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Nishtar M, Mark R, Langford DJ, McDermott MP, Markman JD, Evans SR, France FO, Park M, Sharma S, Turk DC, Dworkin RH, Gewandter JS. Evaluating the balance of benefits and harms in chronic pain clinical trials: prioritizing individual participants over individual outcomes. Reg Anesth Pain Med 2024; 49:363-367. [PMID: 37963675 PMCID: PMC11081843 DOI: 10.1136/rapm-2023-104809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/26/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) generally assess efficacy and safety separately, with the conclusion of whether a treatment is beneficial based solely on the efficacy endpoint. However, assessing and combining efficacy and safety domains, using a single composite outcome measure, can provide a more comprehensive assessment of the overall effect of a treatment. Furthermore, composite outcomes can incorporate information regarding the relationship between the individual outcomes. In fact, such outcomes have been suggested in the clinical trials literature for at least 15 years. OBJECTIVES To (1) identify whether recent primary publications of chronic pain RCTs from major pain journals included a composite outcome measure of benefits and harms and (2) discuss the potential benefits of such outcomes in various stages of treatment development, including as outcome measures in RCTs, and to support decisions of Data and Safety Monitoring Boards and ordering of treatments in the context of treatment guidelines. EVIDENCE REVIEW RCTs published in 6 major pain journals published between 2016 and 2021 that investigated interventions for chronic pain were reviewed. FINDINGS Of 73 RCTs identified, only 2 included a composite outcome measure of benefits and harms. Both of these articles compared 2 active treatments. CONCLUSIONS Composite outcomes of benefits and harms are underutilized in chronic pain RCTs. The advantages and challenges of using such outcomes are discussed.
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Affiliation(s)
- Mahd Nishtar
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Remington Mark
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Dale J Langford
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Scott R Evans
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Fallon O France
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Meghan Park
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Sonia Sharma
- School of Medicine and Biomedical Sciences, University at Buffalo Jacobs, Buffalo, New York, USA
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Jennifer S Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
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Goudman L, De Smedt A, Billot M, Roulaud M, Rigoard P, Moens M. Opinions of Health Care Providers About Neuromodulation for Pain: Results of an Online Survey at the 2nd Joint Congress of the International Neuromodulation Society European Chapters. Neuromodulation 2023; 26:1887-1892. [PMID: 35551866 DOI: 10.1016/j.neurom.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/23/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Neuromodulation for pain has been successfully applied for decades, in that the goals and expectations that patients aim to achieve are clearly described. Nevertheless, the point of view of health care providers is less clear. Therefore, this study aimed to explore the goals, expectations, and definition of success for neuromodulation for pain according to health care providers. MATERIALS AND METHODS An online survey was developed and spread at the 2nd Joint Congress of the International Neuromodulation Society (INS) European Chapters in September 2021 in Paris. Respondents were asked 1) to select the goals to treat patients with neuromodulation for pain, 2) to indicate factors that they expect to change according to neuromodulation for pain, and 3) to provide their definition of success of neuromodulation for pain. RESULTS We approached 101 respondents, of whom 88 health care providers at least partly completed the survey. Increasing mobility/functionality (26.7%), decreasing pain intensity (24.5%), and decreasing medication use (16.6%) were the most frequently reported goals of neuromodulation. The same top three variables were selected as factors that health care providers expected to change. For the definition of success, quality of life of patients outranked other definitions. Other highly ranked definitions, in descending order, were obtaining pain relief, increasing functionality, and increasing patient satisfaction. DISCUSSION Goals and expectations of health care providers are not completely in line with previously explored goals of patients that are related to pain relief and improving walking abilities. Health care providers seem to put a high emphasis on the quality of life of the patient when evaluating the success of neuromodulation, which is not completely aligned with the currently used reimbursement rules that are mainly focusing on pain relief instead of incorporating health-related quality of life. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT05013840.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium.
| | - Ann De Smedt
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Rigoard P, Ounajim A, Moens M, Goudman L, Roulaud M, Lorgeoux B, Baron S, Nivole K, Many M, Lampert L, David R, Billot M. Should we Oppose or Combine Waveforms for Spinal Cord Stimulation in PSPS-T2 Patients? A Prospective Randomized Crossover Trial (MULTIWAVE Study). THE JOURNAL OF PAIN 2023; 24:2319-2339. [PMID: 37473903 DOI: 10.1016/j.jpain.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
Refractory persistent spinal pain syndrome after surgery (PSPS-T2) can be successfully addressed by spinal cord stimulation (SCS). While conventional stimulation generates paresthesia, recent systems enable the delivery of paresthesia-free stimulation. Studies have claimed non-inferiority/superiority of selected paresthesia-free stimulation compared with paresthesia-based stimulation, but the comparative efficacy between different waveforms still needs to be determined in a given patient. We designed a randomized controlled 3-month crossover trial to compare pain relief of paresthesia-based stimulation versus high frequency versus burst in 28 PSPS-T2 patients implanted with multiwave SCS systems. Our secondary objectives were to determine the efficacy of these 3 waveforms on pain surface, quality of life, functional capacity, psychological distress, and validated composite multidimensional clinical response index to provide holistic comparisons at 3-, 6-, 9-, and 15-month post-randomization. The preferred stimulation modality was documented during the follow-up periods. No difference between the waveforms was observed in this study (P = .08). SCS led to significant pain relief, quality of life improvement, improvement of multidimensional clinical response index, and of all other clinical outcomes at all follow-up visits. Forty-four percent of the patients chose to keep the paresthesia-based stimulation modality after the 15-month follow-up period. By giving the possibility to switch and/or to combine several waveforms, the overall rate of SCS responders further increased with 25%. In this study, high frequency or burst do not appear superior to paresthesia-based stimulation, wherefore paresthesia-based stimulation should still be considered as a valid option. However, combining paresthesia-based stimulation with paresthesia-free stimulation, through personalized multiwave therapy, might significantly improve SCS responses. PERSPECTIVE: This article assesses clinical SCS efficacy on pain relief, by comparing paresthesia-based stimulation and paresthesia-free stimulation (including high frequency and burst) modalities in patient presenting with PSPS-T2. Switching and/or combining waveforms contribute to increasing the global SCS responders rate.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Kévin Nivole
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Mathilde Many
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Lucie Lampert
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, Poitiers, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
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Stamenkovic D, Baumbach P, Radovanovic D, Novovic M, Ladjevic N, Dubljanin Raspopovic E, Palibrk I, Unic-Stojanovic D, Jukic A, Jankovic R, Bojic S, Gacic J, Stamer UM, Meissner W, Zaslansky R. The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry. Clin J Pain 2023; 39:537-545. [PMID: 37589465 DOI: 10.1097/ajp.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/17/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs). METHODS "PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not. RESULTS Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline. DISCUSSION We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.
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Affiliation(s)
- Dusica Stamenkovic
- Department of Anesthesiology and Intensive Care
- University of Defence, Medical Faculty of the Military Medical Academy
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Dragana Radovanovic
- Department of Anesthesiology and Intensive Care, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad
| | - Milos Novovic
- Department of Anesthesiology and Intensive Care, Prijepolje General Hospital, Prijepolje
| | - Nebojsa Ladjevic
- Department of Anesthesia and Resuscitation of Urology Clinic, Centre of Anesthesia and Resuscitatio
- University of Belgrade, Faculty of Medicine
| | - Emilija Dubljanin Raspopovic
- Department for Physical Medicine and Rehabilitation, Center for Physical Medicine and Rehabilitation
- University of Belgrade, Faculty of Medicine
| | - Ivan Palibrk
- Department of Anesthesiology and Intensive Care, Center for Anesthesiology and Resuscitation, Clinic for Digestive Surgery, University Clinical Center of Serbia
- University of Belgrade, Faculty of Medicine
| | - Dragana Unic-Stojanovic
- University of Belgrade, Faculty of Medicine
- Department of Anesthesiology and Intensive Care, Institute for Cardiovascular Diseases Dedinje, Belgrade
| | - Aleksandra Jukic
- Department of Anesthesiology and Intensive Care, National Cancer Research Center of Serbia
| | - Radmilo Jankovic
- Department of Anesthesiology and Intensive Therapy, University Clinical Center Nis, University of Nis, Nis, Serbia
| | - Suzana Bojic
- University of Belgrade, Faculty of Medicine
- Department of Anesthesiology and Intensive Care, University Hospital Medical Center "Dr.Dragisa Misovic - Dedinje"
| | - Jasna Gacic
- University of Belgrade, Faculty of Medicine
- Department of General Surgery, Clinical Hospital Center, Bezanijska Kosa, Belgrade
| | - Ulrike M Stamer
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Ruth Zaslansky
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Friedrich Schiller University, Jena, Germany
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Deer T, Gilligan C, Falowski S, Desai M, Pilitsis J, Jameson J, Moeschler S, Heros R, Tavel E, Christopher A, Patterson D, Wahezi S, Weisbein J, Antony A, Funk R, Ibrahim M, Lim C, Wilson D, Fishell M, Scarfo K, Dickerson D, Braun E, Buchanan P, Levy RM, Miller N, Duncan J, Xu J, Candido K, Kreiner S, Fahey ME, Yue J. Treatment of Refractory Low Back Pain Using Passive Recharge Burst in Patients Without Options for Corrective Surgery: Findings and Results From the DISTINCT Study, a Prospective Randomized Multicenter Controlled Trial. Neuromodulation 2023; 26:1387-1399. [PMID: 37642628 PMCID: PMC10801705 DOI: 10.1016/j.neurom.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/13/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Spinal cord stimulation (SCS) is effective for relieving chronic intractable pain conditions. The Dorsal spInal cord STImulatioN vs mediCal management for the Treatment of low back pain study evaluates the effectiveness of SCS compared with conventional medical management (CMM) in the treatment of chronic low back pain in patients who had not undergone and were not candidates for lumbar spine surgery. METHODS AND MATERIALS Patients were randomized to passive recharge burst therapy (n = 162) or CMM (n = 107). They reported severe pain and disability for more than a decade and had failed a multitude of therapies. Common diagnoses included degenerative disc disease, spondylosis, stenosis, and scoliosis-yet not to a degree amenable to surgery. The six-month primary end point compared responder rates, defined by a 50% reduction in pain. Hierarchical analyses of seven secondary end points were performed in the following order: composite responder rate (numerical rating scale [NRS] or Oswestry Disability Index [ODI]), NRS, ODI, Pain Catastrophizing Scale responder rate, Patient Global Impression of Change (PGIC) responder rate, and Patient-Reported Outcome Measure Information System-29 in pain interference and physical function. RESULTS Intention-to-treat analysis showed a significant difference in pain responders on NRS between SCS (72.6%) and CMM (7.1%) arms (p < 0.0001). Of note, 85.2% of those who received six months of therapy responded on NRS compared with 6.2% of those with CMM (p < 0.0001). All secondary end points indicated the superiority of burst therapy over CMM. A composite measure on function or pain relief showed 91% of subjects with SCS improved, compared with 16% of subjects with CMM. A substantial improvement of 30 points was observed on ODI compared with a CONCLUSIONS This study found substantial improvement at six months in back pain, back pain-related disability, pain-related emotional suffering, PGIC, pain interference, and physical function in a population with severe, debilitating back pain for more than a decade. These improvements were reported in conjunction with reduced opioid use, injection, and ablation therapy. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT04479787.
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Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Mehul Desai
- International Spine, Pain & Performance Center, Washington, DC, USA
| | | | | | | | | | - Edward Tavel
- Clinical Trials of South Carolina, Charleston, SC, USA
| | | | | | - Sayed Wahezi
- Montefiore Medical Center-Waters Place, New York, NY, USA
| | | | | | | | - Mohab Ibrahim
- Banner University Medical Center Tucson Campus, Tucson, AZ, USA
| | - Chi Lim
- Carolina Orthopaedic & Neurosurgical Associates, SC, USA
| | | | | | | | | | | | - Patrick Buchanan
- Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA
| | | | - Nathan Miller
- Coastal Pain & Spinal Diagnostics Medical Group, Carlsbad, CA, USA
| | - Jonathan Duncan
- Burkhart Research Institute for Orthopaedics, San Antonio, TX, USA
| | - Jijun Xu
- The Cleveland Clinic Foundation, OH, USA
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Bojic S, Ladjevic N, Palibrk I, Soldatovic I, Likic-Ladjevic I, Meissner W, Zaslansky R, Stamer UM, Baumbach P, Stamenkovic D. Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study. Front Public Health 2023; 11:1157484. [PMID: 37744520 PMCID: PMC10513912 DOI: 10.3389/fpubh.2023.1157484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. Materials and methods The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. Results The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. Conclusion The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.
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Affiliation(s)
- Suzana Bojic
- Department of Anesthesiology and Intensive Care, University Hospital Medical Centre “Dr. Dragisa Misovic – Dedinje”, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nebojsa Ladjevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Centre of Anaesthesia and Resuscitation University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivan Palibrk
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Centre of Anaesthesia and Resuscitation University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Likic-Ladjevic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Ruth Zaslansky
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Ulrike M Stamer
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Dusica Stamenkovic
- Medical Faculty of Military Medical Academy, University of Defense, Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia
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Huygen F, Hagedorn JM, Falowski S, Schultz D, Vesper J, Heros RD, Patterson DG, Dehghan S, Ross E, Kyani A, Mansouri MB, Kallewaard JW. Core patient-reported outcome measures for chronic pain patients treated with spinal cord stimulation or dorsal root ganglia stimulation. Health Qual Life Outcomes 2023; 21:77. [PMID: 37474950 PMCID: PMC10357671 DOI: 10.1186/s12955-023-02158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Neurostimulation is a highly effective therapy for the treatment of chronic Intractable pain, however, due to the complexity of pain, measuring a subject's long-term response to the therapy remains difficult. Frequent measurement of patient-reported outcomes (PROs) to reflect multiple aspects of subjects' pain is a crucial step in determining therapy outcomes. However, collecting full-length PROs is burdensome for both patients and clinicians. The objective of this work is to identify the reduced set of questions from multiple validated PROs that can accurately characterize chronic pain patients' responses to neurostimulation therapies. METHODS Validated PROs were used to capture pain, physical function and disability, as well as psychometric, satisfaction, and global health metrics. PROs were collected from 509 patients implanted with Spinal Cord Stimulation (SCS) or Dorsal Root Ganglia (DRG) neurostimulators enrolled in the prospective, international, post-market REALITY study (NCT03876054, Registration Date: March 15, 2019). A combination of linear regression, Pearson's correlation, and factor analysis were used to eliminate highly correlated questions and find the minimal meaningful set of questions within the predefined domains of each scale. RESULTS The shortened versions of the questionnaires presented almost identical accuracy for classifying the therapy outcomes as compared to the validated full-length versions. In addition, principal component analysis was performed on all the PROs and showed a robust clustering of pain intensity, psychological factors, physical function, and sleep across multiple PROs. A selected set of questions captured from multiple PROs can provide adequate information for measuring neurostimulation therapy outcomes. CONCLUSIONS PROs are important subjective measures to evaluate the physiological and psychological aspects of pain. However, these measures are cumbersome to collect. These shorter and more targeted PROs could result in better patient engagement, and enhanced and more frequent data collection processes for digital health platforms that minimize patient burden while increasing therapeutic benefits for chronic pain patients.
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Affiliation(s)
- Frank Huygen
- Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, Postbus 2040, 3000, Rotterdam, CA, Netherlands.
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jan Vesper
- Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
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MacLean RR, Buta E, Higgins DM, Driscoll MA, Edmond SN, LaChappelle KM, Ankawi B, Krein SL, Piette JD, Heapy AA. Using Daily Ratings to Examine Treatment Dose and Response in Cognitive Behavioral Therapy for Chronic Pain: A Secondary Analysis of the Co-Operative Pain Education and Self-Management Clinical Trial. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:846-854. [PMID: 36484691 PMCID: PMC10250557 DOI: 10.1093/pm/pnac192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/15/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cognitive behavioral therapy for chronic pain (CBT-CP) has a strong evidence base, but little is known about when treatment benefits are achieved. The present study is a secondary analysis of individuals with chronic back pain recruited for a noninferiority trial comparing interactive voice response (IVR) CBT-CP with in-person CBT-CP. METHODS On the basis of data from daily IVR surveys, a clinically meaningful change was defined as a 30% reduction in pain intensity (n = 108) or a 45% increase in daily steps (n = 104) compared with the baseline week. We identified individuals who achieved a meaningful change at any point during treatment, and then we compared those who maintained a meaningful change in their final treatment week (i.e., responders) with those who did not or who achieved a meaningful change but lapsed (i.e., nonresponders). RESULTS During treatment, 46% of participants achieved a clinically meaningful decrease in pain intensity, and 66% achieved a clinically significant increase in number of steps per day. A total of 54% of patients were classified as responders in terms of decreases in pain intensity, and 70% were responders in terms of increases in step count. Survival analyses found that 50% of responders first achieved a clinically meaningful change by week 4 for pain intensity and week 2 for daily steps. Dropout and demographic variables were unrelated to responder status, and there was low agreement between the two measures of treatment response. CONCLUSIONS Collectively, results suggest that most responders improve within 4 weeks. Evaluating treatment response is highly specific to the outcome measure, with little correlation across outcomes.
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Affiliation(s)
- R. Ross MacLean
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eugenia Buta
- Yale Center for Analytical Sciences, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Diana M. Higgins
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Mary A. Driscoll
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sara N. Edmond
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kathryn M. LaChappelle
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
| | - Brett Ankawi
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Sarah L. Krein
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - John D. Piette
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Department of Health Behavior Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Alicia A. Heapy
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Health Services Research and Development Center of Innovation, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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9
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Heros R, Patterson D, Huygen F, Skaribas I, Schultz D, Wilson D, Fishman M, Falowski S, Moore G, Kallewaard JW, Dehghan S, Kyani A, Mansouri M. Objective wearable measures and subjective questionnaires for predicting response to neurostimulation in people with chronic pain. Bioelectron Med 2023; 9:13. [PMID: 37340467 PMCID: PMC10283222 DOI: 10.1186/s42234-023-00115-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/06/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Neurostimulation is an effective therapy for treating and management of refractory chronic pain. However, the complex nature of pain and infrequent in-clinic visits, determining subject's long-term response to the therapy remains difficult. Frequent measurement of pain in this population can help with early diagnosis, disease progression monitoring, and evaluating long-term therapeutic efficacy. This paper compares the utilization of the common subjective patient-reported outcomes with objective measures captured through a wearable device for predicting the response to neurostimulation therapy. METHOD Data is from the ongoing international prospective post-market REALITY clinical study, which collects long-term patient-reported outcomes from 557 subjects implanted by Spinal Cord Stimulator (SCS) or Dorsal Root Ganglia (DRG) neurostimulators. The REALITY sub-study was designed for collecting additional wearables data on a subset of 20 participants implanted with SCS devices for up to six months post implantation. We first implemented a combination of dimensionality reduction algorithms and correlation analyses to explore the mathematical relationships between objective wearable data and subjective patient-reported outcomes. We then developed machine learning models to predict therapy outcome based on the subject's response to the numerical rating scale (NRS) or patient global impression of change (PGIC). RESULTS Principal component analysis showed that psychological aspects of pain were associated with heart rate variability, while movement-related measures were strongly associated with patient-reported outcomes related to physical function and social role participation. Our machine learning models using objective wearable data predicted PGIC and NRS outcomes with high accuracy without subjective data. The prediction accuracy was higher for PGIC compared with the NRS using subjective-only measures primarily driven by the patient satisfaction feature. Similarly, the PGIC questions reflect an overall change since the study onset and could be a better predictor of long-term neurostimulation therapy outcome. CONCLUSIONS The significance of this study is to introduce a novel use of wearable data collected from a subset of patients to capture multi-dimensional aspects of pain and compare the prediction power with the subjective data from a larger data set. The discovery of pain digital biomarkers could result in a better understanding of the patient's response to therapy and their general well-being.
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Affiliation(s)
| | | | - Frank Huygen
- Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Michael Fishman
- Center for Interventional Pain and Spine, Lancaster, PA, USA
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10
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Goudman L, Pilitsis JG, Russo M, Slavin KV, Hayek SM, Billot M, Roulaud M, Rigoard P, Moens M. From pain intensity to a holistic composite measure for spinal cord stimulation outcomes. Br J Anaesth 2023:S0007-0912(23)00252-0. [PMID: 37328304 DOI: 10.1016/j.bja.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/18/2023] Open
Affiliation(s)
- Lisa Goudman
- STIMULUS Research Group (reSearch and TeachIng NeuroModULation Uz BruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders (Fonds voor Wetenschappelijk Onderzoek - FWO), Brussels, Belgium; Florida Atlantic University, Boca Raton, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, Australia
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois Chicago, Chicago, USA; Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, USA
| | - Salim M Hayek
- Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, USA
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery Laboratory), Poitiers University Hospital, Poitiers, France
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery Laboratory), Poitiers University Hospital, Poitiers, France
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery Laboratory), Poitiers University Hospital, Poitiers, France; Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, Poitiers, France; Prime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Maarten Moens
- STIMULUS Research Group (reSearch and TeachIng NeuroModULation Uz BruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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11
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Gewandter JS, Edwards RR, Hill KP, Wasan AD, Hooker JE, Lape EC, Besharat S, Cowan P, Foll BL, Ditre JW, Freeman R. Cannabinoid Therapy: Attitudes and Experiences of People With Chronic Pain. Clin J Pain 2023; 39:249-258. [PMID: 36971412 PMCID: PMC10563515 DOI: 10.1097/ajp.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Clinical trials of cannabinoids for chronic pain have mixed and often inconclusive results. In contrast, many prospective observational studies show the analgesic effects of cannabinoids. This survey study aimed to examine the experiences/attitudes of individuals with chronic pain who are currently taking, have previously taken, or never taken cannabinoids for chronic pain to inform future research. METHODS This study is based on a cross-sectional, web-based survey of individuals with self-reported chronic pain. Participants were invited to participate through an email that was distributed to the listservs of patient advocacy groups and foundations that engage individuals with chronic pain. RESULTS Of the 969 respondents, 444 (46%) respondents reported currently taking, 213 (22%) previously taken, and 312 (32%) never taken cannabinoids for pain. Participants reported using cannabinoids to treat a wide variety of chronic pain conditions. Those currently taking cannabinoids (vs previously) more frequently reported: (1) large improvements from cannabinoids in all pain types, including particularly difficult-to-treat chronic overlapping pain conditions (eg, pelvic pain), (2) improvements in comorbid symptoms (eg, sleep), and (3) lower interference from side effects. Those currently taking cannabinoids reported more frequent and satisfactory communication with clinicians regarding cannabinoid use. Those never taken cannabinoids reported a lack of suggestion/approval of a clinician (40%), illegality (25%), and lack of FDA regulation (19%) as reasons for never trying cannabinoids. CONCLUSION These findings underscore the importance of conducting high-quality clinical trials that include diverse pain populations and clinically relevant outcomes that if successful, could support FDA approval of cannabinoid products. Clinicians could then prescribe and monitor these treatments similarly to other chronic pain medications.
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Affiliation(s)
- Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Kevin P. Hill
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julia E. Hooker
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Emma C. Lape
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Soroush Besharat
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, CA
- Addictions Division, Centre for Addiction and Mental Health, Toronto, CA
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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12
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Goudman L, Putman K, Van Doorslaer L, Billot M, Roulaud M, Rigoard P, Moens M. Proportion of clinical holistic responders in patients with persistent spinal pain syndrome type II treated by subthreshold spinal cord stimulation compared to best medical treatment: a study protocol for a multicentric randomised controlled trial (TRADITION). Trials 2023; 24:120. [PMID: 36803412 PMCID: PMC9940414 DOI: 10.1186/s13063-023-07140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Integrating information on bodily functions, pain intensity and quality of life into one composite measure of a holistic responder has recently been proposed as a useful method to evaluate treatment efficacy of spinal cord stimulation (SCS) in patients with therapy-refractory persistent spinal pain syndrome type II (PSPS-T2). Previous studies already demonstrated the efficacy of standard SCS over best medical treatment (BMT) and the superiority of new subthreshold (i.e. paresthesia free) SCS paradigms compared to standard SCS. Nevertheless, the efficacy of subthreshold SCS compared to BMT has not yet been investigated in patients with PSPS-T2, neither with unidimensional outcomes nor with a composite measure. The current objective is to examine whether subthreshold SCS, compared to BMT, provided to patients with PSPS-T2 results in a different proportion of clinical holistic responders (as composite measure) at 6 months. METHODS A two-arm multicentre randomised controlled trial will be conducted whereby 114 patients will be randomised (1:1) to (a) BMT or (b) paresthesia-free SCS. After a follow-up period of 6 months (primary time endpoint), patients receive the opportunity to cross over towards the other treatment group. The primary outcome is the proportion of clinical holistic responders at 6 months (i.e. a composite measure of pain intensity, medication, disability, health-related quality of life and patient satisfaction). The secondary outcomes are work status, self-management, anxiety, depression and healthcare expenditure. DISCUSSION Within the TRADITION project, we propose to shift the focus from a unidimensional outcome measure towards a composite measure as primary outcome measure to evaluate the efficacy of currently used subthreshold SCS paradigms. The lack of methodologically rigorous trials exploring the clinical efficacy and socio-economic consequences of subthreshold SCS paradigms is pressing, especially in light of the growing burden of PSPS-T2 on the society. TRIAL REGISTRATION ClinicalTrials.gov NCT05169047. Registered on December 23, 2021.
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Affiliation(s)
- Lisa Goudman
- STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium. .,Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium. .,Research Foundation Flanders (FWO), Egmontstraat 5, 1000, Brussels, Belgium.
| | - Koen Putman
- grid.8767.e0000 0001 2290 8069Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Interuniversity Centre for Health Economics Research (I-CHER), Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Leen Van Doorslaer
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Maxime Billot
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Manuel Roulaud
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France
| | - Philippe Rigoard
- grid.411162.10000 0000 9336 4276PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France ,grid.411162.10000 0000 9336 4276Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France ,grid.434217.70000 0001 2178 9782Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | | | - Maarten Moens
- grid.8767.e0000 0001 2290 8069STIMULUS Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.8767.e0000 0001 2290 8069Department of Physiotherapy, Pain in Motion Research Group (PAIN), Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium ,grid.411326.30000 0004 0626 3362Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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13
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Zaslansky R, Baumbach P, Edry R, Chetty S, Min LS, Schaub I, Cruz JJ, Meissner W, Stamer UM. Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data. J Clin Med 2023; 12:jcm12020676. [PMID: 36675605 PMCID: PMC9864952 DOI: 10.3390/jcm12020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
- Correspondence: (R.Z.); (U.M.S.)
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ruth Edry
- Acute Pain Service, Department of Anesthesiology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Sean Chetty
- Department of Anaesthesiology& Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7500, South Africa
| | - Lim Siu Min
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Isabelle Schaub
- Department of Anesthesiology and Pain Clinic, Clinique St Jean, 1000 Brussels, Belgium
| | - Jorge Jimenez Cruz
- Department of Obstetrics and Gynecology, Bonn University Hospital, 53127 Bonn, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ulrike M. Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (R.Z.); (U.M.S.)
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14
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Levy RM, Mekhail N, Abd-Elsayed A, Abejón D, Anitescu M, Deer TR, Eldabe S, Goudman L, Kallewaard JW, Moens M, Petersen EA, Pilitsis JG, Pope JE, Poree L, Raslan AM, Russo M, Sayed D, Staats PS, Taylor RS, Thomson S, Verrills P, Duarte RV. Holistic Treatment Response: An International Expert Panel Definition and Criteria for a New Paradigm in the Assessment of Clinical Outcomes of Spinal Cord Stimulation. Neuromodulation 2023:S1094-7159(22)01379-4. [PMID: 36604242 DOI: 10.1016/j.neurom.2022.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Treatment response to spinal cord stimulation (SCS) is focused on the magnitude of effects on pain intensity. However, chronic pain is a multidimensional condition that may affect individuals in different ways and as such it seems reductionist to evaluate treatment response based solely on a unidimensional measure such as pain intensity. AIM The aim of this article is to add to a framework started by IMMPACT for assessing the wider health impact of treatment with SCS for people with chronic pain, a "holistic treatment response". DISCUSSION Several aspects need consideration in the assessment of a holistic treatment response. SCS device data and how it relates to patient outcomes, is essential to improve the understanding of the different types of SCS, improve patient selection, long-term clinical outcomes, and reproducibility of findings. The outcomes to include in the evaluation of a holistic treatment response need to consider clinical relevance for patients and clinicians. Assessment of the holistic response combines two key concepts of patient assessment: (1) patients level of baseline (pre-treatment) unmet need across a range of health domains; (2) demonstration of patient-relevant improvements in these health domains with treatment. The minimal clinical important difference (MCID) is an established approach to reflect changes after a clinical intervention that are meaningful for the patient and can be used to identify treatment response to each individual domain. A holistic treatment response needs to account for MCIDs in all domains of importance for which the patient presents dysfunctional scores pre-treatment. The number of domains included in a holistic treatment response may vary and should be considered on an individual basis. Physiologic confirmation of therapy delivery and utilisation should be included as part of the evaluation of a holistic treatment response and is essential to advance the field of SCS and increase transparency and reproducibility of the findings.
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Affiliation(s)
- Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
| | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Madrid, Spain
| | | | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium
| | - Jan W Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, the Netherlands; Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Brussels, Belgium; STIMULUS research group, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Department of Clinical Neurosciences, Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Lawrence Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia
| | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Rod S Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK; MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Simon Thomson
- Department of Pain Medicine and Neuromodulation, Mid & South Essex University Hospitals, Essex, UK
| | - Paul Verrills
- Metro Pain Group, Melbourne, New South Wales, Australia
| | - Rui V Duarte
- Saluda Medical Pty Ltd, Artarmon, New South Wales, Australia; Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK.
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15
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Maximizing treatment efficacy through patient stratification in neuropathic pain trials. Nat Rev Neurol 2023; 19:53-64. [PMID: 36400867 DOI: 10.1038/s41582-022-00741-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
Treatment of neuropathic pain remains inadequate despite the elucidation of multiple pathophysiological mechanisms and the development of promising therapeutic compounds. The lack of success in translating knowledge into clinical practice has discouraged pharmaceutical companies from investing in pain medicine; however, new patient stratification approaches could help bridge the translation gap and develop individualized therapeutic approaches. As we highlight in this article, subgrouping of patients according to sensory profiles and other baseline characteristics could aid the prediction of treatment success. Furthermore, novel outcome measures have been developed for patients with neuropathic pain. The extent to which sensory profiles and outcome measures can be employed in routine clinical practice and clinical trials and across distinct neuropathic pain aetiologies is yet to be determined. Improvements in animal models, drawing on our knowledge of human pain, and robust public-private partnerships will be needed to pave the way to innovative and effective pain medicine in the future.
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Goudman L, Rigoard P, Billot M, De Smedt A, Roulaud M, Consortium D, Moens M, De Keersmaecker K, Gorissen M, De Clerck C, Donck AV, Braems H, Buyse K, Puylaert M, Duyvendak W, De Smet C, Vissers S, Debeuf J, De Beucker K, Ceuppens J, Germonpré PJ, Mortier S, Van Buyten JP, Smet I, Devos M, Vanhauwaert D, Billet B, Hanssens K, Demeyere A, Casier T, Bertrem B, Van Havenbergh T, Van Looy P, Heylen G, de Schryver C, Vangeneugden J, Louis F, Stalmans V, Remacle JM, Remacle T, Mauviel S, Abeloos L, Theys T, Van Hoylandt A, Bruyninckx D, Das J, Callebaut I, Rigoard P, Roulaud M, Lorgeoux B, De Jaeger M, Espinoza AV, Van Hooff RJ. Spinal Cord Stimulation-Naïve Patients vs Patients With Failed Previous Experiences With Standard Spinal Cord Stimulation: Two Distinct Entities or One Population? Neuromodulation 2023; 26:157-163. [PMID: 35551868 DOI: 10.1016/j.neurom.2022.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/25/2021] [Accepted: 01/26/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Nowadays, the success of spinal cord stimulation (SCS) is evaluated separately in patients who have previous experiences with standard SCS and in SCS-naïve patients. Nevertheless, it is yet to be evaluated whether both patient groups are effectively distinct patient groups. Therefore, the aims of this study are twofold: 1) Are there clusters in the data to distinguish between both patient groups? 2) Can we discriminate both patient groups based on routinely collected clinical parameters? MATERIALS AND METHODS Baseline data from the Discover study were used, in which 263 patients with persistent spinal pain syndrome type 2 were included (185 neurostimulation-naïve patients and 78 patients with previous SCS experience). Pain intensity scores for low back and leg pain, functional disability, medication use, and health-related quality of life utility scores were used in the analysis. Model-based clustering was performed on standardized data. Discriminant analysis was performed with linear and quadratic discriminant analysis, with leave-one-out cross-validation to evaluate model performance. RESULTS Model-based clustering revealed two different clusters in the data. None of the clusters clearly separated SCS-naïve patients from patients with previous SCS experience. Linear discriminant analysis resulted in a leave-one-out cross-validation error rate of 30.0% to discriminate between both patient groups, based on routinely collected clinical parameters. CONCLUSIONS Clustering analysis did not result in clusters that separate SCS-naïve patients from patients with previous SCS experience. This may suggest that both patient groups should not be considered as two different patient groups when comparing them on routine clinical parameters, with potentially profound implications for research and clinical settings. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the Discover study is NCT02787265.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Research Foundation-Flanders, Brussels, Belgium.
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Ann De Smedt
- STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | | | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; STIMULUS consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Brussels, Belgium; Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium; Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Goudman L, Billot M, Duarte RV, Eldabe S, Rigoard P, Moens M. Gradation of Clinical Holistic Response as New Composite Outcome to Evaluate Success in Spinal Cord Stimulation Studies for Pain. Neuromodulation 2023; 26:139-146. [PMID: 35088757 DOI: 10.1016/j.neurom.2021.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/09/2021] [Accepted: 10/12/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The most prominent outcome measurement in the field of neuromodulation is pain relief. Nevertheless, the number of studies that rely on composite outcomes has increased. The aims of this study are twofold: (1) to evaluate which measures are important to include in a composite outcome and (2) to develop this new composite outcome to evaluate the degree of being a clinical holistic responder with a corresponding minimal clinical important difference (MCID). MATERIALS AND METHODS Data from patients with persistent spinal pain syndrome type 2 treated with High-Dose Spinal Cord Stimulation (HD-SCS) were used. Pain intensity for low back and leg pain, disability, health-related quality of life, medication use, and patient satisfaction were measured at baseline and after 12 months of HD-SCS. Exploratory and Confirmatory Factor Analyses were used to evaluate which measures should be included in the composite outcome. Anchor-based and distribution-based methods were applied to determine the MCID of the newly developed outcome measurement. RESULTS A three-factor model was the most appropriate for this data set, in which leg pain intensity, EQ5D VAS, and disability had the largest loading on these factors. A clinical holistic outcome was created with a total score ranging from 0 (=better [no pain, no disability, and perfect health status]) to 300 (=worse [maximal pain, maximal disability, and worst health status]). The MCID value based on an absolute change score from baseline up to 12 months of HD-SCS was 87.97. When calculating with percentage changes, a MCID value of 48.4% was revealed. CONCLUSIONS This new composite outcome evaluating the degree of deviation from being a holistic responder is a step toward a meaningful, overall outcome assessment for patients who are treated with SCS. Further studies to evaluate the psychometric properties and the generalizability toward other patient populations still need to be performed.
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Affiliation(s)
- Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan, Brussels, Belgium; STIMULUS Research Group (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France
| | - Rui V Duarte
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Sam Eldabe
- Pain Clinic, The James Cook University Hospital, Middlesbrough, UK
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, Poitiers, France; Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, Poitiers, France; Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, Chasseneuil-du-Poitou, France
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan, Brussels, Belgium; STIMULUS Research Group (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Pain in Motion (PAIN) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan, Brussels, Belgium.
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Analgesic use and favourable patient-reported outcome measures after paediatric surgery: an analysis of registry data. Br J Anaesth 2023; 130:74-82. [PMID: 36470745 DOI: 10.1016/j.bja.2022.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/30/2022] [Accepted: 09/26/2022] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Pain after paediatric appendectomy and tonsillectomy is often undertreated. Benchmarking of hospitals could reveal which measures are associated with improved patient- or parent-reported pain-related outcomes. METHODS A total of 898 anonymised cases from 11 European hospitals participating in PAIN OUT infant were analysed. The children completed a questionnaire on patient-reported outcomes (PROs) 24 h after surgery. According to a composite PRO measure, including pain intensity and pain-related interference, hospitals were allocated to Group I (favourable results), II (average results), and III (unfavourable results). Benchmarking of hospital groups was performed investigating process variables (dosing of non-opioid analgesics, opioids, and dexamethasone) associated with PROs, side-effects, and children's perception of care. Variables associated with PROs were analysed using multinomial regression analysis with the PRO score-related hospital group as a dependent variable (estimated odds ratios [OR], 95% confidence interval [CI]). RESULTS During the first 24 h after surgery, 1.2 (1.1-1.3) full daily doses of non-opioid analgesics (non-steroidal anti-inflammatory drug [NSAID], paracetamol, metamizole) were administered in group I and 0.7 (0.6-0.8) in group III (P<0.001). Intraoperative dexamethasone was administered to 70.1 and 52.6% of the children in Group I and Group III, respectively (P<0.001). A lower number of full daily doses of non-opioid analgesics: 0.22 [0.15-0.31]), less dexamethasone (0.49 [0.33-0.71]), fewer non-opioid analgesics before the end of surgery (0.37 [0.22-0.62]) and higher opioid doses were associated with hospital allocation to group III vs group I (Nagelkerke's R2=0.433). CONCLUSIONS The results indicated substantial deficits in the concept, application, and dosing of analgesics in paediatric patients after surgery. Timely administration of adequate analgesic doses can easily be introduced into daily clinical practice. CLINICAL TRIAL REGISTRATION clinicaltrials.gov NCT02083835.
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Hofer DM, Lehmann T, Zaslansky R, Harnik M, Meissner W, Stüber F, Stamer UM. Rethinking the definition of chronic postsurgical pain: composites of patient-reported pain-related outcomes vs pain intensities alone. Pain 2022; 163:2457-2465. [PMID: 35442934 PMCID: PMC9667383 DOI: 10.1097/j.pain.0000000000002653] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 04/05/2022] [Accepted: 04/08/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Chronic postsurgical pain (CPSP) is defined by pain intensity and pain-related functional interference. This study included measures of function in a composite score of patient-reported outcomes (PROs) to investigate the incidence of CPSP. Registry data were analyzed for PROs 1 day and 12 months postoperatively. Based on pain intensity and pain-related interference with function, patients were allocated to the groups " CPSPF " (at least moderate pain with interference), " mixed " (milder symptoms), and " no CPSPF ". The incidence of CPSPF was compared with CPSP rates referring to published data. Variables associated with the PRO-12 score (composite PROs at 12 months; numeric rating scale 0-10) were analyzed by linear regression analysis. Of 2319 patients, 8.6%, 32.5%, and 58.9% were allocated to the groups CPSPF , mixed , and no CPSPF , respectively. Exclusion of patients whose pain scores did not increase compared with the preoperative status, resulted in a 3.3% incidence. Of the patients without pre-existing pain, 4.1% had CPSPF. Previously published pain cutoffs of numeric rating scale >0, ≥3, or ≥4, used to define CPSP, produced rates of 37.5%, 9.7%, and 5.7%. Pre-existing chronic pain, preoperative opioid medication, and type of surgery were associated with the PRO-12 score (all P < 0.05). Opioid doses and PROs 24 hours postoperatively improved the fit of the regression model. A more comprehensive assessment of pain and interference resulted in lower CPSP rates than previously reported. Although inclusion of CPSP in the ICD-11 is a welcome step, evaluation of pain characteristics would be helpful in differentiation between CPSPF and continuation of pre-existing chronic pain.
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Affiliation(s)
- Debora M. Hofer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, University Hospital Jena, Jena, Germany
| | - Ruth Zaslansky
- Department of Anaesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Michael Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
| | - Winfried Meissner
- Department of Anaesthesiology and Intensive Care, University Hospital Jena, Jena, Germany
| | - Frank Stüber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Ulrike M. Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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Combining Awake Anesthesia with Minimal Invasive Surgery Optimizes Intraoperative Surgical Spinal Cord Stimulation Lead Placement. J Clin Med 2022; 11:jcm11195575. [PMID: 36233439 PMCID: PMC9571566 DOI: 10.3390/jcm11195575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Spinal cord stimulation (SCS) is an effective and validated treatment to address chronic refractory neuropathic pain in persistent spinal pain syndrome-type 2 (PSPS-T2) patients. Surgical SCS lead placement is traditionally performed under general anesthesia due to its invasiveness. In parallel, recent works have suggested that awake anesthesia (AA), consisting of target controlled intra-venous anesthesia (TCIVA), could be an interesting tool to optimize lead anatomical placement using patient intra-operative feedback. We hypothesized that combining AA with minimal invasive surgery (MIS) could improve SCS outcomes. The goal of this study was to evaluate SCS lead performance (defined by the area of pain adequately covered by paraesthesia generated via SCS), using an intraoperative objective quantitative mapping tool, and secondarily, to assess pain relief, functional improvement and change in quality of life with a composite score. We analyzed data from a prospective multicenter study (ESTIMET) to compare the outcomes of 115 patients implanted with MIS under AA (MISAA group) or general anesthesia (MISGA group), or by laminectomy under general anesthesia (LGA group). All in all, awake surgery appears to show significantly better performance than general anesthesia in terms of patient pain coverage (65% vs. 34–62%), pain surface (50–76% vs. 50–61%) and pain intensity (65% vs. 35–40%), as well as improved secondary outcomes (quality of life, functional disability and depression). One step further, our results suggest that MISAA combined with intra-operative hypnosis could potentialize patient intraoperative cooperation and could be proposed as a personalized package offered to PSPS-T2 patients eligible for SCS implantation in highly dedicated neuromodulation centers.
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David R, Billot M, Ojardias E, Parratte B, Roulaud M, Ounajim A, Louis F, Meklat H, Foucault P, Lombard C, Jossart A, Mainini L, Lavallière M, Goudman L, Moens M, Laroche D, Salga M, Genêt F, Daviet JC, Perrochon A, Compagnat M, Rigoard P. A 6-Month Home-Based Functional Electrical Stimulation Program for Foot Drop in a Post-Stroke Patient: Considerations on a Time Course Analysis of Walking Performance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159204. [PMID: 35954558 PMCID: PMC9367978 DOI: 10.3390/ijerph19159204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/20/2022] [Accepted: 07/23/2022] [Indexed: 12/04/2022]
Abstract
Foot drop is a common disability in post-stroke patients and represents a challenge for the clinician. To date, ankle foot orthosis (AFO) combined with conventional rehabilitation is the gold standard of rehabilitation management. AFO has a palliative mechanical action without actively restoring the associated neural function. Functional electrical stimulation (FES), consisting of stimulation of the peroneal nerve pathway, represents an alternative approach. By providing an FES device (Bioness L-300, BIONESS, Valencia, CA, USA) for 6 months to a post-stroke 22-year-old woman with a foot drop, our goal was to quantify its potential benefit on walking capacity. The gait parameters and the temporal evolution of the speed were collected with a specific connected sole device (Feet Me®) during the 10-m walking, the time up and go, and the 6-minute walking tests with AFO, FES, or without any device (NO). As a result, the walking speed changes on 10-m were clinically significant with an increase from the baseline to 6 months in AFO (+0.14 m.s−1), FES (+0.36 m.s−1) and NO (+0.32 m.s−1) conditions. In addition, the speed decreased at about 4-min in the 6-minute walking test in NO and AFO conditions, while the speed increased in the FES conditions at baseline and after 1, 3, and 6 months. In addition to the walking performance improvement, monitoring the gait speed in an endurance test after an ecological rehabilitation training program helps to examine the walking performance in post-stroke patients and to propose a specific rehabilitation program.
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Affiliation(s)
- Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
- Department of Physical and Rehabilitation Medicine, Poitiers University Hospital, 86000 Poitiers, France; (A.J.); (L.M.)
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
- Correspondence: ; Tel.: +33-05-49-44-43-24
| | - Etienne Ojardias
- Physical Medicine and Rehabilitation Department, University Hospital of Saint-Etienne, 42270 Saint-Etienne, France;
| | - Bernard Parratte
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
| | - Frédéric Louis
- Department of Physical and Rehabilitation Medicine le Grand Feu, Rue de la Verrerie, 79000 Niort, France;
| | - Hachemi Meklat
- Department of Physical and Rehabilitation Medicine Richelieu, Rue Philippe-Vincent, 17028 La Rochelle, France; (H.M.); (P.F.); (C.L.)
| | - Philippe Foucault
- Department of Physical and Rehabilitation Medicine Richelieu, Rue Philippe-Vincent, 17028 La Rochelle, France; (H.M.); (P.F.); (C.L.)
| | - Christophe Lombard
- Department of Physical and Rehabilitation Medicine Richelieu, Rue Philippe-Vincent, 17028 La Rochelle, France; (H.M.); (P.F.); (C.L.)
| | - Anne Jossart
- Department of Physical and Rehabilitation Medicine, Poitiers University Hospital, 86000 Poitiers, France; (A.J.); (L.M.)
| | - Laura Mainini
- Department of Physical and Rehabilitation Medicine, Poitiers University Hospital, 86000 Poitiers, France; (A.J.); (L.M.)
| | - Martin Lavallière
- Module de Kinésiologie, Département des Sciences de la Santé, CISD, & Lab BioNR, Université du Québec à Chicoutimi, Chicoutimi, QC G7H 2B1, Canada;
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Research Foundation—Flanders (FWO), 1090 Brussels, Belgium
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STIMULUS Consortium (reSearch and TeachIng neuroModULation Uz bruSsel), Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Radiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Davy Laroche
- INSERM UMR1093 Cognition, Action and Sensorimotor Plasticity Research Unit, UFR des Sciences du Sport, Université Bourgogne Franche-Comté, 21078 Dijon, France;
- INSERM, Centre d’Investigation Clinique 1432, Module Plurithematique, Plateforme d’Investigation Technologique, CHU Dijon-Bourgogne, Centre d’Investigation Clinique, Module Plurithématique, Plateforme d’Investigation Technologique, 21079 Dijon, France
| | - Marjorie Salga
- UPOH (Unité Péri Opératoire du Handicap, Perioperative Disability Unit), Physical and Rehabilitation Medicine Department, Raymond-Poincaré Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92380 Garches, France; (M.S.); (F.G.)
- Inserm U1179, END-ICAP (Handicap neuromusculaire: Physiopathologie, Biothérapie et Pharmacologie Appliquées), UFR Simone Veil—Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), 78180 Montigny-le-Bretonneux, France
| | - François Genêt
- UPOH (Unité Péri Opératoire du Handicap, Perioperative Disability Unit), Physical and Rehabilitation Medicine Department, Raymond-Poincaré Hospital, Assistance Publique—Hôpitaux de Paris (AP-HP), 92380 Garches, France; (M.S.); (F.G.)
- Inserm U1179, END-ICAP (Handicap neuromusculaire: Physiopathologie, Biothérapie et Pharmacologie Appliquées), UFR Simone Veil—Santé, Versailles Saint-Quentin-en-Yvelines University (UVSQ), 78180 Montigny-le-Bretonneux, France
| | - Jean-Christophe Daviet
- HAVAE UR20217 (Handicap, Ageing, Autonomy, Environment), University of Limoges, 87000 Limoges, France; (J.-C.D.); (A.P.); (M.C.)
- Department of Physical Medicine and Rehabilitation, University Hospital Center of Limoges, 87000 Limoges, France
| | - Anaick Perrochon
- HAVAE UR20217 (Handicap, Ageing, Autonomy, Environment), University of Limoges, 87000 Limoges, France; (J.-C.D.); (A.P.); (M.C.)
| | - Maxence Compagnat
- HAVAE UR20217 (Handicap, Ageing, Autonomy, Environment), University of Limoges, 87000 Limoges, France; (J.-C.D.); (A.P.); (M.C.)
- Department of Physical Medicine and Rehabilitation, University Hospital Center of Limoges, 87000 Limoges, France
| | - Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86000 Poitiers, France; (R.D.); (B.P.); (M.R.); (A.O.); (P.R.)
- Department of Neuro-Spine & Neuromodulation, Poitiers University Hospital, 86000 Poitiers, France
- Prime Institute UPR 3346, CNRS, ISAE-ENSMA (Institut Supérieur de l’Aéronautique et de l’Espace—École Nationale Supérieure de Mécanique et d’Aérotechnique Poitiers Futuroscope), University of Poitiers, 86000 Poitiers, France
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Hasvik E, Gran JM, Haugen AJ, Grøvle L. Strategies to manage auxiliary pain medications in chronic pain trials: a topical review. Eur J Clin Pharmacol 2022; 78:1377-1384. [PMID: 35842457 PMCID: PMC9365733 DOI: 10.1007/s00228-022-03355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
Chronic pain trials commonly allow auxiliary pain medications such as rescue and concomitant analgesics in addition to the randomized treatment. Changes in auxiliary pain medications after randomization represent intercurrent events that may affect either the interpretation or the existence of the measurements associated with the clinical question of interest, complicating the assessment of treatment efficacy. In chronic pain trials, pain intensity typically varies and patients may take the auxiliary medications 1 day but not the next or increase and decrease the dosages temporarily while continuing their randomized study medication. This distinctive feature of auxiliary pain medications as an intercurrent event has received little attention in the literature. Further clarifications on how to manage these issues are therefore pressing. Here we provide perspectives on issues related to auxiliary pain medication-related intercurrent events in randomized controlled chronic pain trials considering the strategies suggested in the E9(R1) addendum to the ICH guideline on statistical principles for clinical trials.
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Affiliation(s)
- Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, 1714, Grålum, Norway.
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | | | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
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Kleykamp BA, Dworkin RH, Turk DC, Bhagwagar Z, Cowan P, Eccleston C, Ellenberg SS, Evans SR, Farrar JT, Freeman RL, Garrison LP, Gewandter JS, Goli V, Iyengar S, Jadad AR, Jensen MP, Junor R, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, McDermott MP, Mease PJ, O'Connor AB, Patel KV, Raja SN, Rowbotham MC, Sampaio C, Singh JA, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations. Pain 2022; 163:1006-1018. [PMID: 34510135 PMCID: PMC8904641 DOI: 10.1097/j.pain.0000000000002475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.
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Affiliation(s)
- Bethea A Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, CT, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | | | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy L Freeman
- Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders, Boston, MA, United States
| | - Louis P Garrison
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Veeraindar Goli
- Pfizer, Inc, New York, NY, United States. Dr. Goli is now with the Emeritus Professor, Duke University School of Medicine, Durham, NC, United States
| | - Smriti Iyengar
- Division of Translational Research, NINDS, NIH, Rockville, MD, United States
| | - Alejandro R Jadad
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Beati, Inc, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Wayland, MA, United States
| | | | | | - Dmitri Lissin
- DURECT Corporation, Cupertino, CA, United States. Dr. Lissin is now woth the Scilex Pharmaceuticals, Inc., San Diego, CA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Philip J Mease
- Division of Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C Rowbotham
- Department of Anesthesia, UCSF School of Medicine, Research Institute, CPMC Sutter Health, San Francisco, CA, United States
| | - Cristina Sampaio
- Clinical Pharmacology Lab, Faculdade de Medicina de Lisboa, University Lisbon, Lisbon, Portugal
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, United States
- Department of Medicine at the School of Medicine, University of Alabama (UAB) at Birmingham, Birmingham, AL, United States
- Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, United States
| | - Ilona Steigerwald
- Chief Medical Officer SVP Neumentum, Inc, Morristown NJ, United States
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, United States
| | - Leslie A Tive
- Department of Biopharmaceuticals, Pfizer, Inc, New York, NY, United States
| | | | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, United States
| | - Hilary D Wilson
- Patient Affairs and Engagement, Boehringer Ingelheim, Ridgefield, CT, United States
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Petersen KKS, Drewes AM, Olesen AE, Ammitzbøll N, Bertoli D, Brock C, Arendt-Nielsen L. The Effect of Duloxetine on Mechanistic Pain Profiles, Cognitive Factors, and Clinical Pain in Patients with Painful Knee Osteoarthritis - A Randomized, Double-Blind, Placebo-Controlled, Crossover Study. Eur J Pain 2022; 26:1650-1664. [PMID: 35638317 PMCID: PMC9541875 DOI: 10.1002/ejp.1988] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/03/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Duloxetine is indicated in the management of pain in osteoarthritis. Evidence suggests that duloxetine modulate central pain mechanisms and cognitive factors, and these factors are assumed contributing to the analgesic effect. This proof-of-mechanism, randomized, placebo-controlled, crossover, double-blinded trial evaluated the effect of duloxetine on quantitative sensory testing (QST), cognitive factors, and clinical pain in patients with osteoarthritis and to predict the analgesic effect. METHODS Twenty-five patients completed this cross-over study with either 18-weeks duloxetine (maximum 60 mg/daily) followed by placebo or vice-versa. Pressure pain thresholds, temporal summation of pain, and conditioned pain modulation were assessed using cuff algometry. The Hospital Anxiety and Depression Scale and the Pain Catastrophizing Scale evaluated cognitive factors. Clinical pain was assessed using Brief Pain Inventory and Western Ontario and McMaster Universities Osteoarthritis Index. Linear regression models were used to predict the analgesic effect of duloxetine. RESULTS Depending on the clinical pain outcome, 40-68% of patients were classified as responders to duloxetine. Linear regression models predicted the analgesic effect (predictive value of 45-75% depending on clinical pain outcome parameter) using a combination of pre-treatment QST parameters, cognitive factors, and clinical pain. No significant changes were found for QST, cognitive factors, or clinical pain on a group level when comparing duloxetine to placebo. CONCLUSION A combination of pre-treatment QST, cognitive factors, and clinical pain was able to predict the analgesic response of duloxetine. However, in this relatively small study, duloxetine did not selectively modulate QST, cognitive factors, or clinical pain intensity when compared with placebo.
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Affiliation(s)
- Kristian Kjaer-Staal Petersen
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Estrup Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Nadia Ammitzbøll
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Davide Bertoli
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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25
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Pingree MJ, Hurdle MF, Spinner DA, Valimahomed A, Crosby ND, Boggs JW. Real-world evidence of sustained improvement following 60-day peripheral nerve stimulation treatment for pain: a cross-sectional follow-up survey. Pain Manag 2022; 12:611-621. [PMID: 35510333 DOI: 10.2217/pmt-2022-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: This study presents real-world data from a cross-sectional follow-up survey of patients who previously received 60-day peripheral nerve stimulation (PNS) treatment for pain. Materials & methods: A survey including validated pain and other related outcome measures was distributed to patients who previously underwent implantation of temporary PNS leads for 60-day PNS treatment. Results: Among survey respondents who were at least 3 months from the start of treatment, most reported sustained clinically significant improvements in pain and/or quality of life, with the length of follow-up at the time of survey completion ranging from 3 to 30 months. Conclusion: These real-world data support recent prospective studies indicating that 60-day percutaneous PNS provides significant and sustained relief across a wide range of pain conditions.
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Affiliation(s)
- Matthew J Pingree
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Mark Fb Hurdle
- Pain Medicine & Spine Care, Mayo Clinic, Jacksonville, FL 32224, USA
| | - David A Spinner
- Rehabilitation Medicine, Mount Sinai Health System, New York, NY 10029, USA
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26
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Taylor RS, Soliday N, Leitner A, Hunter CW, Staats PS, Li S, Thomson S, Kallewaard JW, Russo M, Duarte RV. Association Between Levels of Functional Disability and Health-Related Quality of Life With Spinal Cord Stimulation for Chronic Pain. Neuromodulation 2022:S1094-7159(22)00650-X. [DOI: 10.1016/j.neurom.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022]
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27
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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28
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Rigoard P, Ounajim A, Goudman L, Louis PY, Slaoui Y, Roulaud M, Naiditch N, Bouche B, Page P, Lorgeoux B, Baron S, Charrier E, Poupin L, Rannou D, de Montgazon GB, Roy-Moreau B, Grimaud N, Adjali N, Nivole K, Many M, David R, Wood C, Rigoard R, Moens M, Billot M. A Novel Multi-Dimensional Clinical Response Index Dedicated to Improving Global Assessment of Pain in Patients with Persistent Spinal Pain Syndrome after Spinal Surgery, Based on a Real-Life Prospective Multicentric Study (PREDIBACK) and Machine Learning Techniques. J Clin Med 2021; 10:4910. [PMID: 34768428 PMCID: PMC8585086 DOI: 10.3390/jcm10214910] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 01/01/2023] Open
Abstract
The multidimensionality of chronic pain forces us to look beyond isolated assessment such as pain intensity, which does not consider multiple key parameters, particularly in post-operative Persistent Spinal Pain Syndrome (PSPS-T2) patients. Our ambition was to produce a novel Multi-dimensional Clinical Response Index (MCRI), including not only pain intensity but also functional capacity, anxiety-depression, quality of life and quantitative pain mapping, the objective being to achieve instantaneous assessment using machine learning techniques. Two hundred PSPS-T2 patients were enrolled in the real-life observational prospective PREDIBACK study with 12-month follow-up and received various treatments. From a multitude of questionnaires/scores, specific items were combined, as exploratory factor analyses helped to create a single composite MCRI; using pairwise correlations between measurements, it appeared to more accurately represent all pain dimensions than any previous classical score. It represented the best compromise among all existing indexes, showing the highest sensitivity/specificity related to Patient Global Impression of Change (PGIC). Novel composite indexes could help to refine pain assessment by informing the physician's perception of patient condition on the basis of objective and holistic metrics, and also by providing new insights regarding therapy efficacy/patient outcome assessments, before ultimately being adapted to other pathologies.
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Affiliation(s)
- Philippe Rigoard
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
- Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360 Chasseneuil-du-Poitou, France
| | - Amine Ounajim
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
- Laboratoire de Mathématiques et Applications UMR 7348, CNRS, University of Poitiers, 86073 Poitiers, France;
| | - Lisa Goudman
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STIMULUS Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Pierre-Yves Louis
- AgroSup Dijon, PAM UMR 02.102, Université Bourgogne Franche-Comté, 21000 Dijon, France;
- Institut de Mathématiques de Bourgogne, UMR 5584 CNRS, Université Bourgogne Franche-Comté, 21000 Dijon, France
| | - Yousri Slaoui
- Laboratoire de Mathématiques et Applications UMR 7348, CNRS, University of Poitiers, 86073 Poitiers, France;
| | - Manuel Roulaud
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Nicolas Naiditch
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Bénédicte Bouche
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
| | - Philippe Page
- Department of Spine Surgery & Neuromodulation, Poitiers University Hospital, 86021 Poitiers, France;
| | - Bertille Lorgeoux
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Sandrine Baron
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Elodie Charrier
- Pain Evaluation and Treatment Centre, Poitiers University Hospital, 86021 Poitiers, France; (E.C.); (L.P.); (D.R.)
| | - Laure Poupin
- Pain Evaluation and Treatment Centre, Poitiers University Hospital, 86021 Poitiers, France; (E.C.); (L.P.); (D.R.)
| | - Delphine Rannou
- Pain Evaluation and Treatment Centre, Poitiers University Hospital, 86021 Poitiers, France; (E.C.); (L.P.); (D.R.)
| | | | - Brigitte Roy-Moreau
- Pain Evaluation and Treatment Centre, Nord Deux-Sèvres Hospital, 79000 Niort, France;
| | - Nelly Grimaud
- Pain Evaluation and Treatment Centre, Centre Clinical Elsan, 16800 Soyaux, France;
| | - Nihel Adjali
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Kevin Nivole
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Mathilde Many
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Romain David
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
- Physical and Rehabilitation Medicine Unit, Poitiers University Hospital, University of Poitiers, 86021 Poitiers, France
| | - Chantal Wood
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
| | - Raphael Rigoard
- CEA Cadarache, Département de Support Technique et Gestion, Service des Technologies de l’Information et de la Communication, 13108 Saint-Paul-Lez-Durance, France;
| | - Maarten Moens
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium; (L.G.); (M.M.)
- STIMULUS Research Group, Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Maxime Billot
- PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021 Poitiers, France; (A.O.); (M.R.); (N.N.); (B.B.); (B.L.); (S.B.); (N.A.); (K.N.); (M.M.); (R.D.); (C.W.); (M.B.)
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Setchell J, Costa N, Abrosimoff M, Hodges PW. Exploring why people with back pain use the pain management strategies they do: Is research looking in the wrong places? PAIN MEDICINE 2021; 22:2298-2306. [PMID: 34373916 DOI: 10.1093/pm/pnab246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Low back pain (LBP) is a significant issue with considerable impact on people's lives and economies. A plethora of research investigates interventions to manage LBP. However, despite considerable knowledge translation efforts, individuals with the condition frequently use management strategies considered to be 'ineffective'. To address this concern, our aim was to explore why people with LBP choose the management strategies they do. METHODS We employed a predominantly inductive, descriptive qualitative design. We interviewed 20 Australian adults who have, or have had, LBP to investigate the management strategies they have employed and why. Data were analysed thematically. RESULTS Analysis identified three interrelated themes that highlight that participants chose management strategies, at least in part, because they: 1) reduce symptoms in the very short-term (e.g., immediately, a few hours); 2) have effects beyond the condition (e.g., low cost, lack of negative side effects, convenience, social effects); and 3) are pleasurable. DISCUSSION These outcomes suggest that people with LBP are likely to have nuanced reasons for choosing the management strategies they use, and this can contrast with the outcomes tested in empirical studies. Our findings suggest that researchers may need to broaden or rethink which outcomes they measure and how, including by meaningfully engaging consumers in research design. Further, clinicians could better explore their patient's reasons for using the strategies they do, before suggesting they discard existing strategies, or offering new ones.
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Affiliation(s)
- Jenny Setchell
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | - Nathalia Costa
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
| | | | - Paul W Hodges
- The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Australia
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30
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Yeung J, Small C. Impact of regional analgesia in surgery. Br J Surg 2021; 108:1009-1010. [PMID: 34131701 PMCID: PMC10364902 DOI: 10.1093/bjs/znab214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/16/2021] [Indexed: 11/14/2022]
Affiliation(s)
- J Yeung
- Warwick Medical School, Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - C Small
- Hereford County Hospital, Wye Valley NHS Trust, Hereford, UK
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