Developing consensus on core outcome sets of domains for acute, the transition from acute to chronic, recurrent/episodic, and chronic pain: results of the INTEGRATE-pain Delphi process

Harmonizing neuropathic pain research: outcomes of the London consensus meeting on peripheral tissue studies

ABSTRACT

Neuropathic pain remains difficult to treat, with drug development hampered by an incomplete understanding of the pathogenesis of the condition, as well as a lack of biomarkers. The problem is compounded by the scarcity of relevant human peripheral tissues, including skin, nerves, and dorsal root ganglia. Efforts to obtain such samples are accelerating, increasing the need for standardisation across laboratories. In this white paper, we report on a consensus meeting attended by neuropathic pain experts, designed to accelerate protocol alignment and harmonization of studies involving relevant peripheral tissues. The meeting was held in London in March 2024 and attended by 28 networking partners, including industry and patient representatives. We achieved consensus on minimal recommended phenotyping, harmonised wet laboratory protocols, statistical design, reporting, and data sharing. Here, we also share a variety of relevant standard operating procedures as supplementary protocols. We envision that our recommendations will help unify human tissue research in the field and accelerate our understanding of how abnormal interactions between sensory neurons and their local peripheral environment contribute towards neuropathic pain.

A core outcome set of measurement instruments for assessing effectiveness and efficacy of perioperative pain management: results of the international IMI-PainCare PROMPT Delphi consensus process

BACKGROUND

Effective perioperative pain management is crucial to prevent patient suffering, delayed recovery, chronic postsurgical pain, and long-term opioid use. However, the heterogeneous use of outcomes in studies complicates evidence synthesis and might not accurately reflect the experiences of individual patients. We initiated a consensus process to establish a core outcome set (COS) of patient-reported outcome measures (PROMs) in postoperative pain, building upon the earlier consensus on a COS of domains.

METHODS

Potential PROMs were identified via systematic literature searches for the domains pain intensity (with subdomains at rest and during activity), physical function, self-efficacy, and adverse events, followed by appraisal of psychometric properties according to the COnsensus-based Standards for the selection of health Measurement INstruments methodology. Then, a consensus meeting was convened, followed by a Delphi process with an international, multiprofessional panel of stakeholders, including those with lived experience. A conclusive consensus meeting approved the final COS of PROMs.

RESULTS

The final COS consists of one unidimensional numerical rating scale for assessing pain intensity on average, worst pain intensity, pain intensity at rest, and procedure-specific pain intensity during activity; one unidimensional scale for pain interfering with activities in bed; one procedure-specific scale for assessing physical function; the IMI-PainCare PROMPT adaptation of the Arthritis Self-Efficacy Scale for assessing self-efficacy; and the IMI-PainCare PROMPT adaptation of the Opioid-Related Symptom Distress Scale for assessing adverse events.

CONCLUSIONS

Comprehensive use of a core outcome set will help harmonise outcome assessment, facilitate comparisons between studies, promote patient-centred research, and improve postoperative pain care.

Developing consensus on the most important equity-relevant items to include in pain research: a modified e-Delphi study

ABSTRACT

There is increasing recognition of the need for routine measurement and reporting of data that can reveal social factors that contribute to health inequities for people with pain. Prioritising what data to collect and understanding how to collect it can be challenging, and no clear guidance exists. We conducted a 3-round Delphi study to develop consensus on the most important items to include in a minimum dataset of equity-relevant variables. An international panel of experts and interest-holders were invited to participate based on expertise in pain, social determinants of health and health equity, or a lived experience of persistent pain. In round 1, 168 participants rated the importance of an initial set of 43 equity-relevant items and categorised them according to the PROGRESS-Plus Framework. Twenty-nine items reached agreement for inclusion (based on a threshold of panel median of ≥7 of 9); none of the items were excluded. Participant comments were collated, and 21 new items were proposed. In round 2, 152 participants (90% of round 1) voted on 35 items, 25 of which reached agreement for inclusion. In round 3, 142 participants (93% of round 2) prioritised the 54 items that reached the threshold for inclusion within each category and rated the PROGRESS-Plus category importance. Our results indicated consistent agreement that it is important to collect data on a wide range of social factors and provide rich data to inform the development of a consensus-derived, globally applicable, "minimum dataset" that will be recommended for routine use in all human pain research.

Pain and physical function are common core domains across 40 core outcome sets of musculoskeletal conditions: a systematic review

OBJECTIVES

To determine common domains across existing musculoskeletal core outcome sets (COSs). Secondary aims were to assess the development quality of existing musculoskeletal COSs and whether development quality and patient participation was associated with domain selection.

STUDY DESIGN AND SETTING

A systematic review of musculoskeletal COSs. We searched six databases from inception until December 2023. Studies were included if they reported on the development of a COS in adults with musculoskeletal conditions for any type of intervention. Quality was assessed using the Core Outcome Set-Standards for Development recommendations (COS-STAD). Data extracted included scope of the COS, health condition, interventions, and outcome domains. We defined a common core domain when present in >66% of all COSs. Analyses were performed using descriptive statistics.

RESULTS

We included 51 studies reporting on 40 COSs, 25 were developed for research settings only, five for clinical settings only, and 10 for both. We identified 310 domains consisting of 255 mandatory or compulsory or not specified, 45 important, and 10 for further research. Pain (90%) and physical function (88%) were common core domains. COS development quality varied (range: 4-11 recommendations met); six COS met all standards. Domain definitions were provided in 13 COSs, 27 included patients or representatives in their development process, while nine met all recommendations for the consensus process. COSs involving patients were of higher quality (median: nine vs five for those not involving patients).

CONCLUSION

Pain and physical function core domains should be considered for inclusion in all new musculoskeletal COSs. Developers should follow COS development recommendations and include patients or their representatives.

Enhancing the trustworthiness of pain research: A call to action

The personal, social and economic burden of chronic pain is enormous. Tremendous research efforts are being directed toward understanding, preventing, and managing chronic pain. Yet patients with chronic pain, clinicians and the public are sometimes poorly served by an evidence architecture that contains multiple structural weaknesses. These include incomplete research governance, a lack of diversity and inclusivity, inadequate stakeholder engagement, poor methodological rigour and incomplete reporting, a lack of data accessibility and transparency, and a failure to communicate findings with appropriate balance. These issues span pre-clinical research, clinical trials and systematic reviews and impact the development of clinical guidance and practice. Research misconduct and inauthentic data present a further critical risk. Combined, they increase uncertainty in this highly challenging area of study and practice, drive the provision of low value care, increase costs and impede the discovery of more effective solutions. In this focus article, we explore how we can increase trust in pain science, by examining critical challenges using contemporary examples, and describe a novel integrated conceptual framework for enhancing the trustworthiness of pain science. We end with a call for collective action to address this critical issue. PERSPECTIVE: Multiple challenges can adversely impact the trustworthiness of pain research and health research more broadly. We present ENTRUST-PE, a novel, integrated framework for more trustworthy pain research with recommendations for all stakeholders in the research ecosystem, and make a call to action to the pain research community.

Pyoderma gangrenosum refined elements for core item selection and evaluation (PRECISE-PG): a study protocol for reaching consensus on core outcome domain items in clinical trials of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a debilitating inflammatory skin condition characterized by painful, necrotic ulcers, significantly impairing patient quality of life. The variability in clinical outcomes and the lack of standardized treatment protocols challenge effective PG clinical management and research. The Understanding Pyoderma Gangrenosum, Review and Assessment of Disease Effects (UPGRADE) project seeks to address this gap by establishing a core outcome set (COS) for PG clinical trials. UPGRADE has reached consensus on three core outcome domains: Pain, Quality of Life, and Clinical Signs. Here we describe a protocol detailing the next steps of UPGRADE's COS development to employ an international multistakeholder modified Delphi consensus process to reach consensus on the content of each core domain through the identification and definition of core domain-specific domain items. The process outlined in this protocol will involve generating domain items from the existing literature, refining these items through iterative e-Delphi surveys, and finalizing them in a consensus meeting. This work will enhance the granularity of these domains and facilitate more precise outcome measurement in clinical trials. The development of these detailed domain items is crucial for standardizing outcome reporting across PG trials, thereby improving research quality and enabling better treatment strategies, ultimately enhancing patient outcomes.

Heterogeneity in Pancreatitis: Recognizing Heterogeneity and Its Role in the Management of Pancreatitis Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

ABSTRACT

Both the clinical management and study of recurrent acute pancreatitis and chronic pancreatitis are complicated by significant heterogeneity in the etiology, mechanisms, symptoms, and complications of pancreatitis. The National Institutes of Diabetes and Digestive and Kidney Disease recently convened a workshop to address current knowledge and knowledge gaps in the field. Preclinical models that better replicate human disease are important for development of new therapies. Pain is often the most common and most difficult symptom to treat, as the causes are multifactorial and effective treatment may vary depending on whether pain is neuropathic or nociceptive in origin, and the placebo effect can complicate evaluation of the efficacy of medical and procedural interventions. Novel technologies like functional magnetic resonance imaging and virtual reality may offer novel means for assessing and treating pain, respectively. Clinical trial designs will need to consider best approaches to addressing the heterogeneity of chronic pancreatitis, including careful attention to designing eligibility criteria, and establishing accepted and validated core outcomes criteria for the field. The latter may be informed by consensus in pain research. Recruitment of participants into clinical trials has been challenging, often requiring multiple centers. Establishment of a clinical trials network would facilitate greater opportunities for therapeutic trials in pancreatitis.

Development of a Core Outcome Set of Domains to Evaluate Acute Pain Treatment After Lumbar Spine Surgery: A Modified Delphi Study

BACKGROUND

After lumbar spine surgery, a Core Outcome Set (COS) for acute pain is essential to ensure that the most meaningful outcomes are monitored consistently in the perioperative period. The aim of the present study was to consent on a COS for assessing the efficacy of acute pain management for patients undergoing lumbar spinal surgery.

METHOD

A modified Delphi procedure was conducted among a national (Dutch) expert panel. External endorsement of the final COS was conducted among an international panel of anaesthesiologists and the Dutch chronic pain patient association.

RESULTS

A panel of 35 experts representing 10 stakeholder groups, including orthopaedic surgeons, anaesthesiologists, patient representatives, physician assistants, researchers, a neurosurgeon, nurses, and a psychologist, took part in the Delphi procedure. Five outcome domains reached consensus for inclusion in this COS. This COS contains the following domains: pain intensity, analgesic use, early mobilisation, length of stay, and adverse events. Of an international panel of 27 key opinion leaders, 77% agreed on the final COS. The patient association also consented to the final COS.

CONCLUSIONS

A COS to evaluate acute pain treatment after lumbar surgery is proposed after national Delphi consensus rounds and (international) external endorsement. Future research should focus on determining suitable measurement instruments, assessing feasibility, validation, and implementation of the COS in daily clinical practice and research.

SIGNIFICANCE

This research proposes a clinically relevant spine-specific core outcome set (COS) of domains focusing on the acute postoperative phase (until 30 days). This is the first COS for evaluation of acute pain after lumbar spine surgery.

The comparative effectiveness of medicinal cannabis for chronic pain versus prescription medication treatment

ABSTRACT

Reviews of the effectiveness of medicinal cannabis for chronic pain vary in their conclusions. IASP has identified that a key missing evidence in this debate is data from observational cohort studies, analyzed with comparative effectiveness methods. In a medically supervised context to the use of marijuana for chronic pain, we identified 440 patients certified for medical marijuana by pain specialists in a single healthcare system. They were characterized by a battery of patient-reported outcomes stored electronically in the University of Pittsburgh Patient Outcomes Repository for Treatment (PORT). At 3 months, 38.6% were responders, based on clinically meaningful improvements in pain, function, or global impression of change, and maintained this response at 6 months. In the 157 patients who were coprescribed opioids, at 6 months there was a mean 39.3% decrease in morphine milligram equivalents (P < 0.05 for the difference vs baseline). In addition, 8114 patients treated in the same pain clinics with prescription pain medications instead (nonopioid or opioid) during the same timeframe were selected from PORT as a control group for comparison. They had a 34.9% rate of response at 3 months. Using the causal inference method of stratified modeling, logistic regression revealed an odds ratio of 2.6 in favor of medical marijuana vs medication treatment (P < 0.01). Potential harms data were not available in the PORT registry. Medical marijuana was comparatively more effective than prescription medications for the treatment of chronic pain at 3 months, although the populations compared were slightly different.

The overlooked burden of persistent physical symptoms: a call for action in European healthcare

Regardless of their cause, persistent physical symptoms are distressing somatic complaints that occur on most days for at least several months. They are common in patients with somatic diseases, functional somatic disorders, mental disorders, and undiagnosed medical conditions and are often associated with significant impairment and medical costs. Despite their prevalence and impact, persistent physical symptoms are often overlooked in medical care. This Personal View stresses the importance of recognising persistent physical symptoms as a European health issue. It advocates improvements in research, clinical management, public health, and policy. Efforts should prioritise integrating models of symptom perception and biopsychosocial perspectives into medical care and education, fostering interdisciplinary collaboration, and developing standardised guidelines to enhance patient care, reduce stigma, and improve clinical outcomes. Increased research funding can accelerate progress in understanding and effectively managing persistent physical symptoms. Addressing these priorities will support patients and healthcare professionals, ensuring adequate care and a higher quality of life for affected individuals.

A systematic literature review on patient-reported outcome domains and measures in nonsurgical efficacy trials related to chronic pain associated with endometriosis: an urgent call to action

ABSTRACT

Endometriosis, a common cause for chronic pelvic pain, significantly affects quality of life, fertility, and overall productivity of those affected. Therapeutic options remain limited, and collating evidence on treatment efficacy is complicated. One reason could be the heterogeneity of assessed outcomes in nonsurgical clinical trials, impeding meaningful result comparisons. This systematic literature review examines outcome domains and patient-reported outcome measures (PROMs) used in clinical trials. Through comprehensive search of Embase, MEDLINE, and CENTRAL up until July 2022, we screened 1286 records, of which 191 were included in our analyses. Methodological quality (GRADE criteria), information about publication, patient population, and intervention were assessed, and domains as well as PROMs were extracted and analyzed. In accordance with IMMPACT domain framework, the domain pain was assessed in almost all studies (98.4%), followed by adverse events (73.8%). By contrast, assessment of physical functioning (29.8%), improvement and satisfaction (14.1%), and emotional functioning (6.8%) occurred less frequently. Studies of a better methodological quality tended to use more different domains. Nevertheless, combinations of more than 2 domains were rare, failing to comprehensively capture the bio-psycho-social aspects of endometriosis-associated pain. The PROMs used showed an even broader heterogeneity across all studies. Our findings underscore the large heterogeneity of assessed domains and PROMs in clinical pain-related endometriosis trials. This highlights the urgent need for a standardized approach to both, assessed domains and high-quality PROMs ideally realized through development and implementation of a core outcome set, encompassing the most pivotal domains and PROMs for both, stakeholders and patients.

Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society

BACKGROUND

Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients.

METHODS

We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals.

RESULTS

We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain.

CONCLUSIONS

We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

Systematic reviews and quality assessment of patient-reported outcome measures for physical function in comparative effectiveness studies regarding acute postoperative pain after total knee arthroplasty-Do we need to start all over again?

BACKGROUND AND OBJECTIVE

Recently, a consensus process specified a core outcome set (COS) of domains to be assessed in each comparative effectiveness research and clinical practice related to acute postoperative pain. Physical function (PF) was one of these domains. The aim of this review was to investigate which patient-reported outcome measures (PROMs) are used to assess PF after total knee arthroplasty (TKA) in clinical trials and if they fulfil basic requirements for a COS of PROMs based on their psychometric properties.

METHODS

A systematic review of randomized controlled trials and observational studies based on a search in MEDLINE, EMBASE and CENTRAL was undertaken. PROMs and performance measures were extracted and investigated, including evaluation of psychometric properties of PROMs based on COSMIN recommendations.

RESULTS

From initially 2896 identified records, 479 studies were included in the qualitative synthesis. Only 87 of these trials (18%) assessed PF using PROMs, whereas especially performance outcome measures were used in 470 studies (98%). Application of the 'COSMIN Risk-of-Bias-Box 1' to 13 of the 14 identified PROMs resulted in insufficient content validity of the included PROMs regarding the target population based on the inauguration or development articles.

CONCLUSION

Our data indicate that a patient-centred postoperative assessment of PF in pain-related clinical trials early after TKA is not common, even though patient-reported assessment is widely recommended. In addition, none of the applied PROMs shows content validity based on their inauguration or development articles for the assessment of postoperative pain-related PF after TKA.

SIGNIFICANCE

A systematic search for patient-reported outcome measures assessing postoperative, pain-related physical function after total knee arthroplasty in clinical trials and assessment of their content validity revealed none that fulfilled requirements based on COSMIN recommendations.