Interpretation of chronic pain clinical trial outcomes: IMMPACT recommended considerations

A Semi-structured Interview Predicts Spinal Cord Stimulator Implantation in Patients with Chronic Pain

Pre-surgical psychological evaluations (PSPE) are required during the spinal cord stimulator (SCS) implantation process, but there is no standard protocol for SCS PSPE. In this study, we assessed the concurrent and predictive validity of the Stanford Integrated Pyschosocial Assessment for Transplantation (SIPAT) compared with patient-reported measures and election for SCS implantation. This study used prospectively collected data at the time of PSPE from N = 222 patients at a Midwestern academic medical center. We collected SIPAT scores and Patient-Reported Outcome Measurement Information Systems (PROMIS) scores, and recorded receipt of permanent SCS implantation as a binary (yes/no) outcome. The SIPAT correlated with patient-reported outcomes of Anxiety, Depression, Fatigue, Sleep, and Pain Interference in the expected direction. The SIPAT was a significant predictor of election for permanent SCS implantation when accounting for age and pain diagnosis, such that individuals with higher SIPAT scores were less likely to elect for surgery. Exploratory analyses showed that the SIPAT Patient Readiness subscale and patient-reported Anxiety and Depression PROMIS scales correlated with election for SCS surgery. Results of this study demonstrated validity of the SIPAT in a novel population, patients with chronic pain referred for SCS implantation.

A pre-, peri- and postoperative rehabilitation pathway for lumbar fusion surgery (REACT): a nonrandomized controlled clinical trial

PURPOSE

To evaluate the effectiveness of an evidence-based pre-, peri- and postoperative rehabilitation pathway (i.e. the REACT rehabilitation pathway) on disability in patients undergoing lumbar fusion surgery (LFS), compared to usual care.

METHODS

A prospective, nonrandomized controlled trial included 72 patients scheduled for one- or two-level LFS for degenerative conditions or adult isthmic spondylolisthesis. Participants were allocated to usual care (N = 36) or the REACT rehabilitation pathway (N = 36). The REACT rehabilitation pathway includes prehabilitation, early mobilization and avoidance of unsubstantiated postoperative restrictions, early postoperative physiotherapy, patient empowerment, case manager guidance, and support towards an early return to activity. The primary outcome was disability; key secondary outcomes were back and leg pain intensity, and return-to-work rate. Additional secondary outcomes included fear of movement, pain catastrophizing, negative emotional states, sit-to-stand performance, analgesic use, length of stay, and adverse events. Data were collected preoperatively and at five time points up to one year postoperatively.

RESULTS

Participants in the REACT group demonstrated significantly greater improvements in disability (p = 0.003), back pain intensity (p = 0.007), and return-to-work rates (88% vs 56%, p = 0.34) compared to the control group. The REACT group also showed greater improvements in fear of movement (p = 0.038), pain catastrophizing (p < 0.001), combined negative emotional states (p = 0.007), sit-to-stand performance (p = 0.021), and reduced analgesic use (p = 0.001). No significant differences were observed in leg pain intensity (p = 0.042), length of hospital stay (p = 0.095) or adverse events (p = 1.00).

CONCLUSION

The REACT rehabilitation pathway significantly reduced disability in the first postoperative year after LFS compared to usual care. The most promising result is the significantly higher return-to-work rate in the REACT group.

Cyclic sighing in the clinic waiting room may decrease pain: results from a pilot randomized controlled trial

Pain is a common medical experience, and patient access to pain management could be improved with novel intervention formats. Emerging evidence indicates brief, asynchronous, single-session interventions delivered in the clinic waiting room can improve patient outcomes, but only a few treatment modalities have been investigated to date. Breathwork is a promising approach to managing acute clinical pain that could be delivered asynchronously in the clinic waiting room. However, the direct impact of a breathwork intervention (e.g., brief cyclic sighing) on patients' pain and psychological distress (e.g., anxiety and depression symptoms) while waiting in the clinic waiting room remains unexamined. This single-site, pilot, randomized controlled trial examined the impact of a 4-minute, asynchronous, cyclic sighing intervention on participants' acute clinical symptoms in the x-ray waiting room of a walk-in orthopedic clinic relative to a time- and attention-matched injury management control condition. Pain unpleasantness, pain intensity, anxiety symptoms, and depression symptoms were measured in the study. Participants receiving the cyclic sighing intervention reported significantly less pain unpleasantness and pain intensity while waiting for an x-ray relative to controls. Anxiety symptoms and depression symptoms were not found to differ by condition. Results from this RCT indicate a brief, asynchronous, cyclic sighing intervention may be capable of quickly decreasing pain in the waiting room. Continued investigation is now needed to determine if embedding brief, asynchronous, cyclic sighing interventions in clinic waiting rooms has the potential to help people experiencing acute pain feel better faster. CLINICAL TRIAL REGISTRATIONS: NCT06292793.

Pretreatment TMS-EEG connectivity assessment as a potential predictor of rTMS effectiveness in chronic pain: A feasibility pilot study

OBJECTIVE

Around half of chronic pain patients report pain intensity reduction to high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS) delivered to the primary motor cortex (M1). However, the other half do not respond, making it essential to identify which patients are likely to benefit before starting treatment. Combining TMS with electroencephalogram (TMS-EEG) allows for exploring cortical connectivity, and evaluating this connectivity before administering rTMS may provide insights into which patients are likely to respond favorably to the treatment.

METHODS

Seven chronic pain patients underwent TMS-EEG assessment of M1 before ten daily sessions of 10 Hz rTMS. Pain intensity was measured at baseline and post-treatment, with responders defined as those showing a 30 % reduction on an 11-point numerical rating scale. TMS-evoked potentials were analyzed using the debiased weighted phase lag index to assess connectivity, quantified by phase (connections exceeding the 95 % confidence interval) and space (Euclidean distance between significantly connected EEG channels). Normative connectivity values were also collected from 82 healthy volunteers.

RESULTS

Four patients responded to M1 rTMS, while three did not, with an average pain intensity reduction of 1.4±1.5. TMS-EEG showed low connectivity indices in all responders to rTMS, whereas two non-responders had higher indices, above the 75th percentile of healthy volunteers.

CONCLUSIONS

This pilot feasibility study showed that the use of TMS-EEG informed rTMS is feasible, and proceeding to larger randomized clinical trials will allow to test this approach.

SIGNIFICANCE

Pre-treatment TMS-EEG connectivity measures may identify rTMS responders, optimizing chronic pain management.

Scapular stabilization exercise on pain and functional recovery in people with shoulder impingement syndrome: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of scapular stabilization exercise training on pain and functional recovery in people with shoulder impingement syndrome. Design: A systematic review protocol was registered with PROSPERO. We systematically searched different databases. A random-effects model was used to determine the mean difference (MD) and 95% confidence interval (CI) for pain and functional recovery. Heterogeneity among studies was examined using the I2 statistic.

RESULTS

Fourteen studies (666 participants) were included in the analysis. Addition of scapular stabilization-based exercise training to general exercises reduce pain MD - 0.8 cm (95% CI, -1.07 to -0.4; I² = 0%) and improve the functional recovery and shoulder abduction range of motion MD -13.27 (95% CI, -16.85 to -9.69; I² = 5%) and MD 2.74 degrees (95% CI, 0.3 to 5.2; I² = 0%), respectively. However, the certainty of the evidence is low to very low. No significant differences in pain or functional recovery were found between participants in the scapular stabilization-based exercise training with the feedback group and those in the scapular stabilization-based exercise training without the feedback group.

CONCLUSION

Our findings are promising; however, higher quality RCT is needed to better establish the superiority of the rehabilitation programs that include scapular stabilization exercises.

Implementation of Pharmacist Driven Gabapentinoid Titration for Diabetic Peripheral Neuropathy in a Primary Care Setting

Previous studies suggest that patients with diabetic peripheral neuropathy (DPN) frequently do not receive the minimum effective doses of a gabapentinoid according to guidance from national organizations. There is opportunity to assess the implementation of pharmacist intervention for patients not meeting minimum effective gabapentinoid dosing for DPN. This prospective, single site quality improvement project was conducted at a primary care clinic and included patients with DPN prescribed a gabapentinoid by their primary care provider (PCP) at a dose lower than minimum effective dosing. Pharmacists assessed patient-reported pain ratings, adverse effects, and renal function for appropriate dosing and titrated to minimum effective dosing based on clinical judgment. All patients that were followed through week 13 had a clinically significant improvement in pain. No patients met a 50% reduction in patient-reported pain rating scales on guidance-directed minimum effective dosing. No patients were able to meet the minimum effective dose. The majority of patients declined pharmacist services due to neuropathy being controlled on the current gabapentinoid dose. This study supports the ability for pharmacists to assess patient specific factors for adequate dosing, titration, and deprescribing recommendations for analgesic medications in diabetic peripheral neuropathy.

Mindful Jazz and Preferred Music Interventions Reduce Pain Among Patients With Chronic Pain and Anxiety: A Pilot Randomized Controlled Trial

BACKGROUND

A mindfulness-based intervention (MBI) focused on listening to music might reduce chronic pain and provide a new approach to overcoming challenges from traditional MBIs (e.g., breathing). Due to the potential unpredictability and unfamiliarity of jazz, an MBI focused on listening to improvisational jazz music might be a particularly efficacious pain reduction intervention. This pilot study explores whether mindfully listening to music, including jazz, can reduce pain-related outcomes.

METHODS

Chronic musculoskeletal pain (CMP) participants (n=30 per group, N = 120 total) were enrolled online between 12/7/2023 and 2/8/2024. Participants were randomly assigned to one of four groups in a 2 (Mindful Music Listening/Intervention vs. Music Education/Control) X 2 (Preferred Music (choose their own music genre) vs Jazz (assigned to listen to improvisational jazz)) experiment, for a total of four groups (Mindful Jazz, Mindful Music, Jazz Education, and Music Education). Patients in each group were provided with training in either mindful listening to music (Intervention groups) or music education (Control groups) and given four sets of weekly recordings related to their group for daily listening/practice. Patients completed online surveys on pain-related outcomes (e.g., pain catastrophizing, pain intensity, and anxiety) pre- and post-training (immediate outcomes), and throughout a four-week period (longer-term outcomes). The main outcomes analyses compared the intervention and control groups, with secondary sub-analyses among participants who listened to at least 2/3 of their recordings (10 minutes), and among those who experienced a clinically meaningful (20%) reduction in pain.

RESULTS

Mindful Jazz and Mindful Music (Intervention) participants reported significantly less pain intensity (p < 0.001) and pain unpleasantness (p < 0.001) immediately after the training relative to the Jazz Education and Music Education (Control) participants. Mindful Jazz participants also reported a significant reduction in anxiety compared to the Jazz and Music Education groups (p < 0.05). Throughout the four-week period, Mindful Jazz participants reported less pain intensity relative to both control groups (Jazz and Music Education); Mindful Music participants reported significantly less pain intensity relative to only the Jazz Education participants. Mindful Jazz participants reported a >20% decrease in pain intensity more frequently than Jazz Education (Χ2=48.71, p<0.001), Music Education (Χ2=65.13, p<0.001), and Mindful Music (Χ2=8.74, p=0.003) participants. Similarly, among the instances when a participant listened to at least 10 minutes of their audio recording, the proportion who achieved a >20% decrease in pain intensity differed significantly ((Χ2=84.03, p<0.001): Jazz Education, 29%; Music Education, 26%, Mindful Jazz, 50%; Mindful Music 41%).

CONCLUSION

Mindfully listening to music can help to reduce pain-related outcomes. Both music education (i.e., music listening without mindfulness training) and mindfully listening to music (i.e., listening with mindfulness training) helped to decrease pain and anxiety from baseline to follow-up. However, mindful listening reduced pain to a greater amount compared to music education, suggesting that mindfully listening to music is a more impactful pain reduction intervention compared to listening without mindfulness training. Future research is warranted with a larger sample.

Estimating minimal important change of the National Institutes of health research task force impact score using computer adaptive measures: a secondary analysis of two randomized clinical trials in a military population with chronic pain

BACKGROUND

The National Institutes of Health (NIH) Research Task Force (RTF) on Research Standards for Chronic Low Back Pain impact score is a composite measure of Patient Reported Outcomes Measurement Information System (PROMIS) pain intensity, pain interference and physical function. PROMIS surveys are available in short-form and computer adaptive testing (CAT) formats. Minimal important change (MIC) can be estimated to determine if between-group differences are large enough to be important. To date, three anchor-based estimates of impact score MIC ranging from 3 to 7.5 have been published, and all were based on data collected using PROMIS short-form surveys. None used CAT versions of PROMIS surveys.

METHODS

Secondary analysis of data collected during the conduct of two randomized clinical trials of 6-week courses of nonpharmacological pain therapies. Research subjects were US active-duty service members referred to an interdisciplinary pain management center. Impact score was assessed at the beginning and end of treatment. The Patient Global Impression of Change (PGIC) questionnaire was administered at the end of treatment and asked respondents to report their status compared to the start of treatment using a 7-item categorical scale ranging from very much improved to very much worse. A PGIC response of "much" or "very much" improved defined important improvement. Receiver operating characteristic (ROC) curve analysis and predictive logistic regression models were used to estimate MIC for the full combined sample and stratified by study sample and baseline impact score. Measures of individual statistical change were also computed.

RESULTS

Overall, a decrease of 3 points in impact score was the estimated MIC (2.5 for ROC analysis and 3.4 for predictive modeling approach). Larger decreases in impact score were needed for participants with moderate and severe baseline pain impact to report important improvement. Thresholds for individual statistically significant change ranged from 6 to 14.

CONCLUSIONS

Using data collected with CAT surveys, we calculated an MIC of 3 points for the NIH RTF impact score, and estimates ranged from 1.3 to 7.2 depending on the baseline impact score and statistical approach used. These findings are consistent with previous MIC estimates that were based on non-adaptive short form surveys and have implications for improving the accuracy of pain treatment response assessment.

REGISTRY INFORMATION

Trial registration.

CLINICALTRIALS

gov. Registry numbers: NCT03297905 (registered 9/29/17) and NCT04656340 (registered 11/30/20). Link to full applications: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03297905?titles=Determinants+of+Optimal+Dosage%26cntry=US%26draw=2%26rank=1 ; https://classic.

CLINICALTRIALS

gov/ct2/show/results/NCT04656340?titles=Complementary+and+Integrative+pain+therapies+and+functional+restoration+%28IMPPPORT%29%26draw=2%26rank=1 . Patient enrollment dates: SMART: 17 March 2021, prospectively registered; IMPPPORT: 9 December 2015, retrospectively registered.

Evaluating Mirror Therapy Protocols in Phantom Limb Pain Clinical Trials: A Scoping Review

Mirror therapy is among the most widely used treatments for phantom limb pain. However, discrepancies exist in the way it is conducted, and its effectiveness varies widely. The aim of this scoping review was to evaluate the application of mirror therapy across the literature and to identify treatment features unique to studies with clinically significant pain reduction outcomes. Articles published until July 2024 were identified through a systematic search of the following electronic databases: Medline (via EBSCOhost), PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, PsycINFO (via EBSCOhost), Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), Africa-Wide Information (via EBSCOhost), and Scopus. Two reviewers independently conducted the screening of titles and abstracts, review of full-text articles, and data extraction. The results were analyzed descriptively. We included 32 studies in this review, 21 of which were deemed effective for achieving clinically significant pain reduction of 50% or 2 points on a 0-10 scale. There were inconsistencies in various treatment components including treatment setting, type of pre-treatment education, treatment technique, method of exercise delivery, treatment duration, and frequency of treatment sessions. Despite identifying common treatment features across studies with clinically significant pain reduction outcomes, we found no evidence of unanimous consensus in the literature towards any specific protocol for mirror therapy. Establishing a standardized treatment protocol could enhance the reliability and reproducibility of treatment outcomes in future studies and ensure a meaningful comparison between mirror therapy and other treatments in clinical trials and meta-analyses.

Pain Coping Skills Training for Patients Receiving Hemodialysis: The HOPE Consortium Randomized Clinical Trial

Importance

Chronic pain is common among individuals with dialysis-dependent kidney failure.

Objective

To evaluate the effectiveness of pain coping skills training (PCST), a cognitive behavioral intervention, on pain interference.

Design, Setting, and Participants

This multicenter randomized clinical trial of PCST vs usual care was conducted across 16 academic centers and 103 outpatient dialysis facilities in the US. Adults undergoing maintenance hemodialysis and experiencing chronic pain were randomly assigned to PCST or usual care in a 1:1 ratio. Participants were followed in the trial for 36 weeks. Enrollment began on January 4, 2021, and follow-up ended on December 21, 2023.

Interventions

PCST consisting of 12 weekly coach-led sessions via video or telephone conferencing, followed by 12 weeks of daily interactive voice response sessions. Usual care had no trial-driven pain intervention.

Main Outcomes

The primary outcome was pain interference measured with the Brief Pain Inventory (BPI) Interference subscale (score range of 0-10, with higher scores indicating more pain interference). Secondary outcomes included pain intensity, pain catastrophizing, quality of life, depression, and anxiety.

Results

A total of 643 participants (mean [SD] age, 60.3 [12.6] years; 288 [44.8%] female) were randomized, with 319 assigned to PCST and 324 assigned to usual care. At week 12 (primary end point), the PCST group had a larger reduction in the BPI Interference score than the usual care group (between-group difference, -0.49; 95% CI, -0.85 to -0.12; P = .009). The effect persisted at week 24 (between-group difference in BPI Interference score, -0.48; 95% CI, -0.86 to -0.11) but was diminished at week 36 (between-group difference in BPI Interference score, -0.34; 95% CI, -0.72 to 0.04). A decrease in BPI Interference score greater than 1 point (minimal clinically important difference) occurred in 143 of 281 participants (50.9%) in the PCST group vs 108 of 295 participants (36.6%) in the usual care group at 12 weeks (odds ratio, 1.79; 95% CI, 1.28-2.49) and 142 of 258 participants (55.0%) in the PCST group vs 113 of 264 participants (42.8%) in the usual care group at 24 weeks (odds ratio, 1.59; 95% CI, 1.13-2.24). Favorable changes with PCST were also apparent for secondary outcomes of pain intensity, quality of life, depression, and anxiety at weeks 12 and/or 24, as well as for pain catastrophizing at weeks 24 and 36.

Conclusions and Relevance

In this randomized clinical trial of patients undergoing maintenance hemodialysis, PCST had benefits on pain interference and other pain-associated outcomes. While the effect on the overall cohort was of modest magnitude, the intervention resulted in a clinically meaningful improvement in pain interference for a substantial proportion of participants.

Trial Registration

ClinicalTrials.gov Identifier: NCT04571619.

Evaluating Treatment Preferences and the Efficacy of Capsaicin 179 mg Patch vs. Pregabalin in a Randomized Trial for Postsurgical Neuropathic Pain in Breast Cancer: CAPTRANE

Background/Objectives: CAPTRANE evaluated the efficacy and tolerability of high-concentration capsaicin patch (HCCP) vs. oral pregabalin for the treatment of postsurgical neuropathic pain (PSNP) following breast cancer surgery. The study was designed with the aim of demonstrating noninferiority of one HCCP against daily pregabalin. Methods: This was a multicenter, randomized, parallel-arm, open-label study conducted across nine centers in France. The primary endpoint was a change from baseline in the Numeric Pain Rating Scale (NPRS) score after 2 months. Results: Recruitment challenges resulted in the randomization of 140 patients (versus 644 planned); the per-protocol population comprised 107 patients (HCCP: n = 65; pregabalin: n = 42). Baseline characteristics were similar between the two groups. In the per-protocol analysis, the mean (standard deviation) change versus baseline in NPRS score was -1.926 (2.554) with HCCP and -1.634 (2.498) with pregabalin. The prespecified analysis showed that HCCP was not inferior to pregabalin: the lower bound of the 90% confidence interval for the between-arm difference was -0.889 and the upper bound was +0.260 (i.e., below the predefined clinical threshold of +0.4). Patient-reported outcomes showed no statistically significant differences between treatments. The painful area size decreased significantly more with HCCP. Tolerability profiles differed, with HCCP mostly causing application-site reactions. While >50% of patients switched from pregabalin to HCCP, none switched from HCCP to pregabalin. Conclusions: This comparative study in PSNP post breast cancer surgery, evaluating a single treatment of HCCP, shows a noninferior reduction in pain intensity, a superior reduction in painful area size, and a patient preference for HCCP compared with pregabalin. Despite limitations, it contributes valuable initial data for PSNP management in breast cancer care.

Hypermobile type Ehlers-Danlos syndrome and generalized hypermobile spectrum disorder treatment preferences - a cross-sectional survey of patients

We aimed to assess the typical experiences, desired outcomes, satisfaction with clinical and anticipated outcomes, and the importance of improvements for individuals with Hypermobile Ehlers-Danlos Syndrome (hEDS) and Generalized Hypermobility Spectrum Disorder (G-HSD). A cross-sectional survey was conducted among adults aged 18 and above with hEDS and G-HSD. The survey included the Patient-Centered Outcome Questionnaire and an adapted version addressing common concerns in these individuals. Descriptive statistics were used for analysis. The survey received 483 responses with an 82% completion rate. Most respondents were females (90%), aged 21-30 (30%), living in North America (76%), and diagnosed with hEDS (80%). Participants diagnosed with hEDS reported higher typical levels of pain compared to those diagnosed with G-HSD and higher expected levels of pain and interference with daily activities post-treatment (p < 0.05). The areas of most significant concern were pain, fatigue, interference with daily activities, and walking issues. Our findings revealed no differences in how individuals from both groups rated their treatment expectations, except for the usual pain level and the expected pain level and interference with daily activities post-treatment. Patients' perspectives are essential for developing appropriate treatment plans and improving outcomes for this patient population. Our results will hopefully inform the development of new interventions to impact outcomes that matter to individuals with hEDS and G-HSD.

Clinical Efficacy of Virtual Reality Cave Automatic Virtual Environments (CAVE) for Chronic Musculoskeletal Pain in Older Adults: A Randomized Controlled Trial

OBJECTIVES

To assess whether tai chi assisted by the Cave Automatic Virtual Environment (CAVE), a novel virtual reality (VR) technology, was superior to tai chi alone in managing chronic pain in older adults. CAVE may offer a promising alternative to head-mounted displays in chronic pain treatment.

DESIGN

The study was a 12-week, 2-arm, parallel, randomized controlled trial implemented in VR and non-VR groups (N = 80, each arm = 40). The VR group underwent an 8-week tai chi program in a 3-wall VR-CAVE with projections of nature scenes and music, whereas the control group received tai chi only.

SETTING AND PARTICIPANTS

Community-dwelling older adults with chronic musculoskeletal pain were randomized (1:1) to VR and non-VR groups.

MEASURES

Participants were assessed at baseline, posttreatment at 8 weeks, and 12 weeks. The primary outcome was the Brief Pain Inventory severity score at 8 weeks, modeled within an intention-to-treat framework using generalized estimating equations.

RESULTS

Participants had a mean age of 65.1 ± 5.6 years, with 78.8% female and mean BPI-pain severity score of 4.4 ± 1.5. At 8 weeks, the VR group demonstrated a statistically significant improvement in BPI severity score compared with the non-VR group (β = -0.75, 95% CI -1.48 to -0.03, P = .043), with the effect sustained to 12 weeks (β = -1.18, 95% CI -1.90 to -0.46, P = .001). No major adverse events were reported.

CONCLUSIONS AND IMPLICATIONS

VR-CAVE tai chi was superior to non-VR tai chi for chronic musculoskeletal pain. Future trials that are longer-term, larger in scale, and include other forms of exercise will further inform VR-CAVE's role in post-acute and long-term rehabilitation.

Conceptualizing meaningful between-group difference in change over time: a demonstration of possible viewpoints

PURPOSE

Determining if group-level differences in health outcomes are meaningful has recently been neglected in favour of determining if individuals have experienced a meaningful change. We explore interpretation of a meaningful between-group difference (MBGD) in clinical outcome assessment scores, primarily in the context of randomized clinical trials.

METHODS

We constructed a series of possible 'viewpoints' on how to conceptualize MBGD thresholds. Each viewpoint is discussed critically in terms of potential advantages and disadvantages, with simulated data to facilitate their consideration.

RESULTS

Five viewpoints are presented and discussed. The first considers whether thresholds for meaningful within-individual change over time can be equally applied at the group-level, which is shown to be untenable. Viewpoints 2-4 consider what would have to be observed in treatment groups to conclude a meaningful between-group difference has occurred, framed in terms of the proportion of patients perceiving that they had meaningfully improved. The final viewpoint considers an alternative framework where stakeholders are directly questioned on the meaningfulness of varying magnitudes of between-group differences. The choice of a single threshold versus general interpretative guidelines is discussed.

CONCLUSION

There does not appear to be a single method with clear face validity for determining MBGD thresholds. Additionally, the notion that such thresholds can be purely data-driven is challenged, where a degree of subjective stakeholder judgement is likely required. Areas for future research are proposed, to move towards robust method development.

Trigger point injections for myofascial pain in terminal cancer: a randomized trial

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of a single trigger point injection (TPI) of a local anesthetic for the treatment of myofascial pain syndrome (MPS) in patients with incurable cancer.

METHODS

This multicenter, exploratory, open-label, randomized comparative trial was conducted in five specialized palliative care departments. Hospitalized patients with incurable cancer who had been experiencing pain related to MPS were randomized to receive either a TPI of 1% lidocaine plus conventional care (TPI group) or conventional care alone (control group). The short-term efficacy and occurrence of adverse events (AEs) were compared between groups. The primary endpoint was the percentage of patients who experienced a reduction in pain scores of ≥50%, assessed using an 11-point Numerical Rating Scale, at 3 days post-intervention. Adverse events were assessed using the Common Terminology Criteria for AEs v5.0.

RESULTS

Fifty patients were enrolled, and the trial completion rate was 100%. The proportion of patients who experienced an improvement in Numerical Rating Scale pain scores of ≥50% was 70.8% (95% confidence interval, 52.4%-89.2%) in the TPI group and 0.0% in the control group; the difference was statistically significant (P < .001). In the TPI group, one case (4.2%) of Grade 1 nausea and 1 case (4.2%) of Grade 1 somnolence were reported.

CONCLUSION

A single TPI of a local anesthetic is safe and efficacious in inducing an immediate reduction in MPS-related pain in patients with incurable cancer. Clinical trials registration number: This study was registered with the Japan Registry of Clinical Trials (approval number: jRCTs051210132) on December 16, 2021. https://jrct.niph.go.jp/en-latest-detail/jRCTs051210132.Approval of the research protocol by a Certified Review Board: The present study was approved by the Wakayama Medical University (reference number: CRB5180004. Registered 26 May 2021).

Clinical proof-of-concept results with a novel TRPA1 antagonist (LY3526318) in 3 chronic pain states

ABSTRACT

Transient receptor potential ankyrin 1 (TRPA1) is implicated in physiological and pathological nociceptive signaling, but the clinical benefit of TRPA1 antagonists in chronic pain is not clearly demonstrated. LY3526318 is an oral, potent, and selective novel TRPA1 antagonist. The Chronic Pain Master Protocol was used to evaluate the safety and efficacy of LY3526318 in 3 randomized, placebo-controlled, proof-of-concept studies in knee osteoarthritis pain (OA), chronic low back pain (CLBP), and diabetic peripheral neuropathic pain (DPNP). Participants were randomized (1:2, placebo:LY3526318, 250 mg daily) into an 8-week double-blinded period. At 4 weeks, participants treated with LY3526318 transitioned to a placebo. The primary endpoint was the self-reported daily pain intensity measured using a Numerical Rating Scale (NRS) at 4 weeks. All endpoints were collected for up to 8 weeks. Change from baseline in average weekly NRS was analyzed using Bayesian mixed model repeated measures in the OA (N = 160), CLBP (N = 159), and DPNP (N = 154) studies. Baseline characteristics were balanced between treatment arms. Mean NRS change from baseline to week 4 did not differ significantly between placebo and LY3526318; however, a numerical improvement was observed in the CLBP, not in the OA or DPNP populations. Safety analysis integrated across studies enhanced understanding of the safety profile of LY3526318. LY3526318 showed a potential drug-induced hepatotoxic effect posing a risk for clinical development. No other safety signals were identified. LY3526318 showed potential for different responses among chronic pain indications and patient subpopulations, highlighting challenges in developing TRPA1 antagonists but supporting their value as a target in managing chronic pain.

Peripheral Nerve Stimulation for Chronic Neuropathic Pain: A Health Technology Assessment

Background

Chronic neuropathic pain is a major health problem that adversely affects people's physical and mental well-being, as well as their quality of life. Percutaneous peripheral nerve stimulation (PNS) may offer a minimally invasive option earlier in the treatment continuum for adults with chronic neuropathic pain that is refractory to conventional medical management. We conducted a health technology assessment of PNS for adults with chronic neuropathic pain, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding PNS, and patient preferences and values.

Methods

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool for randomized controlled trials and the Risk of Bias in Non-randomized Studies - of Interventions for observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-utility analysis with a 3-year horizon from a public payer perspective. We also analyzed the budget impact of publicly funding PNS in adults with chronic neuropathic pain in Ontario. To contextualize the potential value of PNS, we spoke to people with chronic pain, and to care partners of patients with chronic pain.

Results

We included 17 publications (2 randomized controlled trials and 12 nonrandomized studies) in the clinical evidence review. These studies included chronic neuropathic pain in the trunk and the upper and lower extremities. Compared with placebo controls in adults with chronic neuropathic pain that is refractory to conventional medical management, permanent PNS likely decreases pain scores, likely improves functional outcomes, and likely improves health-related quality of life, but it has little to no effect on the use of pain medications (all GRADEs: Moderate). Compared with before implantation in adults with chronic neuropathic pain, permanent PNS may decrease pain scores, may decrease the use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). Compared with placebo controls in adults with chronic postamputation pain, temporary PNS may decrease pain scores, may decrease use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). Compared with before implantation in adults with chronic postamputation pain, temporary PNS may decrease pain scores, may decrease the use of pain medications, may improve functional outcomes, and may improve health-related quality of life (all GRADEs: Low). We did not find any studies that compared permanent PNS to temporary PNS. Implantation of a PNS system is a reasonably safe procedure; most adverse events were localized and mild in intensity (GRADEs: Moderate to Low).The incremental cost-effectiveness ratio of PNS in addition to standard care compared with standard care alone is $87,211 per quality-adjusted life-year (QALY) gained. The probability of PNS in addition to standard care being cost-effective versus standard care alone is 1.02% at a willingness-to-pay of $50,000 per QALY gained and 64.88% at a willingness-to-pay of $100,000 per QALY gained. The annual budget impact of publicly funding PNS in Ontario over the next 5 years ranges from an additional $0.97 million in year 1, increasing to $3.15 million in year 5, for a total of $10.09 million over 5 years. People with chronic pain and their family members and care partners viewed PNS favourably. Those who had direct experience with permanent PNS perceived it to be effective in reducing their pain levels, leading to a positive impact on their quality of life and mental health. Current barriers to accessing PNS include lack of awareness, cost, and geography.

Conclusions

In adults with chronic neuropathic pain that is refractory to conventional medical management, permanent PNS likely improves pain outcomes, functional outcomes, and health-related quality of life but has little to no effect on the use of pain medications compared with placebo controls. Temporary PNS may improve pain outcomes, functional outcomes, and health-related quality of life, and it may reduce the use of pain medications. Implantation of a permanent or temporary PNS system is reasonably safe. The incremental cost-effectiveness ratio of PNS in addition to standard care compared with standard care alone is $87,211 per QALY gained. We estimate that publicly funding PNS in Ontario would result in additional costs of $10.09 million over the next 5 years. People who had direct experience with permanent PNS spoke of its effectiveness in reducing their pain levels and its positive impact on their quality of life and mental health. Barriers to accessing PNS include lack of awareness, cost, and geography.

Efficacy of naproxen in patients with sciatica: multicenter, randomized, double-blind, placebo-controlled trial

ABSTRACT

This trial assessed the efficacy of naproxen in patients with sciatica in outpatient clinics across 4 Norwegian hospitals. A total of 123 adults with radiating pain below the knee (≥4 on a 0-10 numeric rating scale) and signs consistent with nerve root involvement were included. Participants were randomized to receive either naproxen 500 mg or a placebo twice daily for 10 days. The primary outcome, daily leg pain intensity measured on a 0 to 10 numeric rating scale throughout the treatment period, revealed a statistically significant difference in favor of naproxen, with an adjusted mean difference of -0.5 (95% CI -0.8 to -0.1, P = 0.015). In the naproxen group, the treatment effect was significantly related to time, and over the whole 10-day period, the average adjusted difference was -0.6 (95% CI -0.8 to -0.5). Mean numbers needed to treat for 30% and 50% improvement were 9.9 (95% CI 4.7-15.0) and 20.7 (8.7-32.7), respectively. The adjusted mean difference for back pain was -0.4 (95% CI -0.8 to 0.0), and for Roland Morris Disability Questionnaire for Sciatica, it was -1.5 (95% CI -3.0 to 0.0). No differences were found for sciatica bothersomeness or consumption of rescue medication or opioids. Participants in the naproxen group exhibited an adjusted odds ratio of 4.7 (95% CI 1.3-16.2) for improvement by 1 level on the global perceived change scale. In conclusion, naproxen treatment showed small, likely clinically unimportant benefits compared with placebo in patients with moderate-to-severe sciatica.

Mindfulness in the Clinic Waiting Room May Decrease Pain: Results from Three Pilot Randomized Controlled Trials

Introduction: Mindfulness interventions can improve a broad range of patient outcomes, but traditional mindfulness-based interventions are time and resource intensive. Emerging evidence indicates brief, single-session mindfulness interventions can also improve patient outcomes, and brief mindfulness interventions can be embedded into medical care pathways with minimal disruption. However, the direct impact of a brief mindfulness intervention on patients' pain while waiting in the clinic waiting room remains unexamined. Objective: A series of three, pilot, randomized controlled trials (RCTs) were conducted to examine the impact of a brief, audio-recorded, mindfulness intervention on patients' pain in the clinic waiting room. Method: Study 1 examined an 8-min mindfulness recording delivered before a provider visit; Study 2 examined a 5-min mindfulness recording after a provider visit; and Study 3 examined a 4-min mindfulness recording before a provider visit. Time- and attention-matched control conditions were used in each study. Studies 1 and 2 were conducted in an academic cancer hospital. Study 3 was conducted at a walk-in orthopedic clinic. Pain intensity was measured in each of the three studies. Anxiety and depression symptoms were measured in Studies 2 and 3. Pain unpleasantness was measured in Study 3. Results: A brief (i.e., 4- to 8-min), audio-recorded mindfulness intervention decreased patients' pain intensity in the clinic waiting room, whether delivered before (Study 1 Cohen's d=1.01, Study 3 Cohen's d=0.39) or after (Study 2 Cohen's d=0.89) a provider visit. Mindfulness had a significant effect on anxiety symptoms in both studies in which it was measured. No effect on depression symptoms was observed. Conclusions: Results from these three pilot RCTs indicate brief, audio-recorded, mindfulness interventions may be capable of quickly decreasing clinical symptoms. As such, embedding brief, audio-recorded, mindfulness interventions in clinic waiting rooms may have the potential to improve patient outcomes. The continued investigation of this intervention approach is needed. Clinical Trial Registrations: NCT04477278 and NCT06099964.

Emotions in search of words: Does alexithymia predict treatment outcome in chronic musculoskeletal pain?

Chronic pain, with its complex and multidimensional nature, poses significant challenges in identifying effective long-term treatments. There is growing scientific interest in how psychopathological and personality dimensions may influence the maintenance and development of chronic pain. This longitudinal study aimed to investigate whether alexithymia can predict the improvement of pain severity following a treatment-as-usual programme for chronic musculoskeletal pain over and above psychological cofactors (emotional distress, catastrophizing, and self-efficacy). A consecutive sample of 129 patients with diagnosed chronic musculoskeletal pain referred to two tertiary care centres was recruited and treated for 16 weeks. Clinical pain, psychological distress, self-efficacy, catastrophizing, and alexithymia were assessed with validated self-report measures at the first medical visit (T0) and at 16-week follow-up (T1). Compared with non-responder patients (n = 72, 55.8%), those who responded (i.e., reduction of >30% in pain severity; n = 57, 44.2%) reported an overall improvement in psychological variables except alexithymia. Alexithymia showed relative stability between baseline and follow-up within the entire sample and remained a significant predictor of treatment outcome even when other predictive cofactors (i.e., pain interference, depressive symptoms, and catastrophizing) were considered simultaneously. Our results suggest that identifying patients with a co-occurrence between alexithymia, depressive symptoms, catastrophizing, and the stressful experience of chronic pain can be clinically relevant in pain prevention and intervention programs.

Telehealth Mindfulness-Based Interventions for Chronic Pain: The LAMP Randomized Clinical Trial

Importance

Although mindfulness-based interventions (MBIs) are evidence-based treatments for chronic pain and comorbid conditions, implementing them at scale poses many challenges, such as the need for dedicated space and trained instructors.

Objective

To examine group and self-paced, scalable, telehealth MBIs, for veterans with chronic pain, compared to usual care.

Design, Setting, and Participants

This was a randomized clinical trial of veterans with moderate to severe chronic pain, recruited from 3 Veterans Affairs facilities from November 2020 to May 2022. Follow-up was completed in August 2023.

Interventions

Two 8-week telehealth MBIs (group and self-paced) were compared to usual care (control). The group MBI was done via videoconference with prerecorded mindfulness education and skill training videos by an experienced instructor, accompanied by facilitated discussions. The self-paced MBI was similar but completed asynchronously and supplemented by 3 individual facilitator calls.

Main Outcomes and Measures

The primary outcome was pain-related function using the Brief Pain Inventory interference scale at 3 time points: 10 weeks, 6 months, and 1 year. Secondary outcomes included biopsychosocial outcomes: pain intensity, physical function, anxiety, fatigue, sleep disturbance, participation in social roles and activities, depression, patient ratings of improvement of pain, and posttraumatic stress disorder.

Results

Among 811 veterans randomized (mean [SD] age, 54.6 [12.9] years; 387 [47.7%] women), 694 participants (85.6%) completed the trial. Averaged across all 3 time points, pain interference scores were significantly lower for both MBIs compared to usual care (group MBI vs control difference: -0.4 [95% CI, -0.7 to -0.2]; self-paced vs control difference: -0.7 [95% CI, -1.0 to -0.4]). Additionally, both MBI arms had significantly better scores on the following secondary outcomes: pain intensity, patient global impression of change, physical function, fatigue, sleep disturbance, social roles and activities, depression, and posttraumatic stress disorder. Both group and self-paced MBIs did not significantly differ from one another. The probability of 30% improvement from baseline compared to control was greater for group MBI at 10 weeks and 6 months, and for self-paced MBI, at all 3 time points.

Conclusions and Relevance

In this randomized clinical trial, scalable telehealth MBIs improved pain-related function and biopsychosocial outcomes compared to usual care among veterans with chronic pain. Relatively low-resource telehealth-based MBIs could help accelerate and improve the implementation of nonpharmacological pain treatment in health care systems.

Trial Registration

ClinicalTrials.gov Identifier: NCT04526158.

Neuromodulation for Neuropathic Pain Syndromes

OBJECTIVE

This article reviews the principles, applications, and emerging trends of neuromodulation as a therapeutic approach for managing painful neuropathic diseases. By parsing evidence for possible mechanisms of action and clinical trial outcomes for various diseases, this article focuses on five common therapy modalities: cutaneous, peripheral nerve, spinal cord, and brain stimulation, and intrathecal drug delivery.

LATEST DEVELOPMENTS

Recent advances in both invasive and noninvasive neuromodulation for pain have introduced personalized and closed-loop techniques, integrating real-time feedback mechanisms and combining therapies to improve physical and psychosocial function. Novel stimulation waveforms may influence distinct neural tissues to rectify pathologic pain signaling.

ESSENTIAL POINTS

With appropriate patient selection, peripheral nerve stimulation or epidural stimulation of the spinal cord can provide enduring relief for a variety of chronic pain syndromes. Newer technology using high frequencies, unique waveforms, or closed-loop stimulation may have selective advantages, but our current understanding of therapy mechanisms is very poor. For certain diagnoses and patients who meet clinical criteria, neuromodulation can provide profound, long-lasting relief that significantly improves quality of life. While many therapies are supported by data from large clinical trials, there is a risk of bias as most clinical studies were funded by device manufacturers or insurance companies, which increases the importance of real-world data analysis. Emerging methods like invasive or noninvasive brain stimulation may help us dissect basic mechanisms of pain processing and hold promise for personalized therapies for refractory pain syndromes. Finally, intrathecal delivery of drugs directly to segments of the spinal cord can also modify pain signaling to provide therapy for severe pain syndromes.

Topical amitriptyline in burning mouth syndrome: A retrospective real-world evidence study

OBJECTIVE

To evaluate the effectiveness, tolerability, and safety of topical amitriptyline as a potential route of administration for the management of burning mouth syndrome.

BACKGROUND

Burning mouth syndrome is a complex, idiopathic, and debilitating orofacial pain disorder that impairs quality of life, with a prevalence of up to 18% in menopausal women. Available drugs to alleviate its burning sensation have inconsistent and limited efficacy. Given its physicochemical properties, excellent tolerability, and ability to target peripheral pathways, topical amitriptyline seems a promising mechanistically specific analgesic drug for burning mouth syndrome.

METHODS

In this retrospective cross-sectional real-world evidence study, patients with burning mouth syndrome who were prescribed topical amitriptyline for 8 weeks were identified. Eligibility criteria stemmed from ICHD-3, ICOP, and consensus definitions. The primary outcome measure was mean daily pain intensity (on a 0-10 scale); secondary outcomes included adverse events and patient global impression of improvement. Data are given as the mean ± SD.

RESULTS

A total of 15 patients fulfilling the eligibility criteria were included and analyzed. Mean daily pain was 6.7 ± 2.1 at baseline and 3.7 ± 2.3 after treatment, with a mean reduction of 3.1 ± 2.8 (p = 0.002). Half of the patients experienced a decrease in pain by at least 50% (p = 0.008). Several mild adverse events were reported, such as somnolence or dry mouth.

CONCLUSIONS

Topical amitriptyline may be a safe and potent route of administration in the treatment of burning mouth syndrome, a hypothesis to be tested in further controlled trials.

The Contribution of Sleep Quality and Psychological Factors to the Experience of Within-Day Pain Fluctuations Among Individuals With Temporomandibular Disorders

We assessed the impact of day-to-day sleep quality and psychological variables (catastrophizing, negative affect, and positive affect) to within-day pain fluctuations in 42 females with painful temporomandibular disorders (TMD) using electronic diaries. More specifically, we examined the contribution of these variables to the likelihood of experiencing pain exacerbations defined as 1) an increase of 20 points (or more) in pain intensity on a 0 to 100 visual analog scale from morning to evening, and/or 2) a transition from mild-to-moderate pain over the course of the day; and pain decreases defined as 3) a decrease of 20 points (or more) in pain intensity (visual analog scale) from morning to evening, and/or 4) a reduction from moderate-to-mild pain over the day. The results indicated significantly main effects of sleep on both pain exacerbation outcomes (both P's < .05), indicating that nights with better sleep quality were less likely to be followed by clinically meaningful pain exacerbations on the next day. The results also indicated that days characterized by higher levels of catastrophizing were associated with a greater likelihood of pain exacerbations on the same day (both P's < .05). Daily catastrophizing was the only variable significantly associated with within-day pain decrease indices (both P's < .05). None of the other variables were associated with these outcomes (all P's > .05). These results underscore the importance of addressing patients' sleep quality and psychological states in the management of painful TMD. PERSPECTIVE: These findings highlight the significance of sleep quality and pain catastrophizing in the experience of within-day pain fluctuations among individuals with TMD. Addressing these components through tailored interventions may help to alleviate the impact of pain fluctuations and enhance the overall well-being of TMD patients.

Current Trends in Modalities of Pain Assessment: A Narrative Review

Pain is a common complaint among a spectrum of diseases. Although an ideal objective method of pain assessment is lacking, several validated tools are available for use in clinical research and practice. The tool considerations are based upon the parameters to be assessed and factors specific to patient, disease, and availability of instruments. This review classifies and brings the key aspects of currently available pain assessment tools on a single platform to ease the selection process for researchers/practitioners. The tools utilized for pain assessment were collected from articles available in PubMed and Google Scholar databases and classified into the following domains: unidimensional, multi-dimensional, investigation-based, and computerized algorithm-based tools. Their purpose of use and limitations are reviewed. The unidimensional scales are used to describe only the characteristics of pain, like intensity (e.g. numerical rating scale), type (e.g. neuropathic pain questionnaire), or pattern. In contrast, multi-dimensional tools, like Mc Gill Questionnaire, assess not only pain as an individual symptom but also its influence on physical functioning and general well-being. However, certain components like ethnicity, age, cognitive impairment, sedation, and emotion become a limiting factor in selecting the scale. In addition to these scales, a potential role of parameters such as biopotentials/markers has also been shown in pain assessment. Last, artificial intelligence is also being applied in evaluation of pain. Pain measurement is subjective in nature as assessed through questionnaires and observational tools. Currently, multi-dimensional approaches of pain assessment are available, which can lead to precision pain management.

Intravenous Lidocaine for Refractory Pain in Patients With Pancreatic Ductal Adenocarcinoma and Chronic Pancreatitis: A Multicenter Prospective Nonrandomized Pilot Study

INTRODUCTION

Refractory pain is a major clinical problem in patients with pancreatic ductal adenocarcinoma (PDAC) and chronic pancreatitis (CP). New, effective therapies to reduce pain are urgently needed. Intravenous lidocaine is used in clinical practice in patients with PDAC and CP, but its efficacy has not been studied prospectively.

METHODS

Multicenter prospective nonrandomized pilot study included patients with moderate or severe pain (Numeric Rating Scale ≥ 4) associated with PDAC or CP in 5 Dutch centers. An intravenous lidocaine bolus of 1.5 mg/kg was followed by continuous infusion at 1.5 mg/kg/hr. The dose was raised every 15 minutes until treatment response (up to a maximum 2 mg/kg/hr) and consecutively administered for 2 hours. Primary outcome was the mean difference in pain severity, preinfusion, and the first day after (Brief Pain Inventory [BPI] scale 1-10). A BPI decrease ≥1.3 points was considered clinically relevant.

RESULTS

Overall, 30 patients were included, 19 with PDAC (63%) and 11 with CP (37%). The mean difference in BPI at day 1 was 1.1 (SD ± 1.3) points for patients with PDAC and 0.5 (SD ± 1.7) for patients with CP. A clinically relevant decrease in BPI on day 1 was reported in 9 of 29 patients (31%), and this response lasted up to 1 month. No serious complications were reported, and only 3 minor complications (vertigo, nausea, and tingling of mouth). Treatment with lidocaine did not impact quality of life.

DISCUSSION

Intravenous lidocaine in patients with painful PDAC and CP did not show an overall clinically relevant reduction of pain. However, this pilot study shows that the treatment is feasible in this patient group and had a positive effect in a third of patients which lasted up to a month with only minor side effects. To prove or exclude the efficacy of intravenous lidocaine, the study should be performed in a study with a greater sample size and less heterogeneous patient group.

A Single-Session, 2-Hour Version of Mindfulness-Oriented Recovery Enhancement (One MORE) Improves Chronic Pain Patients' Pain-Related Outcomes Through 3-Month Follow-Up in a Randomized Controlled Trial

Introduction: Traditional, 8-week, mindfulness-based interventions can effectively treat chronic pain, but require a time and resource investment too burdensome for many patients and providers. The solution to this logistical challenge may be to distill the core, therapeutic elements of an efficacious 8-week, mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), into a 2-h, single-session intervention. Methods: In this study, the authors conducted a waitlist-controlled, randomized clinical trial to assess the impact of a 2-h, single-session adaptation of MORE (i.e., One MORE) on chronic pain patients' (N = 40) pain-related outcomes through 3-month follow-up. Results: Results indicated that One MORE significantly improved chronic pain patients' pain catastrophizing (i.e., primary outcome; F = 9.97, p = 0.002), pain intensity (F = 26.58, p < 0.001), pain interference (F = 39.43, p < 0.001), physical function (F = 16.29, p < 0.001), sleep (F = 16.66, p < 0.001), anxiety (F = 12.54, p < 0.001), and depression (F = 17.48, p < 0.001). One MORE also significantly increased theoretically indicated therapeutic mechanisms through the 3-month follow-up: mindfulness, positive reappraisal, savoring, self-transcendence. Discussion: Study results are promising, and if replicated, would suggest that One MORE is a highly scalable, low-cost (e.g., sustainable), nonpharmacologic treatment for chronic pain. Clinical Trial Registration: NCT05194241.

Efficacy of a Pain Self-Management Intervention Tailored to People With HIV: A Randomized Clinical Trial

Importance

Chronic pain is a common condition for which efficacious interventions tailored to highly affected populations are urgently needed. People with HIV have a high prevalence of chronic pain and share phenotypic similarities with other highly affected populations.

Objective

To evaluate the efficacy of a behavioral pain self-management intervention called Skills to Manage Pain (STOMP) compared to enhanced usual care (EUC).

Design, Setting, and Participants

This randomized clinical trial included adults with HIV who experienced at least moderate chronic pain for 3 months or more. The study was set at the University of Alabama at Birmingham and the University of North Carolina-Chapel Hill large medical centers from August 2019 to September 2022.

Intervention

STOMP combined 1-on-1 skill-building sessions delivered by staff interventionists with group sessions co-led by peer interventionists. The EUC control group received the STOMP manual without any 1-on-1 or group instructional sessions.

Main Outcomes and Measures

The primary outcome was pain severity and the impact of pain on function, measured by the Brief Pain Inventory (BPI) summary score. The primary a priori hypothesis was that STOMP would be associated with a decreased BPI in people with HIV compared to EUC.

Results

Among 407 individuals screened, 278 were randomized to STOMP intervention (n = 139) or EUC control group (n = 139). Among the 278 people with HIV who were randomized, the mean (SD) age was 53.5 (10.0) years; 126 (45.0%) identified as female, 146 (53.0%) identified as male, 6 (2.0%) identified as transgender female. Of the 6 possible 1-on-1 sessions, participants attended a mean (SD) of 2.9 (2.5) sessions. Of the 6 possible group sessions, participants attended a mean (SD) of 2.4 (2.1) sessions. Immediately after the intervention compared to EUC, STOMP was associated with a statistically significant mean difference for the primary outcome, BPI total score: -1.25 points (95% CI, -1.71 to -0.78 points; P < .001). Three months after the intervention, the mean difference in BPI total score remained statistically significant, favoring the STOMP intervention -0.62 points (95% CI, -1.09 to -0.14 points; P = .01).

Conclusion and Relevance

The findings of this randomized clinical trial support the efficaciousness of STOMP as an intervention for chronic pain in people with HIV. Future research will include implementation studies and work to understand the optimal delivery of the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692611.

Applying AI to Safely and Effectively Scale Care to Address Chronic MSK Conditions

Background/Objectives: The rising prevalence of musculoskeletal (MSK) conditions has not been balanced by a sufficient increase in healthcare providers. Scalability challenges are being addressed through the use of artificial intelligence (AI) in some healthcare sectors, with this showing potential to also improve MSK care. Digital care programs (DCP) generate automatically collected data, thus making them ideal candidates for AI implementation into workflows, with the potential to unlock care scalability. In this study, we aimed to assess the impact of scaling care through AI in patient outcomes, engagement, satisfaction, and adverse events. Methods: Post hoc analysis of a prospective, pre-post cohort study assessing the impact on outcomes after a 2.3-fold increase in PT-to-patient ratio, supported by the implementation of a machine learning-based tool to assist physical therapists (PTs) in patient care management. The intervention group (IG) consisted of a DCP supported by an AI tool, while the comparison group (CG) consisted of the DCP alone. The primary outcome concerned the pain response rate (reaching a minimal clinically important change of 30%). Other outcomes included mental health, program engagement, satisfaction, and the adverse event rate. Results: Similar improvements in pain response were observed, regardless of the group (response rate: 64% vs. 63%; p = 0.399). Equivalent recoveries were also reported in mental health outcomes, specifically in anxiety (p = 0.928) and depression (p = 0.187). Higher completion rates were observed in the IG (79.9% (N = 19,252) vs. CG 70.1% (N = 8489); p < 0.001). Patient engagement remained consistent in both groups, as well as high satisfaction (IG: 8.76/10, SD 1.75 vs. CG: 8.60/10, SD 1.76; p = 0.021). Intervention-related adverse events were rare and even across groups (IG: 0.58% and CG 0.69%; p = 0.231). Conclusions: The study underscores the potential of scaling MSK care that is supported by AI without compromising patient outcomes, despite the increase in PT-to-patient ratios.

Synthesis of temporomandibular disorders management intervention outcomes for development of core outcome sets: A systematic review

INTRODUCTION

The selection of appropriate outcomes in clinical trials and systematic reviews is a crucial factor in determining the results that are useful, reliable, and relevant for both patients and healthcare professionals. Clinicians and researchers have been encouraged to develop and apply core outcome sets (COS) to minimise the discrepancy between studies.

AIM

This systematic review is the first phase of the COS development project for clinical trials in temporomandibular disorders (COS-TMD). It aims to identify and synthesise the outcomes used in the randomised controlled trials (RCT) that evaluated the effectiveness of interventions used in TMD management.

MATERIALS AND METHODS

An electronic search was performed in several databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library and EMBASE. The eligibility criteria comprised RCT that applied any intervention to treat temporomandibular joint disorders or masticatory muscle disorders. The identified outcomes were categorised according to domains of the Initiative on Methods, Measurement and Pain Assessment in Clinical Trials (IMMPACT).

RESULTS

The electronic search resulted in 1606 studies. After removing duplicates and applying the eligibility criteria, 106 RCT were included. A total of 43 studies evaluated masticatory muscle disorders, 27 evaluated temporomandibular joint disorders, and 36 analysed mixed TMD.

CONCLUSIONS

The evaluation showed significant variability in the types of outcomes and their measurement instruments. In addition, some domains such as physical and emotional functioning, participant ratings of global improvement and adverse events have been neglected when determining the effectiveness of treatments for TMD.

Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction

BACKGROUND

Adults with refractory, mechanical chronic low back pain associated with impaired neuromuscular control of the lumbar multifidus muscle have few treatment options that provide long-term clinical benefit. This study hypothesized that restorative neurostimulation, a rehabilitative treatment that activates the lumbar multifidus muscles to overcome underlying dysfunction, is safe and provides relevant and durable clinical benefit to patients with this specific etiology.

MATERIALS AND METHODS

In this prospective five-year longitudinal follow-up of the ReActiv8-B pivotal trial, participants (N = 204) had activity-limiting, moderate-to-severe, refractory, mechanical chronic low back pain, a positive prone instability test result indicating impaired multifidus muscle control, and no indications for spine surgery. Low back pain intensity (10-cm visual analog scale [VAS]), disability (Oswestry Disability Index), and quality of life (EuroQol's "EQ-5D-5L" index) were compared with baseline and following the intent-to-treat principle, with a supporting mixed-effects model for repeated measures that accounted for missing data.

RESULTS

At five years (n = 126), low back pain VAS had improved from 7.3 to 2.4 cm (-4.9; 95% CI, -5.3 to -4.5 cm; p < 0.0001), and 71.8% of participants had a reduction of ≥50%. The Oswestry Disability Index improved from 39.1 to 16.5 (-22.7; 95% CI, -25.4 to -20.8; p < 0.0001), and 61.1% of participants had reduction of ≥20 points. The EQ-5D-5L index improved from 0.585 to 0.807 (0.231; 95% CI, 0.195-0.267; p < 0.0001). Although the mixed-effects model attenuated completed-case results, conclusions and statistical significance were maintained. Of 52 subjects who were on opioids at baseline and had a five-year visit, 46% discontinued, and 23% decreased intake. The safety profile compared favorably with neurostimulator treatments for other types of back pain. No lead migrations were observed.

CONCLUSION

Over a five-year period, restorative neurostimulation provided clinically substantial and durable benefits with a favorable safety profile in patients with refractory chronic low back pain associated with multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02577354; registration date: October 15, 2016; principal investigator: Christopher Gilligan, MD, Brigham and Women's Hospital, Boston, MA, USA. The study was conducted in Australia (Broadmeadow, New South Wales; Noosa Heads, Queensland; Welland, South Australia; Clayton, Victoria), Belgium (Sint-Niklaas; Wilrijk), The Netherlands (Rotterdam), UK (Leeds, London, Middlesbrough), and USA (La Jolla, CA; Santa Monica, CA; Aurora, CO; Carmel, IN; Indianapolis, IN; Kansas City, KS; Boston, MA; Royal Oak, MI; Durham, NC; Winston-Salem, NC; Cleveland, OH; Providence, RI; Spartanburg, SC; Spokane, WA; Charleston, WV).

Internet-Delivered Psychological Pain-Management for Young Adults With Chronic Pain: An Investigation of Clinical Trial Data

Young adults report chronic pain at rates of around 12% but lack access to clinical services. There is interest in learning how this emerging adult population engages with and responds to treatment. Using data from young adults aged 18 to 30 years (Mage = 25.8, SD = 3.2), taken from 4 previous randomised controlled trials, the current study investigated the feasibility, acceptability, and efficacy of an internet-delivered psychological pain-management intervention for young adults with chronic pain. We compared young adults in a treatment group (n = 104) with 1) a young-adult wait-list control group (n = 48), and 2) a treatment group reflecting the average-aged participant from the previous trials (39-63 years, n = 561). Feasibility was determined through treatment engagement, adherence and completion, and acceptability through a treatment satisfaction measure. Clinical outcomes were disability, pain intensity, anxiety, and depression; assessed at pre-treatment, post-treatment, and 3-month follow-up. Generalised estimation equation analyses were undertaken, using multiple imputations to account for missing data. Young adults had high engagement and acceptability ratings, though 34% did not complete the intervention. The treatment group significant improved across all outcomes, compared with control, with improvements maintained at follow-up. Post-treatment improvements were equivalent for young-adult and average-aged adult treatment groups, with no significant differences in feasibility or acceptability outcomes. Findings indicate young adults can engage with and show improvements following a psychological pain-management intervention designed for all adults with chronic pain. Future research is encouraged to examine outcomes related to role functioning of young adults, and moderators of treatment acceptability and efficacy for this population. PERSPECTIVE: Secondary analysis of data from 4 RCTs found an Internet-delivered psychological pain-management intervention acceptable and clinically efficacious for improving disability, anxiety, depression and pain intensity in young adults (18-30) with chronic pain.

Counting your chickens before they hatch: improvements in an untreated chronic pain population, beyond regression to the mean and the placebo effect

Introduction

Isolating the effect of an intervention from the natural course and fluctuations of a condition is a challenge in any clinical trial, particularly in the field of pain. Regression to the mean (RTM) may explain some of these observed fluctuations.

Objectives

In this paper, we describe and quantify the natural trajectory of questionnaire scores over time, based on initial scores.

Methods

Twenty-seven untreated chronic low back pain patients and 25 healthy controls took part in this observational study, wherein they were asked to complete an array of questionnaires commonly used in pain studies during each of 3 visits (V1, V2, V3) at the 2-month interval. Scores at V1 were classified into 3 subgroups (extremely high, normal, and extremely low), based on z-scores. The average delta (∆ = V2 - V1) was calculated for each subgroup, for each questionnaire, to describe the evolution of scores over time based on initial scores. This analysis was repeated with the data for V2 and V3.

Results

Our results show that high initial scores were widely followed by more average scores, while low initial scores tended to be followed by similar (low) scores.

Conclusion

These trajectories cannot be attributable to RTM alone because of their asymmetry, nor to the placebo effect as they occurred in the absence of any intervention. However, they could be the result of an Effect of Care, wherein participants had meaningful improvements simply from taking part in a study. The improvement observed in patients with high initial scores should be carefully taken into account when interpreting results from clinical trials.

A Systematic Review of Chronic Pain Management Interventions Among Veterans of Recent Wars and Armed Conflicts

OBJECTIVES

To identify chronic pain management strategies aimed to reduce pain intensity and enhance functional outcomes in veterans of wars and armed conflict.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

Key words "chronic pain," "veterans," and "injuries" were used to search for articles in the MEDLINE, CINAHL, APA PsycInfo, and Embase databases. Articles published in English between 2000 and 2023 were included.

REVIEW/ANALYSIS METHODS

A systematic literature search was conducted in June 2020, updated in April 2023, and managed using Covidence review software. Inclusion criteria focused on combat-injured veterans with chronic pain, excluding nonveterans and civilians treated for acute or chronic pain. Data from included studies were extracted, summarized, and critically appraised using the 2018 Mixed Methods Appraisal Tool. This review is registered with PROSPERO (CRD42020207435).

RESULTS

Fourteen studies met the inclusion criteria, with 10 of them supporting nonpharmacological approaches for managing chronic pain among veterans of armed conflicts and wars. Interventions included psychological/behavioral therapies, peer support, biofeedback training via telephone-based therapy, manual therapy, yoga, cognitive processing therapy, cognitive-behavioral therapy, and social and community integration to reduce pain intensity and enhance functional outcomes.

CONCLUSION

Nonpharmacological treatments for chronic pain have increased in recent years, a shift from earlier reliance on pharmacological treatments. More evidence from randomized controlled trials on the benefits of combined pain interventions could improve pain management of veterans with complex care needs.

Effects of athletic tape on orofacial pain and jaw movements after 24 hours of use: a randomized clinical trial

PURPOSE

To analyze the sensation of pain and the range of mandibular movements of adult individuals with temporomandibular disorder, before and after the application of the athletic tape.

METHOD

This is a double-blind randomized clinical trial, in which 22 adults with temporomandibular disorder participated, randomly allocated into two groups, with group A comprising 10 women and one man (mean age 28.2±8.3 years) and group B comprising nine women and two men (mean age 26.2±3.9 years). Group A was submitted to the application of the athletic tape on the masseter with 40% stretch and the group B to the application of the athletic tape on the masseter without stretching. All participants underwent the application of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Pain threshold assessment was performed using an algometer to apply pressure to measurement points. The measurement of mandibular movements was performed using a caliper. The athletic tape was glued using the I technique, with a fixed point over the insertion and a movable point over the origin of the masseter muscle. Participants remained with the athletic tape for 24 hours and were re-evaluated.

RESULTS

There was pain relief in the group A in the temporomandibular joint on the right and at the origin of the masseter on the left. The group B showed a reduction in pain in the left anterior temporal region. No differences were found in mandibular movements after intervention, as well as no difference was found in the comparison by groups.

CONCLUSION

The use of the athletic tape over the masseter muscle, with stretching, for 24 hours produced relief from the sensation of pain, on the origin of the right masseter and in the right temporomandibular joint, and, without stretching, in the left anterior temporal muscle. There was no difference in the range of mandibular movements.

A Scoping Review of the Effect of EEG Neurofeedback on Pain Complaints in Adults with Chronic Pain

Background and Aim: Non-pharmacological treatments such as electroencephalogram (EEG) neurofeedback have become more important in multidisciplinary approaches to treat chronic pain. The aim of this scoping review is to identify the literature on the effects of EEG neurofeedback in reducing pain complaints in adult chronic-pain patients and to elaborate on the neurophysiological rationale for using specific frequency bands as targets for EEG neurofeedback. Methods: A pre-registered scoping review was set up and reported following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews (PRISMA-ScR). The data were collected by searching for studies published between 1985 and January 2023 in PubMed, EMBASE, and PsycINFO. Results: Thirty-two studies on various types of chronic pain were included. The intervention was well-tolerated. Approximately half of the studies used a protocol that reinforced alpha or sensorimotor rhythms and suppressed theta or beta activity. However, the underlying neurophysiological rationale behind these specific frequency bands remains unclear. Conclusions: There are indications that neurofeedback in patients with chronic pain probably has short-term analgesic effects; however, the long-term effects are less clear. In order to draw more stable conclusions on the effectiveness of neurofeedback in chronic pain, additional research on the neurophysiological mechanisms of targeted frequency bands is definitely worthwhile. Several recommendations for setting up and evaluating the effect of neurofeedback protocols are suggested.

Effectiveness and safety of manual therapy when compared with oral pain medications in patients with neck pain: a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis seeks to investigate the effectiveness and safety of manual therapy (MT) interventions compared to oral pain medication in the management of neck pain.

METHODS

We searched from inception to March 2023, in Cochrane Central Register of Controller Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED) and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO) for randomized controlled trials that examined the effect of manual therapy interventions for neck pain when compared to medication in adults with self-reported neck pain, irrespective of radicular findings, specific cause, and associated cervicogenic headaches. We used the Cochrane Risk of Bias 2 tool to assess the potential risk of bias in the included studies, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to grade the quality of the evidence.

RESULTS

Nine trials (779 participants) were included in the meta-analysis. We found low certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the short-term (Standardized Mean Difference: -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants), and moderate certainty of evidence that MT interventions may be more effective than oral pain medication in pain reduction in the long-term (Standardized Mean Difference: - 0.36; 95% CI - 0.55 to - 0.17; 6 trials, 567 participants). We found low certainty evidence that the risk of adverse events may be lower for patients that received MT compared to the ones that received oral pain medication (Risk Ratio: 0.59; 95% CI 0.43 to 0.79; 5 trials, 426 participants).

CONCLUSIONS

MT may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events. Future MT trials should create and adhere to strict reporting strategies with regards to adverse events to help gain a better understanding on the nature of potential MT-induced adverse events and to ensure patient safety.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023421147.

Clinical Relevance of Physical Function Outcomes in Cancer Cachexia

Managing clinical manifestations of cancer/treatment burden on functional status and quality of life remains paramount across the cancer trajectory, particularly for patients with cachexia who display reduced functional capacity. However, clinically relevant criteria for classifying functional impairment at a single point in time or for classifying meaningful functional changes subsequent to disease and/or treatment progression are lacking. This unmet clinical need remains a major obstacle to the development of therapies for cancer cachexia. This review aims to describe current literature-based evidence for clinically meaningful criteria for (1) functional impairment at a single timepoint between cancer patients with or without cachexia and (2) changes in physical function over time across interventional studies conducted in patients with cancer cachexia. The most common functional assessment in cross-sectional and interventional studies was hand grip strength (HGS). We observed suggestive evidence that an HGS deficit between 3 and 6 kg in cancer cachexia may display clinical relevance. In interventional studies, we observed that long-duration multimodal therapies with a focus on skeletal muscle may benefit HGS in patients with considerable weight loss. Future studies should derive cohort-specific clinically relevant criteria to confirm these observations in addition to other functional outcomes and investigate appropriate patient-reported anchors.

Thoracolumbar Interfascial Plane (TLIP) block verses other paraspinal fascial plane blocks and local infiltration for enhanced pain control after spine surgery: a systematic review

Spinal surgeries are accompanied by excessive pain due to extensive dissection and muscle retraction during the procedure. Thoracolumbar interfascial plane (TLIP) blocks for spinal surgeries are a recent addition to regional anesthesia to improve postoperative pain management. When performing a classical TLIP (cTLIP) block, anesthetics are injected between the muscle (m.) multifidus and m. longissimus. During a modified TLIP (mTLIP) block, anesthetics are injected between the m. longissimus and m. iliocostalis instead. Our systematic review provides a comprehensive evaluation of the effectiveness of TLIP blocks in improving postoperative outcomes in spinal surgery through an analysis of randomized controlled trials (RCTs).We conducted a systematic review based on the PRISMA guidelines using PubMed and Scopus databases. Inclusion criteria required studies to be RCTs in English that used TLIP blocks during spinal surgery and report both outcome measures. Outcome data includes postoperative opioid consumption and pain.A total of 17 RCTs were included. The use of a TLIP block significantly decreases postoperative opioid use and pain compared to using general anesthesia (GA) plus 0.9% saline with no increase in complications. There were mixed outcomes when compared against wound infiltration with local anesthesia. When compared with erector spinae plane blocks (ESPB), TLIP blocks often decreased analgesic use, however, this did not always translate to decreased pain. The cTLIP and mTLP block methods had comparable postoperative outcomes but the mTLIP block had a significantly higher percentage of one-time block success.The accumulation of the current literature demonstrates that TLIP blocks are superior to non-block procedures in terms of analgesia requirements and reported pain throughout the hospitalization in patients who underwent spinal surgery. The various levels of success seen with wound infiltration and ESPB could be due to the nature of the different spinal procedures. For example, studies that saw superiority with TLIP blocks included fusion surgeries which is a more invasive procedure resulting in increased postoperative pain compared to discectomies.The results of our systematic review include moderate-quality evidence that show TLIP blocks provide effective pain control after spinal surgery. Although, the application of mTLIP blocks is more successful, more studies are needed to confirm that superiority of mTLIP over cTLIP blocks. Additionally, further high-quality research is needed to verify the potential benefit of TLIP blocks as a common practice for spinal surgeries.

Is the Capsaicin 179 mg (8% w/w) Cutaneous Patch an Appropriate Treatment Option for Older Patients with Peripheral Neuropathic Pain?

Introduction

Capsaicin 179 mg (8% weight per weight) cutaneous patch ("capsaicin patch") is a recommended topical treatment for peripheral neuropathic pain (PNP). In older patients, topical treatments may be preferred over systemic treatments, but data specific to the older population are scarce.

Methods

We conducted pooled analyses of multiple clinical trials to evaluate efficacy and safety of capsaicin patch in older patients. The analysis of efficacy included four randomized, double-blind, 12-week studies with similar trial design comparing a single treatment of capsaicin 179 mg cutaneous patch vs low-dose control patch in post-herpetic neuralgia. For the safety evaluation, data were pooled from 18 interventional studies in which capsaicin patch was used in PNP with varying etiologies.

Results

Capsaicin patch had similar analgesic efficacy in elderly (n=582) and non-elderly patients (n=545) in terms of change from baseline to 2-12 weeks in the 11-point numeric pain rating scale (NPRS) score for average pain over the previous 24 hours. In both age groups, decrease in NPRS score was significantly greater with capsaicin patch vs control. Older patients treated with capsaicin patch were significantly more likely than those in the control group to achieve responder status (ie mean decrease in NPRS score from baseline to week 2-12 of at least 30% or ≥2 points): 36.1% vs 27.1% (odds ratio [OR] [95% CI] 1.52 [1.06, 2.18]; P=0.0231) and 33.1% vs 20.9% (OR [95% CI] 1.90 [1.30, 2.78]; P=0.0009) for active treatment vs control group, respectively. Similar proportions of non-elderly patients (n=2,311) and elderly patients (n=537) treated with capsaicin patch experienced treatment-emergent adverse events (TEAEs) (81.6% and 78.1%, respectively) and serious TEAEs (8.2% and 7.2%), with application-site reactions the most common TEAEs in both groups.

Conclusion

The capsaicin patch was equally efficacious and well tolerated in older patients as in younger patients.

Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

Prediction of duloxetine efficacy in addition to self-management in painful temporomandibular disorders: A randomised, placebo-controlled clinical trial

BACKGROUND

Conditioned pain modulation (CPM) is a potential predictor of treatment response that has not been studied in temporomandibular disorders (TMD).

OBJECTIVES

We conducted a randomised, double-blind, placebo-controlled trial (RCT) of duloxetine in addition to self-management (SM) strategies to investigate its efficacy to reduce pain intensity in painful TMD patients. Moreover, we investigated whether baseline CPM would predict the duloxetine efficacy to reduce TMD pain intensity.

METHODS

Eighty participants were randomised to duloxetine 60 mg or placebo for 12 weeks. The primary outcomes were the change in the pain intensity from baseline to week-12 and CPM-sequential paradigm at baseline. Safety, physical and emotional functioning outcomes were also evaluated.

RESULTS

Of 80 participants randomised, 78 were included in intention-to-treat analysis. Pain intensity decreased for SM-duloxetine and SM-placebo but did not differ between groups (p = .82). A more efficient CPM was associated with a greater pain intensity reduction regardless of the treatment group (p = .035). Physical and emotional functioning did not differ between groups, but adverse events (p = .014), sleep impairment (p = .003) and catastrophizing symptoms (p = .001) were more prevalent in SM-duloxetine group.

CONCLUSION

This study failed to provide evidence of a beneficial effect of adding duloxetine to SM strategies for treatment of painful TMD. Nonetheless, this RCT has shown the feasibility of applying pain modulation assessment to predict short-term treatment response in painful TMD patients, which confirms previous finds that CPM evaluation may serve a step forward in individualising pain treatment.

The effectiveness of cervical transforaminal epidural steroid injections for the treatment of cervical radicular pain: A prospective cohort study reporting 12-month outcomes

Objectives

To evaluate the effectiveness of cervical transforaminal epidural steroid injection (CTFESI) for the treatment of unilateral cervical radicular pain.

Design

Single-group prospective cohort study.

Methods

Outcomes included ≥50% reductions in Numeric Rating Scale (NRS) for arm pain, ≥30% Neck Disability Index (NDI-5) improvement, health-related quality of life (EQ-5D), global improvement (PGIC), personal goal achievement (COMBI), Chronic Pain Sleep Index (CPSI), and healthcare utilization at one, three, six, and 12 months. Data analysis included descriptive statistics with the calculations of 95% confidence intervals (CIs), contingency table analysis, and multilevel logistic regression (LR) analysis, including a worst-case (WC) sensitivity analysis in which missing data were treated as treatment failure. Participants who were treated surgically were considered failures in the categorical analyses.

Results

33 consecutively enrolled participants (63.6% females, 51.2 ± 12.2 years of age, BMI 28.3 ± 4.5 kg/m2) were analyzed. Success rates for ≥50% reduction in NRS for arm pain at one, three, six and 12 months were 57.6% (95% CI 40.8-72.8%), 71.9% (95% CI 54.6-84.4%), 64.5% (95% CI 46.9-78.9%), and 64.5% (95% CI 46.9-78.9%). Success rates for ≥30% improvement in NDI-5 were 60.6% (95% CI 43.7-75.3%), 68.8% (95% CI 51.4-82.0%), 61.3% (95% CI 43.8-76.3%), and 71.0% (95% CI 53.4-83.9%). In WC analysis, success rates for ≥50% arm NRS and NDI-5 were 0-4.3% lower between 1 and 12 months. PGIC scores were at least "much improved" or "very much improved," in 48.4-65.6% of participants between 1 and 12 months. 6.1%, 6.1%, and 3.0% had one, two, or three repeat injections, respectively. 18.2% of participants underwent surgery by 12 months. Participants showed significant improvements in arm NRS and NDI-5 after treatment (p < 0.05), multilevel logistic regression models showed no significant decline in improvements across the follow-up time points (p > 0.05).

Conclusion

Statistically significant and clinically meaningful improvements in pain and disability were observed after CTFESI for up to 12 months in individuals with unilateral cervical radicular pain.

Minimally Invasive Bleb Surgery for Glaucoma: A Health Technology Assessment

Background

Glaucoma is the term for a group of eye disorders that causes progressive damage to the optic nerve, which can lead to visual impairment and, potentially, irreversible blindness. Minimally invasive bleb surgery (MIBS) reduces eye pressure through the implantation of a device that creates a new subconjunctival outflow pathway for eye fluid drainage. MIBS is a less invasive alternative to conventional/incisional glaucoma surgery (e.g., trabeculectomy). We conducted a health technology assessment of MIBS for people with glaucoma, which included an evaluation of effectiveness, safety, the budget impact of publicly funding MIBS, and patient preferences and values.

Methods

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias 1.0 tool for randomized controlled trials (RCTs) and the Risk of Bias Assessment tool for Nonrandomized Studies (RoBANS) for comparative observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We conducted an economic literature search and we estimated the budget impact of publicly funding MIBS in Ontario. We did not conduct a primary economic evaluation due to the limited long-term effectiveness data. We summarized the preferences and values evidence from previous health technology assessments to understand the perspectives and experiences of patients with glaucoma.

Results

We included 41 studies (2 RCTs and 39 comparative observational studies) in the clinical evidence review. MIBS may reduce intraocular pressure and the number of medications used, but we are uncertain if MIBS results in outcomes similar to trabeculectomy (GRADE: Moderate to Very low). Compared with trabeculectomy, MIBS may result in fewer follow-up visits and interventions, and adverse events (GRADE: Moderate to Very Low). MIBS may also reduce intraocular pressure and the number of antiglaucoma medications used, compared with other glaucoma treatments, but the evidence is uncertain (GRADE: Very low). Our economic evidence review identified two directly applicable studies. The results of these studies indicate that the cost-effectiveness of MIBS is highly uncertain, and the cost of glaucoma interventions are likely to vary across provinces. The annual budget impact of publicly funding MIBS in Ontario ranged from $0.11 million in year 1 to $0.67 million in year 5, for a total 5-year budget impact estimate of $1.93 million. Preferences and values evidence suggests that fear of ultimate blindness and difficulty managing medication for glaucoma led patients to explore other treatment options such as MIBS. Glaucoma patients found minimally invasive glaucoma surgery (MIGS) procedure beneficial, with minimal side effects and recovery time.

Conclusions

Minimally invasive bleb surgery reduces intraocular eye pressure and the number of antiglaucoma medications needed, but we are uncertain if the outcomes are similar to trabeculectomy (GRADE: Moderate to Very low). However, MIBS may be safer than trabeculectomy (GRADE: Moderate to Very low) and result in fewer follow-ups (GRADE: Moderate to Very low). MIBS may also improve glaucoma symptoms compared with other glaucoma treatments, but the evidence is very uncertain (GRADE: Very low).We estimate that publicly funding MIBS would result in an additional cost of $1.93 million over 5 years. Patients who underwent MIGS procedures found them to be generally successful and beneficial, with minimal side effects and recovery time. We could not draw conclusions about specific MIBS procedures or long-term outcomes.

Intrathecal Drug Delivery Systems for Cancer Pain: A Health Technology Assessment

Background

Pain is a common and very distressing symptom for adults and children with cancer. Compared with other routes of delivery, infusing pain medication directly into the intrathecal space around the spinal cord may reduce the incidence of systemic side effects and allow for more rapid and effective pain relief. We conducted a health technology assessment of intrathecal drug delivery systems (IDDSs) for adults and children with cancer pain, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding IDDSs, patient preferences and values, and ethical considerations.

Methods

We performed a systematic literature search of the clinical evidence to retrieve systematic reviews, and we selected and reported results from 2 recent reviews that were relevant to our research questions. We complemented the chosen systematic reviews with a literature search to identify primary studies published after December 2020. We used the Risk of Bias in Systematic Reviews (ROBIS) tool to assess the risk of bias of each included systematic review. We assessed the quality of the body of evidence according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search and conducted a cost-effectiveness analysis comparing IDDSs with standard care (i.e., non-IDDS methods of pain management) from a public payer perspective. We also analyzed the budget impact of publicly funding IDDSs in Ontario. To contextualize the potential value of IDDSs, we spoke with patients with cancer pain and with caregivers of patients with cancer pain. We explored ethical considerations from a review of published literature on the use of IDDSs for the management of cancer pain in adults and children as well as a review of the other components of this health technology assessment to identify ethical considerations relevant to the Ontario context.

Results

We included 2 systematic reviews (1 on adults and 1 on children) in the clinical evidence review. In adults with cancer pain who have a life expectancy greater than 6 months, intrathecal drug delivery was associated with a significant reduction in pain intensity compared with before implantation up to a 1-year follow-up (GRADE: Moderate to Low). Improved pain management appeared to be maintained beyond a 4-week follow-up. IDDSs likely decrease the use of systemic opioids (GRADE: Moderate to Low). They may also improve health-related quality of life (GRADE: Low), functional outcomes (GRADE: Low), and survival (GRADE: Low to Very low). In children with cancer pain, IDDSs may reduce pain intensity, improve functional outcomes, and improve survival, but the evidence is very uncertain (all GRADEs: Very low). IDDS implantation carries certain rare risks related to mechanical errors, drug-related side effects, and surgical complications. There are inherent limitations in conducting research in patients with refractory cancer pain; therefore, it is unlikely that higher-quality evidence will emerge in the next few years. Our primary economic evaluation found that IDDSs are more effective and more costly than standard care. The incremental cost-effectiveness ratio of IDDSs compared with standard care is $57,314 per quality-adjusted life-year (QALY) gained. The probability of IDDSs being cost-effective versus standard care is 43.46% at a willingness-to-pay of $50,000 per QALY gained and 72.54% at a willingness-to-pay of $100,000 per QALY gained. Publicly funding IDDSs in Ontario would cost an additional $0.27 million per year, for a total of $1.34 million over the next 5 years. The patients with cancer pain and caregivers with whom we spoke described the debilitating nature of cancer pain and the difficulty of finding effective pain management options. Patients with experience of an IDDS spoke of its effectiveness and its positive impact on their quality of life and mental health. Implementing IDDSs for patients with cancer pain raises several ethical and equity considerations related to the experiences and management of cancer pain, how limitations in evidence may entail uncertainties in clinical and health system decision-making, as well as clinical, geographic, and health system access barriers.

Conclusions

Intrathecal drug delivery likely reduces pain intensity and decreases the use of systemic opioids in adults with cancer pain who have a life expectancy greater than 6 months. It may also improve health-related quality of life, functional outcomes, and survival, although the evidence for survival is very uncertain. The clinical evidence in children with cancer pain is very uncertain. IDDS implantation is reasonably safe. Intrathecal drug delivery is more effective and more costly than standard care. We estimate that funding IDDSs in Ontario will result in additional costs of $0.27 million per year, for a total of $1.34 million over the next 5 years. Considerations related to funding and implementing IDDSs for patients with cancer pain in Ontario will require explicit and focused attention to considerations of equity and access in the diagnosis and management of cancer pain and in the use, clinical uptake, and delivery of IDDS pain management.

Non-pharmacological management of neuropathic pain in older adults: a systematic review

INTRODUCTION

Neuropathic pain encompasses multiple diagnoses with detrimental impacts on quality of life and overall health. In older adults, pharmacological management is limited by adverse effects and drug interactions, while surgical management involves perioperative risk. Prior reviews addressing non-pharmacological interventions for neuropathic pain have not focused on this demographic. Therefore, this systematic review synthesizes the evidence regarding the effectiveness of non-pharmacological interventions in reducing neuropathic pain severity in older adults.

METHODS

PubMed, CINAHL, Web of Science, and PsycInfo were searched using key terms, with inclusion criteria of age ≥ 65, neuropathic pain, non-pharmacological intervention, pain severity measurement, English language, peer-reviewed, and either randomized controlled trial (RCT) or quasi-experimental design. In total, 2759 records were identified, with an additional 28 records identified by review of reference lists. After removal of duplicates, 2288 records were screened by title and abstract, 404 full-text articles were assessed, and 19 articles were critically reviewed and synthesized.

RESULTS

Of the 14 RCTs and 5 quasi-experimental studies included in the review, the most common intervention was electric and/or magnetic therapy, followed by acupuncture, mindfulness meditation, exercise, and light therapy. Several studies revealed both statistical and clinical significance, but conclusions were limited by small sample sizes and methodological shortcomings. The interventions were generally safe and acceptable.

CONCLUSIONS

Results should be interpreted with consideration of clinical vs statistical significance, mediators of pain severity, and individual variations in effectiveness. Further research should address multimodal and novel interventions, newer models of care, and technology-based interventions.

The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review

OBJECTIVE

Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain.

DESIGN

Systematic review.

POPULATION

Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging.

INTERVENTION

Fluoroscopically guided or computed tomography-guided IDCI.

COMPARISON

Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment.

OUTCOMES

Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index.

METHODS

Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2).

RESULTS

Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography.

CONCLUSION

According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography.

STUDY REGISTRATION

PROSPERO (CRD42021287421).

In trials of physiotherapy for chronic low back pain, clinical relevance is rarely interpreted, with great heterogeneity in the frameworks and thresholds used: a meta-research study

QUESTIONS

How do authors of randomised controlled trials (RCTs) interpret the clinical relevance of the effects of physiotherapy interventions compared with no intervention on pain intensity, physical function and time to recovery in people with chronic low back pain (CLBP)? How can the clinical relevance be re-interpreted based on the available smallest worthwhile effect (SWE) threshold for this comparison? Are the studies in this field adequately powered?

DESIGN

Cross-sectional meta-research study.

PARTICIPANTS

People with CLBP.

OUTCOME MEASURES

Pain intensity, physical function and time to recovery.

RESULTS

This review included 23 RCTs with 1,645 participants. Twenty-two and 18 studies were included in the analysis of pain intensity and physical function, respectively. No studies investigated time to recovery. Sixteen studies reported varying thresholds to interpret clinical relevance for physical function and pain intensity. Discrepancies between interpretation using the minimal important difference and SWE values were observed in five studies. Study power ranged from 9% to 98%, with only four studies having a power > 80%.

CONCLUSION

Little attention is given to the interpretation of clinical relevance in RCTs comparing physiotherapy with no intervention in CLBP, with great heterogeneity in the frameworks and thresholds used. Future trials should inform patients and clinicians on whether the effect of an intervention is large enough to be worthwhile, using a reliable and comprehensive approach like available SWE estimates.

REGISTRATION

medRxiv https://doi.org/10.1101/2022.12.14.22283454.

Minimal important change and difference in health outcome: An overview of approaches, concepts, and methods

OBJECTIVE

To provide an overview of approaches, concepts, and methods used to define and assess minimal important change and difference in health outcome.

METHOD

A narrative review of the literature, guided by a conceptual framework.

RESULTS

We distinguish between (i) interpretation of health outcome in individuals versus groups, (ii) change within individuals or groups versus difference between change within individuals or groups; and (iii) the responder approach (based on the proportion of patients that obtain a defined response) versus the group average approach (based on the average amount of change in a group). We review approaches, concepts, and methods.

CONCLUSION

By bringing together and juxtaposing various approaches, concepts, and methods, we set a precursory step in the direction of consensus building in the field concerned with defining and assessing minimal important change and difference in health outcome. We emphasize the need for conceptual clarification and terminological standardization. We argue that assessing minimal importance of change and difference in health outcome is essentially a value judgment involving a range of considerations and perspectives.

Exercise Training for Chronic Pain: Available Evidence, Current Recommendations, and Potential Mechanisms

Chronic pain conditions pose a significant global burden of disability, with epidemiological data indicating a rising incidence. Exercise training is commonly recommended as a standalone or complementary approach for managing various chronic pain conditions like low back pain, osteoarthritis, rheumatoid arthritis, fibromyalgia syndrome, and neuropathic pain. Regardless of the specific condition or underlying cause (e.g., autoimmune disease, chronic inflammation), exercise training consistently leads to moderate to large reductions in pain. Moreover, exercise yields numerous benefits beyond pain alleviation, including small-to-moderate improvements in disability, quality of life, and physical function. Despite its efficacy, there is a lack of comprehensive research delineating the optimal intensity, duration, and type of exercise for maximal benefits; however, evidence suggests that sustained engagement in regular exercise or physical activity is necessary to achieve and maintain reductions in both clinical pain intensity ratings and the level that pain interferes with activities of daily living. Additionally, the precise mechanisms through which exercise mitigates pain remain poorly understood and likely vary based on the pathophysiological mechanisms underlying each condition.