension group. Among the predictors assessed, pre-infusion MAP (OR, 1.15; 95% CI, 1.070 – 1.236) and hypertension (OR, 4.146; 95% CI, 1.009 - 17.031) were independent factors for a significant hemodynamic change.

CONCLUSION: Administration of IV PCM is associated with a reduction in blood pressure when given in the intraoperative setting. Clinicians should be aware of this potential deleterious effect, especially in patients with underlying hypertension or high baseline MAP values. Further studies are warranted to determine clinical implications of this unfamiliar adverse reaction of a seemingly safe, old drug that comes in a new formulation.

The Effect of Granisetron and Ondansetron on Hemodynamic During Cesarean Section Under Spinal Anesthesia

Ahmad Nur Islam1, Muhammad Ramli Ahmad1

1 Medical Faculty Of Hasanuddin University Makassar/ Indonesia

AIM OF INVESTIGATION: Spinal anesthesia is the most popular technique of anaesthesia for Caesarean section (Cs) which is frequently associated with hypotension and bradycardia. Hypotension is harmful for maternal and fetal outcome. The Bezold–Jarisch reflex (BJR) is one of the mechanisms which explain the occurrence of hypo tension after spinal anesthesia through serotonin- mediated vasodilatation. These receptors located peripherally as cardiac chemoreceptors on the cardiac vagal afferent and centrally in the chemoreceptor trigger zone. The aim of our study was to evaluate the effect 5-hydroxytryptamine 3 (5-HT3) receptor antagonists between Granisetron and Ondansetron on hemodynamic in parturients undergoing Cs with spinal anesthesia

MATERIALS AND METHODS: Fourty patients underwent Cs under spinal anesthesia randomly divided into two groups (20 parturients in each group). Group G received intravenous 0.03 mg/kg Granisetron 30 min before spinal anesthesia, group O recieved intravenous 0.1 mg/kg Ondansetron. Mean Arterial Blood Pressure (MABP), Heart Rate (HR), and vasopressor used were assessed.

RESULTS: Mean Arterial Blood Pressure (MABP), Heart Rate (HR), and vasopressor used were assessed. MABP changes was higher in group O compared to group G (p<0.05), although this result was not statistically significant (p>0.05). However, incidence of nausea and vomiting was significantly decreased in group G (p<0.05).

CONCLUSION: Granisetron and Ondansetron has similar effect on preventing hemodynamic changes during Cs under spinal anesthesia.

Pain Management in Spinal Cord Injury are we Achieving Functional Improvement

Shivani Rajasegaran1

1 Hospital Raja Permaisuri Bainun, Ipoh/ Malaysia

AIM OF INVESTIGATION: To determine if pain management among Spinal Cord Injury (SCI) patients yields improvement in pain scores and functional gain.

MATERIALS AND METHODS: All patients living with SCI for at least 6 months were included in the study. Data was collected based on medical records from the rehabilitation medicine department from January till September 2018. This data was analyzed to determine method of pain management, tabulation of pain and functional scores before and after treatment.

RESULTS: 62 individuals with SCI were included in the study. 66% had pain post spinal cord injury with 75 % having neuropathic type of pain. Among those with neuropathic pain, 47% were treated with medication and using anticonvulsant (Gabapentin) as the first line of treatment. 34% had combination of medication and non-pharmacological treatment prescribed for pain. 19 % were treated with non-pharmacological methods alone. 51% achieved reduction of pain scores with treatment. A majority of 90% achieved improvement in functional gains.

CONCLUSION: Good pain management is essential to achieve functional gains among the SCI population.

A Retrospective Study on Prevalence of Pain Among Chronic Kidney Disease Patients in a Palliative Care Unit.

Choo Yoke Ling1, Saiful Adni Bin Abd Latif1, Tan Pei Wen1

1 HOSPITAL SELAYANG/ Malaysia

AIM OF INVESTIGATION: To determine the prevalence of pain among all new cases of adult chronic kidney disease (CKD) patients that were referred to palliative care unit (PCU) of Selayang Hospital.

MATERIALS AND METHODS: All new cases of adult CKD patients referred to PCU of Hospital Selayang, either via admissions, consultations, outpatient clinics or walk-ins from 1 st January to 30 th June 2018 were included. Patients’ pain assessment (severity of pain, types of pain) and treatment given for pain (including types of analgesia, prescriber, dosages administered) on their first encounter with PCU team would be reviewed from patients’ electronic medical records. Analysis were done using SPSS.

RESULTS: A total of 76 CKD patients were reviewed and the prevalence of pain was 18.4%, with mild pain of 7.9%, moderate pain of 6.6% and severe pain of 3.9%. There was a paucity of data on types of pain documented. About 80% of analgesia were initiated by the palliative team. The types of analgesia used for mild pain were mainly paracetamol, while moderate to severe pain were mainly prescribed opioid, mainly tramadol or fentanyl. Morphine, if prescribed, was whenever necessary.

CONCLUSION: The prevalence of pain among all adult CKD patients in PCU of Selayang Hospital was below the prevalence reported in other studies, at 38- 48%. This study highlighted the need to step up in pain recognition and assessment among CKD patients in Selayang Hospital. We hope with better pain management, this would improve the quality of life among CKD patients in PCU.

Erector Spinae Plane (ESP) Block Catheter Technique as Analgesic Adjunct in Traumatic Rib Fractures in Intensive Care Units: A Report Of 2 Cases

Beh Zhi Yuen1, Lim Siu Min1, Mohamad Fadhil Hadi Bin Jamaluddin1, Siew Gee Ho1, Marzida Binti Mansor1

1 University Of Malaya/ Malaysia

INTRODUCTION: Traumatic rib fractures are painful. Inadequate pain control would impair breathing, adequate coughing with clearance of pulmonary secretions and compliance with chest physiotherapy. Consequently, patient is at risk of secondary pulmonary complications, i.e. atelectasis, pneumonia, respiratory failure, and the need for respiratory support. Multimodal analgesia with opioid has been the mainstay of pain management. Analgesic adjuncts like thoracic epidural, paravertebral or intercostal blocks are advocated.

REPORT: Two patients sustained multilevel rib fractures with lung injury requiring close monitoring in intensive care unit (ICU) and non-invasive ventilatory support. They had received multimodal analgesia (IV paracetamol & parecoxib) with PCA morphine. They required high morphine usage (40- 70mg/24hrs) and still in severe pain, unable to perform chest physiotherapy. Thoracic epidural was not feasible due to high level rib fractures. Paravertebral blocks appeared difficult because patients were obese and equipment limitation. A novel regional technique - erector spinae plane (ESP) block was delivered using ultrasound guidance catheter technique at the most painful site. Patients’ opioid requirement reduced significantly next few days and they only required oxygen via nasal cannula upon discharge from ICU. Patient A had fractures of anterior and posterior right 1st rib, posterior right 2nd & 3rd rib with right pneumothorax, subcutaneous emphysema, pneumomediastinum and lung contusion. Patient B had left 1st-7th, 10th-11th ribs fractures, right 1st rib fracture, bilateral lung contusion and left haemothorax.

CONCLUSION: ESP block is a promising regional technique. It is a safe alternative in managing painful rib fractures as reported by other papers.

Correlated Factors with Neuropathic Pain Among Industrial Workers in Vietnam: A Multi-site Cross-sectional study

Bach Xuan Tran1, Tung Thanh Tran2

1 Hanoi Medical University, Vietnam 2 Nguyen Tat Thanh University, Vietnam

AIM OF INVESTIGATION: Neuropathic pain is a debilitating condition resulting from various etiologies such as diabetes, multiple sclerosis, and infection, and is associated with decreased quality of life, poor health outcomes, and increased economic burden. However, epidemiological studies on neuropathic pain have been largely limited in Vietnam.

MATERIALS AND METHODS: A cross-sectional study was conducted on adult Vietnamese industrial workers across three manufacturing plants. Demographic, socioeconomic, occupational and health data were collected. Prevalence of neuropathic pain was assessed using the Douleur Neuropathique 4 scale. Regression modeling was utilized to identify predictors of pain.

RESULTS: Among 287 workers, the prevalence of neuropathic pain was 1.0%. Living with a spouse/partner (coef. = 1.20; 95% CI 0.50 to 1.91), job experience (coef. = 0.03; 95% CI 0.01 to 0.06), prior medical conditions (coef. = 0.35; 95% CI 0.15 to 0.54), and exposure to hot temperatures (coef. = 0.63; 95% CI 0.15 to 1.11), low-light (coef. = 0.42; 95% CI 0.17 to 0.66), and toxic chemicals (coef. = 0.56; 95% CI 0.07 to 1.05) were associated with a higher score of neuropathic pain, while female gender (coef. = -0.38; 95% CI -0.46 to -0.30) was related to a lower score.

CONCLUSION: Neuropathic pain appears to be associated with several socioeconomic and occupational risk factors within a cohort of Vietnamese industrial workers. These results may inform the adoption of pain screening and other programs that increase health care access for this population, as well as more stringent occupational health and safety standards.

Correlation of HbA1c Level with Electrodiagnostic Parameters of Diabetic Autonomic Neuropathy (Sympathetic Skin Response and Interval R-R Study)

Isnaini Ashar1

1 Universitas Gadjah Mada, Indonesia

AIM OF INVESTIGATION: To find the correlation coefficient between HbA1c levels and Sympathetic Skin Response (SSR) and R-R intervals.

MATERIALS AND METHODS: A cross sectional study, the subjects are DM patients in the neurology clinic of Dr. Sardjito Yogyakarta Hospital who met the inclusion and exclusion criteria. The HbA1c levels, examination of SSR latency and amplitude and R-R interval at lower extremities were assessed. The correlation between HbA1c levels, demographic and laboratory variables with SSR latency, SSR amplitude and R-R interval are tested with Pearson/Spearman correlation test followed by linear regression test.

RESULTS: There were 41 DM patients, mean levels of HbA1c 8.7±3.02%, mean SSR latency 2586.58±778.69 ms, mean SSR amplitude 0.51±0.61 mV, mean R- R interval ratio 0.96±0.28. The results of a significant bivariate correlation test are correlation of HbA1c with SSR latency r =0.312; p =0.047, HbA1c with R-R interval ratio r =0.-392; p =0.011, duration of DM with SSR latency r =0.524; p =0.000, duration of DM with SSR amplitude r = -0.444; p =0.003 and duration of DM with interval R-R ratio r =-0.320; p =0.041. In the multivariate test, duration of DM correlated significantly with SSR latency with B =0.417; p =0.008 and SSR amplitude with B =-0.351; p =0.021, for HbA1c with SSR latency B =0.175; p =0.248 and for HbA1c with the R-R interval ratio B =-0.298; p =0.063.

CONCLUSION: Both of HbA1c and duration of DM are positively correlated with SSR latency, and negatively correlated with the R-R interval

High Opioid Dose Escalation to 100 And 200 Mg Per Day in Patients with Long Term Opioid Therapy: Sex Difference

Che Suraya Zin1

1 International Islamic University Malaysia, Malaysia

AIM OF INVESTIGATION: This study examined the relationship between sex difference and opioid dose escalation in patients with long-term opioid therapy

MATERIALS AND METHODS: This retrospective cohort study was conducted at tertiary hospital settings in Malaysia using electronic prescription records. Patients with long-term opioid therapy of ≥90 days of opioid prescriptions with at least one opioid prescription (buprenorphine, morphine, oxycodone, fentanyl, dihydrocodeine and tramadol) between 1st January 2011, and 31st December 2016 were included. Follow-up was started from patients’ first opioid prescription until discontinuation of therapy, death from any cause or the end of the study period, with no interval of 120 days between the successive. The risk of dose escalation was measured using a Cox proportional hazard model analyzed using Stata v15.1

RESULTS: A total of 4688 patients with long-term opioid therapy were identified. Of these, 248 (5.29%) escalated to high opioid doses of ≥100mg/day and 69 (1.47%) escalated to ≥200mg/day. The median time at risk to reach ≥100 and ≥200 mg/day was 126 days for men and 162 days for women. After adjusted for age, men were more likely than women to be escalated to high-dose opioid therapy of ≥100 mg/day (adjusted hazard ratio 2.32; 95% CI 1.79 to 3.00, p<0.0001) and ≥200 mg/day (adjusted hazard ratio 6.10; 95% CI 3.39 to 10.98, p<0.0001).

CONCLUSION: The risk of opioid dose escalation was different between men and women in which men are at higher risk than women for escalation to high- dose opioid therapy.

Characteristics of Mixed Pain Patients in Dr. Zainoel Abidin Hospital Banda Aceh, Indonesia

Dessy Rakhmawati Emril1, Oktavia Widyasari Harahap1, Saiful Basri1

1 Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia/ Indonesia

AIM OF INVESTIGATION: To determine the characteristics of mixed pain patients in dr. Zainoel Abidin Hospital Banda Aceh.

MATERIALS AND METHODS: This study is a descriptive analytic study using primary data in the form of interviews of mixed pain patients who meet the inclusion criteria in dr. Zainoel Abidin Hospital Banda Aceh from November to December 2017.

RESULTS: A total of 112 pain patients were successfully interviewed. Based on the total number of patients entering the study criteria, the proportion of 70.5% mixed pain was found. The majority of patients were women (62.0%), 60.8% were between 40-60 years old, while history of lower back pain was the most diagnosis (79.7%). Moderate Pain Intensity was the most frequent (62.0%) followed by severe and mild pain 22,8% and 15. 2% respectively. Period of neuropathic pain was more dominant (79.7%), pain was more severe at night ( 65.8%). The pain DETECT (mean score : 21.74) refer to neuropathic pain in 42 patients (53,25%) and 46.8% had ambiguous result (mean score : 15.32%). Radiating pain was 97.5%, while 27 % of patients had a daily different of occurrence between neuropathic and nociceptive pain.

CONCLUSION: Neuropathic pain is the dominant pain. Pain is more severe at night. There are daily time different of occurrence between neuropathic pain and nociceptive pain in the same mixed pain patients.

Association of Pain Intensity and Sleep Quality in Low Back Pain and Chronic Migraine

Raden Ajeng Dwi Pujiastuti1, Yuneldi Anwar1, Nirwan Sembiring1

1 Universitas Sumatera Utara/ Indonesia

AIM OF INVESTIGATION: The aim of this study was to report sleep quality in low back pain and chronic migraine patients and to examine whether pain intensity associated with sleep quality among these patients

MATERIALS AND METHODS: This study was a cross-sectional study taken from March to May 2018 in Adam Malik General Hospital and other teaching hospitals in Medan, Sumatera Utara. Subjects were patients with low back pain and chronic migraine in outpatient department with inclusion and exclusion criteria. We used Pittsburgh Sleep Quality Index (PSQI) to measure the sleep quality and Numerical Rating Scales (NRS) to measure the pain intensity.

RESULTS: Total subjects were 42 patients divided into 2 groups, 21 subjects with low back pain and 21 chronic migraine. Both groups showed higher prevalence of poor sleep quality (>80%). In low back pain group, pain intensity were moderate and severe pain and we analyzed the association with sleep quality (Chi-Square) we found that there was no significant result with p=0.276 (p>0.05). While in chronic migraine, pain intensity were distributed into mild, moderate and severe pain. The result was no significant association found between pain intensity and sleep quality p=0.299 (p>0.05).

CONCLUSION: Sleep disorders were frequently correlated with pain. Most people suffered with chronic pain also suffered from sleep disorders. In this study, most of the subjects in both groups reports poor sleep quality, however we did not find significant association between pain intensity and sleep quality (p>0.05).

Paravertebral Block as Surgical Anaesthesia for Video Assisted Thoracoscopy and Lung Biopsy in High Risk Patient A Case Report

Beh Zhi Yuen1, Kevin Ng Wei Shan1, Ahmad Shafwan Bin Abdullah1, Noorjahan Haneem Binti Md Hashim1, Sivakumar Krishnasamy1

1 University Of Malaya/ Malaysia

INTRODUCTION: Truncal block as primary anaesthetic technique for chest wall surgery are seldom reported. It is usually reserved for patients deemed at high risk for general anaesthesia and undergoing straightforward surgical procedures. According to literature, paravertebral block is the most reliable truncal block for surgical anaesthesia of thoracic wall surgery.

REPORT: A 42 year-old lady, ASA IV underwent right video-assisted thoracoscopy, lung biopsy and chest tube insertion. Patient has interstitial lung disease which is under investigations. She has severe pulmonary hypertension with PASP 70mmHg, poor effort tolerance NYHA III and metabolic equivalent (MET) less than 4. Her SpO2 under room air was 88%. She is taking inhalers salbutamol, budesonide, oral frusemide and spironolactone. Her HRCT thorax showed diffuse ground glass appearance, patchy consolidation and interlobular septal thickening all segments of lung. Ultrasound guided paravertebral blocks were performed using intercostal approach, in-plane needling technique, multiple injections at T4, T6 and T8 with ropivacaine 0.5% 10ml at each level. Patient received sedation TCI Propofol 0.5 mcg/ml and Dexmedetomidine infusion (0.2 – 0.5mg/kg/hour) during surgery. No further LA supplement required. During gas insufflation, patient had transient desaturation and hypotension requiring mask ventilation with CPAP and small doses of vasopressors. Her condition stabilised. She was put on non-invasive ventilator BIPAP for one night in the cardiothoracic intensive care unit (CICU), pain free and discharged home 6 days later.

CONCLUSION: This is a successful yet uncommon case of using ultrasound guided paravertebral blocks as surgical anaesthesia for high risk patient underwent thoracic wall surgery.

Gaucher's Disease

Nhoung Pheakdey1

1 Angkor Hospital For Children/ Cambodia

INTRODUCTION: Gaucher’s disease is a genetic disease in which a fatty substance (lipid) accumulates in cells and certain organs. It is caused by a hereditary deficiency of the enzyme glucocerebrosidase (acid beta glucosidase). Glucocerebroside can collect in the pleen, brain, lungs, kidneys and bone marrow. Clinical signs and symptoms: Painless hepatospleenomegalia, hypersplenism and pancytopenia (anemia, neutropenia, leucopenia and thrombocytopenia), severe pain associated with joints, bones, hips and knees, neurologic disorder (dementia, hypertonia) and yellowish brown skin pigmentation.

REPORT: A 10 year old boy had been sick 15 days with nasal discharge, low fever, sore throat, no vomiting, poor appetite. On the last 6 days the patient developed to poor urine output (1-2 times/d), both lower leg edema, poor urine, abdominal pain, weakness. He always presents in hospital with hematologic problem and hospitalized at AHC due to Hepatitis, Leukopenia, Anemia, and neutropenia. He is a 2nd child in family. On examination, he had weakness, dry, edema both lower legs, T 35.1, HR 94, RR 20, O2sat 98%, normal HEENT exam. No abnormal features were seen with cardiorespiratory and nervous systems. He has soft abdomen, hepatomegaly 2cm and splenomegaly1.5cm. He had edema on both lower legs and yellowish brown pigmentation skin. Laboratory results had microcytic anemia, thrombocytopenia, leukopenia and proteinuria.

CONCLUSION: Gaucher's disease is a rare case and had seen only one case in our hospital. Diagnosis was done with appropriated laboratory tests and discussion. This disease was treated with supportive care, supplementary vitamins and family explanation.

Establishment of Chronic Pain Services International Islamic University Malaysia Medical Centre (IIUMMC) Experience

Abdul Hadi Mohamed1, Abdul Hadi M1, Nor Zamzila A1 , Norliza O1 , Syazwani T1 , Norhasmira Z1 , Nurul Hafiza M.N1 , Siti Azura A1 , Norharyani M.R1 , Mohd Mahyuddin M.I. And Muhama1

1 IIUM/ Malaysia

INTRODUCTION: Chronic pain is a major public health problem that may cause serious stress on afflicted individuals and those in close relationship with them. It is associated with reduction in quality of life, poor psychological adjustment, disability, reduced income and high health care cost leading to great economical loss to the nation.

REPORT: Therefore, it is warranted that chronic pain should be appropriately managed at a designated facility. Unfortunately, such facility is very limited particularly in the East Coast of Malaysia. Limited expertise, man power, space, time, financial and resources are among the challenges faced during the establishment of such services. In order to gain support, the concept of multidisciplinary-approached chronic pain management should be first introduced to the hospital administrators, medical specialists and support staff. Once support is attained, this will facilitate the next step. Expert and technical training should be planned and executed tactfully as they have to be taken out of their comfort zone. At the International Islamic University Malaysia Medical Centre (IIUM MC), Multidisplinary Pain Management Services was established in 2016. It started with twice-a-week clinic and comprehensive pain intervention followed by intensive physiotherapy with only one pain specialist, a senior nurse, a medical assistant and a physiotherapist. The response was very encouraging, not only from IIUMMC but also from other hospital in Pahang and Terengganu.

CONCLUSION: We aim to include cognitive behavioural and group therapy in our future management. Hopefully, the establishment of this service will help to promote our centre towards achieving pain free hospital.