1
|
de Andrés Ares J, Eldabe S, Helsen N, Baranidharan G, Barat JL, Bhaskar A, Cassini F, Gillner S, Kallewaard JW, Klessinger S, Mavrocordatos P, Occhigrossi F, Van Zundert J, Huygen F, Stoevelaar H. Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method. Pain Pract 2024. [PMID: 38597223 DOI: 10.1111/papr.13378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain. METHODS The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios. RESULTS For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well-selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e-health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region. CONCLUSIONS A multidisciplinary European expert panel established patient-specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.
Collapse
Affiliation(s)
- Javier de Andrés Ares
- Department of Anesthesiology-Pain Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Nicky Helsen
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| | | | - Jean-Luc Barat
- Service de Neurochirurgie, Hôpital privé Clairval - Ramsay santé, Marseille, France
| | - Arun Bhaskar
- Pain Management Centre, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Fabrizio Cassini
- SS. Antonio e Biagio e C. Arrigo Hospital, Allesandria, Piedmont, Italy
| | - Sebastian Gillner
- Department of Neurosurgery, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Jan Willem Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands
- Department of Anaesthesiology and Pain Treatment, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | | | | | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| |
Collapse
|
2
|
Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
Collapse
Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
3
|
Zuidema X, de Galan B, Brouwer B, Cohen SP, Eldabe S, Argoff CE, Huygen F, Van Zundert J. 4. Painful diabetic polyneuropathy. Pain Pract 2024; 24:308-320. [PMID: 37859565 DOI: 10.1111/papr.13308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Pain as a symptom of diabetic polyneuropathy (DPN) significantly lowers quality of life, increases mortality and is the main reason for patients with diabetes to seek medical attention. The number of people suffering from painful diabetic polyneuropathy (PDPN) has increased significantly over the past decades. METHODS The literature on the diagnosis and treatment of diabetic polyneuropathy was retrieved and summarized. RESULTS The etiology of PDPN is complex, with primary damage to peripheral nociceptors and altered spinal and supra-spinal modulation. To achieve better patient outcomes, the mode of diagnosis and treatment of PDPN evolves toward more precise pain-phenotyping and genotyping based on patient-specific characteristics, new diagnostic tools, and prior response to pharmacological treatments. According to the Toronto Diabetic Neuropathy Expert Group, a presumptive diagnosis of "probable PDPN" is sufficient to initiate treatment. Proper control of plasma glucose levels, and prevention of risk factors are essential in the treatment of PDPN. Mechanism-based pharmacological treatment should be initiated as early as possible. If symptomatic pharmacologic treatment fails, spinal cord stimulation (SCS) should be considered. In isolated cases, where symptomatic pharmacologic treatment and SCS are unsuccessful or cannot be used, sympathetic lumbar chain neurolysis and/or radiofrequency ablation (SLCN/SLCRF), dorsal root ganglion stimulation (DRGs) or posterior tibial nerve stimulation (PTNS) may be considered. However, it is recommended that these treatments be applied only in a study setting in a center of expertise. CONCLUSIONS The diagnosis of PDPN evolves toward pheno-and genotyping and treatment should be mechanism-based.
Collapse
Affiliation(s)
- Xander Zuidema
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Anesthesiology and Pain Management, Diakonessenhuis Utrecht/Zeist, Utrecht, The Netherlands
| | - Bastiaan de Galan
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Brigitte Brouwer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Steven P Cohen
- Department of Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sam Eldabe
- Department of Pain Medicine and Anesthesiology, Durham University, Durham, UK
| | - Charles E Argoff
- Department of Neurology, New York University School of Medicine, and Pain Management Center, North Shore University Hospital, Manhasset, New York, USA
| | - Frank Huygen
- Department of Anesthesiology and Pain Management, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Management, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| |
Collapse
|
4
|
Nijhuis HJA, Hofsté WJ, Krabbenbos IP, Dietz BE, Mugan D, Huygen F. First Report on Real-World Outcomes with Evoked Compound Action Potential (ECAP)-Controlled Closed-Loop Spinal Cord Stimulation for Treatment of Chronic Pain. Pain Ther 2023; 12:1221-1233. [PMID: 37481774 PMCID: PMC10444915 DOI: 10.1007/s40122-023-00540-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/30/2023] [Indexed: 07/25/2023] Open
Abstract
INTRODUCTION A novel closed-loop spinal cord stimulation (SCS) system has recently been approved for use which records evoked compound action potentials (ECAPs) from the spinal cord and utilizes these recordings to automatically adjust the stimulation strength in real time. It automatically compensates for fluctuations in distance between the epidural leads and the spinal cord by maintaining the neural response (ECAP) at a determined target level. This data collection was principally designed to evaluate the performance of this first closed-loop SCS system in a 'real-world' setting under normal conditions of use in a single European center. METHODS In this prospective, single-center observational data collection, 22 patients were recruited at the outpatient pain clinic of the St. Antonius Hospital. All candidates were suffering from chronic pain in the trunk and/or limbs due to PSPS type 2 (persistent spinal pain syndrome). As standard of care, follow-up visits were completed at 3 months, 6 months, and 12 months post-device activation. Patient-reported outcome data (pain intensity, patient satisfaction) and electrophysiological and device data (ECAP amplitude, conduction velocity, current output, pulse width, frequency, usage), and patient interaction with their controller were collected at baseline and during standard of care follow-up visits. RESULTS Significant decreases in pain intensity for overall back or leg pain scores (verbal numerical rating score = VNRS) were observed between baseline [mean ± SEM (standard error of the mean); n = 22; 8.4 ± 0.2)], 3 months (n = 12; 1.9 ± 0.5), 6 months (n = 16; 2.6 ± 0.5), and 12 months (n = 20; 2.0 ± 0.5), with 85.0% of the patients being satisfied at 12 months. Additionally, no significant differences in average pain relief at 3 months and 12 months between the real-world data (77.2%; 76.8%) and the AVALON (71.2%; 73.6%) and EVOKE (78.1%; 76.7%) studies were observed. CONCLUSIONS These initial 'real-world' data on ECAP-controlled, closed-loop SCS in a real-world clinical setting appear to be promising, as they provide novel insights of the beneficial effect of ECAP-controlled, closed-loop SCS in a real-world setting. The presented results demonstrate a noteworthy maintenance of pain relief over 12 months and corroborate the outcomes observed in the AVALON prospective, multicenter, single-arm study and the EVOKE double-blind, multicenter, randomized controlled trial. TRIAL REGISTRATION The data collection is registered on the International Clinical Trials Registry Platform (Trial NL7889).
Collapse
Affiliation(s)
- Harold J. A. Nijhuis
- St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem-Jan Hofsté
- St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Imre P. Krabbenbos
- St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | | | - Dave Mugan
- Saluda Medical Europe Ltd, Harrogate, United Kingdom
| | - Frank Huygen
- Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
5
|
Billar R, Kappen P, Mohammadian S, van den Berg C, de Rijke Y, van den Akker E, van Rosmalen J, Schnater JM, Vincent A, Dirven C, Klimek M, Wijnen R, Jeekel J, Huygen F, Tiemensma J. The effect of recorded music on pain endurance (CRESCENDo) - A randomized controlled trial. Complement Ther Med 2023; 77:102969. [PMID: 37579996 DOI: 10.1016/j.ctim.2023.102969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/05/2023] [Accepted: 08/10/2023] [Indexed: 08/16/2023] Open
Abstract
INTRODUCTION Clarifying the effect of music on pain endurance in an experimental design could aid in how music should be applied during both surgical and non-surgical interventions. This study aims to investigate the effect of music on pain endurance and the involvement of the sympathetic adrenomedullary axis (SAM) and the hypothalamic-pituitary-adrenocortical axis (HPA). MATERIALS AND METHODS In this randomized controlled trial all participants received increasing electric stimuli through their non-dominant index finger. Participants were randomly assigned to the music group (M) receiving a 20-minute music intervention or control group (C) receiving a 20-minute resting period. The primary outcome was pain endurance, defined as amount milliampere tolerated. Secondary outcomes included anxiety level, SAM-axis based on heart rate variability (HRV) and salivary alpha-amylase, and HPA-axis activity based on salivary cortisol. RESULTS In the intention-to-treat analysis, the effect of music on pain tolerance did not statistically differ between the M and C group. A significant positive effect of music on pain endurance was noted after excluding participants with a high skin impedance (p = 0.013, CI 0.35; 2.85). Increased HRV was observed in the M-group compared to the C-group for SDNN (B/95%CI:13.80/2.22;25.39, p = 0.022), RMSSD (B/95%CI:15.97/1.64;30.31, p = 0.032), VLF (B/95%CI:212.08/60.49;363.67, p = 0.008) and HF (B/95%CI:821.15/150.78;1491.52, p = 0.0190). No statistical significance was observed in other secondary outcomes. CONCLUSIONS The effect of the music intervention on pain endurance was not statistically significant in the intention-to-treat analysis. The subgroup analyses revealed an increase in pain endurance in the music group after correcting for skin impedance, which could be attributed to increased parasympathetic activation.
Collapse
Affiliation(s)
- Ryan Billar
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands.
| | - Pablo Kappen
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sepehr Mohammadian
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Corinne van den Berg
- Department of Anesthesiology, Center for Pain Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yolanda de Rijke
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Erica van den Akker
- Department of Pediatric Endocrinology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnaud Vincent
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Clemens Dirven
- Department of Anesthesiology, Center for Pain Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Markus Klimek
- Department of Anesthesiology, Center for Pain Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - René Wijnen
- Department of Pediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Johannes Jeekel
- Department of Neuroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jitske Tiemensma
- Department of Anesthesiology, Center for Pain Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
6
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| | | | | | | | | | | | | | | |
Collapse
|
7
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
Affiliation(s)
| | | | - Frank Huygen
- Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Michael Fishman
- Center for Interventional Pain and Spine, Lancaster, PA, USA
| | | | | | | | | | | | | |
Collapse
|
8
|
Russo MA, Bhatia A, Hayek S, Doshi T, Eldabe S, Huygen F, Levy RM. Problems With O'Connell et al "Implanted Spinal Neuromodulation Interventions for Chronic Pain in Adults" (Cochrane Review). Neuromodulation 2023:S1094-7159(23)00134-4. [PMID: 37029022 DOI: 10.1016/j.neurom.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/01/2023] [Accepted: 03/05/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Marc A Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia; Genesis Research Services, Broadmeadow, New South Wales, Australia; University of Newcastle, School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, Callaghan, New South Wales, Australia.
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Tina Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Frank Huygen
- Center of Pain Medicine Erasmus Medical Center, Rotterdam, The Netherlands; Center of Pain Medicine University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert M Levy
- International Neuromodulation Society, Neuromodulation: Technology at the Neural Interface, San Francisco, CA, USA
| |
Collapse
|
9
|
Petersen EA, Deer TR, Bojanic S, Sankary LR, Strand NH, Al Kaisy A, Huygen F, Sayed D, Steegers M, Verrills P, Schatman ME. Best Practices from the American Society of Pain and Neuroscience (ASPN) for Clinical Research During a Pandemic or Emergency. J Pain Res 2023; 16:327-339. [PMID: 36744112 PMCID: PMC9895883 DOI: 10.2147/jpr.s393539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
The COVID-19 pandemic caught many areas of medicine in a state of unpreparedness for conducting research and completing ongoing projects during a global crisis, including the field of pain medicine. Waves of infection led to a disjointed ability to provide care and conduct clinical research. The American Society of Pain and Neuroscience (ASPN) Research Group has created guidance for pragmatic and ethical considerations for research during future emergency or disaster situations. This analysis uses governmental guidance, scientific best practices, and expert opinion to address procedure-based or device-based clinical trials during such times. Current literature offers limited recommendations on this important issue, and the findings of this group fill a void for protocols to improve patient safety and efficacy, especially as we anticipate the impact of future disasters and spreading global infectious diseases. We recommend local adaptations to best practices and innovations to enable continued research while respecting the stressors to the research subjects, investigator teams, health-care systems, and to local infrastructure.
Collapse
Affiliation(s)
- Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA,Correspondence: Erika A Petersen, Department of Neurosurgery, University of Arkansas for Medical Science, 4301 West Markham Slot #507, Little Rock, AR, 72205, USA, Tel +15016865270, Email
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Stana Bojanic
- Department of Neurosurgery, John Radcliffe University Hospitals NHS Trust, Oxford, UK
| | | | | | - Adnan Al Kaisy
- The Pain Management and Neuromodulation Centre, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK
| | - Frank Huygen
- Department of Anesthesiology, Center of Pain Medicine, Erasmus MC, Rotterdam, the Netherlands
| | - Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Monique Steegers
- Departments of Anesthesiology and Pain and Palliative Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - Paul Verrills
- Pain Medicine, Metro Pain Clinic, Melbourne, Australia
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA,Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
10
|
Thomson S, Huygen F, Prangnell S, Baranidharan G, Belaïd H, Billet B, Eldabe S, De Carolis G, Demartini L, Gatzinsky K, Kallewaard JW, Paroli M, Winkelmüller M, Helsen N, Stoevelaar H. Applicability and Validity of an e-Health Tool for the Appropriate Referral and Selection of Patients With Chronic Pain for Spinal Cord Stimulation: Results From a European Retrospective Study. Neuromodulation 2023; 26:164-171. [PMID: 35088755 DOI: 10.1016/j.neurom.2021.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To support rational decision-making on spinal cord stimulation (SCS), a European expert panel developed an educational e-health tool using the RAND/University of California at Los Angeles Appropriateness Method. This retrospective study aimed to determine the applicability and validity of the tool using data from patients for whom SCS had been considered. MATERIALS AND METHODS A total of 12 European implant centers retrieved data from 25 to 50 consecutive patients for whom SCS was considered in 2018-2019. For each patient, data were captured on the clinical and psychosocial variables included in the e-health tool, center decisions on SCS, and patient outcomes. Patient outcomes included global perception of effect by the patient and observer, and pain reduction (numeric pain rating scale) at six-month follow-up. RESULTS In total, 483 patients were included, of whom 133 received a direct implant, 258 received an implant after a positive trial, 32 had a negative trial, and 60 did not receive SCS for reasons other than a negative trial. The most frequent indication was persistent spinal pain syndrome type 1 and type 2 (74%), followed by neuropathic pain syndromes (13%), complex regional pain syndrome (12%), and ischemic pain syndromes (0.8%). Data on the clinical and psychosocial variables were complete for 95% and 93% of patients, respectively, and missing data did not have a significant impact on the study outcomes. In patients who had received SCS, panel recommendations were significantly associated with patient outcomes (p < 0.001 for all measures). Substantial improvement ranged from 25% if the e-health tool outcome was "not recommended" to 83% if SCS was "strongly recommended". In patients who underwent a trial (N = 290), there was 3% of trial failure when SCS was "strongly recommended" vs 46% when SCS was "not recommended". CONCLUSIONS Retrospective application of the e-health tool on patient data showed a strong relationship between the panel recommendations and both SCS trial results and treatment outcomes.
Collapse
Affiliation(s)
- Simon Thomson
- Pain and Neuromodulation Centre, Mid and South Essex University Hospitals, Basildon, UK
| | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Prangnell
- Clinical Neuropsychology Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Hayat Belaïd
- Department of Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Bart Billet
- Department of Anaesthesiology, AZ Delta, Roeselare, Belgium
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Giuliano De Carolis
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Laura Demartini
- Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Italy
| | - Kliment Gatzinsky
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Willem Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands; Department of Anaesthesiology and Pain Treatment, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mery Paroli
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | | | - Nicky Helsen
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium.
| |
Collapse
|
11
|
Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Sayed D, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Schwab F, Maislin G, Heemels JP, Eldabe S. Three-Year Durability of Restorative Neurostimulation Effectiveness in Patients With Chronic Low Back Pain and Multifidus Muscle Dysfunction. Neuromodulation 2023; 26:98-108. [PMID: 36175320 DOI: 10.1016/j.neurom.2022.08.457] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Restorative neurostimulation is a rehabilitative treatment for patients with refractory chronic low back pain (CLBP) associated with dysfunction of the lumbar multifidus muscle resulting in impaired neuromuscular control. The ReActiv8-B randomized, sham-controlled trial provided evidence of the effectiveness and safety of an implanted, restorative neurostimulator. The two-year analysis previously published in this journal demonstrated accrual of clinical benefits and long-term durability. OBJECTIVE Evaluation of three-year effectiveness and safety in patients with refractory, disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery. MATERIALS AND METHODS Prospective, observational follow-up of the 204 implanted trial participants. Low back pain visual analog scale (VAS), Oswestry Disability Index (ODI), EuroQol quality of life survey, and opioid intake were assessed at baseline, six months, and one, two, and three years after activation. The mixed-effects model repeated measures approach was used to provide implicit imputations of missing data for continuous outcomes and multiple imputation for proportion estimates. RESULTS Data were collected from 133 participants, and 16 patients missed their three-year follow-up because of coronavirus disease restrictions but remain available for future follow-up. A total of 62% of participants had a ≥ 70% VAS reduction, and 67% reported CLBP resolution (VAS ≤ 2.5cm); 63% had a reduction in ODI of ≥ 20 points; 83% had improvements of ≥ 50% in VAS and/or ≥ 20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 71% (36/51) participants on opioids at baseline had voluntarily discontinued (49%) or reduced (22%) opioid intake. The attenuation of effectiveness in the imputed (N = 204) analyses was relatively small and did not affect the statistical significance and clinical relevance of these results. The safety profile remains favorable, and no lead migrations have been observed to date. CONCLUSION At three years, 83% of participants experienced clinically substantial improvements in pain, disability, or both. The results confirm the long-term effectiveness, durability, and safety of restorative neurostimulation in patients with disabling CLBP associated with multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02577354.
Collapse
Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Vivek Mehta
- Barts Neuromodulation Center, St. Bartholomew's Hospital, London, UK
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, USA
| | - Edgar Ross
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Alexios Carayannopoulos
- Departments of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, USA
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, USA
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, USA
| | - James Rathmell
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Frank Schwab
- Northwell Health Orthopaedic Institute, New York, NY, USA
| | - Greg Maislin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
12
|
Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Maislin G, Heemels JP, Eldabe S. Long-Term Outcomes of Restorative Neurostimulation in Patients With Refractory Chronic Low Back Pain Secondary to Multifidus Dysfunction: Two-Year Results of the ReActiv8-B Pivotal Trial. Neuromodulation 2023; 26:87-97. [PMID: 35088722 DOI: 10.1016/j.neurom.2021.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/22/2020] [Accepted: 10/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Impaired neuromuscular control and degeneration of the multifidus muscle have been linked to the development of refractory chronic low back pain (CLBP). An implantable restorative-neurostimulator system can override the underlying multifidus inhibition by eliciting episodic, isolated contractions. The ReActiv8-B randomized, active-sham-controlled trial provided effectiveness and safety evidence for this system, and all participants received therapeutic stimulation from four months onward. OBJECTIVE This study aimed to evaluate the two-year effectiveness of this restorative neurostimulator in patients with disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery. MATERIALS AND METHODS Open-label follow-up of 204 participants implanted with a restorative neurostimulation system (ReActiv8, Mainstay Medical, Dublin, Ireland) was performed. Pain intensity (visual analog scale [VAS]), disability (Oswestry disability index [ODI]), quality-of-life (EQ-5D-5L), and opioid intake were assessed at baseline, six months, one year, and two years after activation. RESULTS At two years (n = 156), the proportion of participants with ≥50% CLBP relief was 71%, and 65% reported CLBP resolution (VAS ≤ 2.5 cm); 61% had a reduction in ODI of ≥20 points, 76% had improvements of ≥50% in VAS and/or ≥20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 87% of participants had continued device use during the second year for a median of 43% of the maximum duration, and 60% (34 of 57) had voluntarily discontinued (39%) or reduced (21%) opioid intake. CONCLUSIONS At two years, 76% of participants experienced substantial, clinically meaningful improvements in pain, disability, or both. These results provide evidence of long-term effectiveness and durability of restorative neurostimulation in patients with disabling CLBP, secondary to multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The study is registered on clinicaltrials.gov with identifier NCT02577354.
Collapse
Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Vivek Mehta
- Barts Neuromodulation Centre, St. Bartholomew's Hospital, London, UK
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, USA
| | - Edgar Ross
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, USA
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, USA
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, USA
| | - James Rathmell
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Greg Maislin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | |
Collapse
|
13
|
Nijhuis H, Hofsté WJ, Huygen F, Gültuna I, Kallewaard JW, Van De Minkelis J. O071 / #840 ECAP-CONTROLLED CLOSED-LOOP SPINAL CORD STIMULATION IN A REAL-WORLD SETTING UNDER NORMAL CLINICAL USE. Neuromodulation 2022. [DOI: 10.1016/j.neurom.2022.08.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
14
|
Van Lange E, Huygen F, Frankema S. PO137 / #1010 EARLY RESULTS OF ECAP-CONTROLLED CLOSED-LOOP SPINAL CORD STIMULATION IN CRPS PATIENTS. Neuromodulation 2022. [DOI: 10.1016/j.neurom.2022.08.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Thomson S, Helsen N, Prangnell S, Paroli M, Baranidharan G, Belaïd H, Billet B, Eldabe S, De Carolis G, Demartini L, Gatzinsky K, Kallewaard JW, Winkelmüller M, Huygen F, Stoevelaar H. Patient selection for spinal cord stimulation: The importance of an integrated assessment of clinical and psychosocial factors. Eur J Pain 2022; 26:1873-1881. [PMID: 35856311 DOI: 10.1002/ejp.2009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND A previously developed educational e-health tool considers both clinical and psychosocial factors when selecting patients with chronic pain for spinal cord stimulation (SCS). The validity of the composite recommendations was evaluated in a retrospective study, demonstrating a strong relationship with patient outcomes after SCS. METHODS An additional retrospective analysis was performed to determine the added value of a psychosocial evaluation as part of the decision-making process on SCS. Data concerned 482 patients who were considered for SCS in 2018-2019. Analysis focused on the relationship between the different layers of the tool recommendations (clinical, psychosocial, composite) with trial results and patient outcomes at 6 months after SCS. Of the initial study population, 381 patients underwent SCS and had follow-up data on at least one of three pain-related outcome measures. RESULTS Pain improvement was observed in 76% of the patients for whom SCS was strongly recommended based on merely the clinical aspects. This percentage varied by the level of psychosocial problems and ranged from 86% in patients without any compromising psychosocial factors to 60% in those with severe problems. Similarly, the severity of psychosocial problems affected trial results in patients for whom SCS was either recommended or strongly recommended. CONCLUSIONS The strong relationship between psychosocial factors embedded in the SCS e-health tool and patient outcomes supports an integrated and multidisciplinary approach in the selection of patients for SCS. The educational e-health tool, combining both clinical and psychosocial aspects, is believed to be helpful for further education and implementation of this approach.
Collapse
Affiliation(s)
- Simon Thomson
- Mid and South Essex University Hospitals, Basildon, United Kingdom
| | - Nicky Helsen
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| | - Simon Prangnell
- Clinical Neuropsychology Service, Oxford University Hospitals, Oxford, United Kingdom
| | - Mery Paroli
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Hayat Belaïd
- Department of Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Bart Billet
- Department of Anaesthesiology, AZ Delta, Roeselare, Belgium
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Giuliano De Carolis
- FederDolore-SICD; Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | | | - Kliment Gatzinsky
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Willem Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands.,Department of Anaesthesiology and Pain Treatment, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| |
Collapse
|
16
|
Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Levy R, Heemels JP, Eldabe S. An implantable restorative-neurostimulator for refractory mechanical chronic low back pain: a randomized sham-controlled clinical trial. Pain 2021; 162:2486-2498. [PMID: 34534176 PMCID: PMC8442741 DOI: 10.1097/j.pain.0000000000002258] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
ABSTRACT Chronic low back pain can be caused by impaired control and degeneration of the multifidus muscles and consequent functional instability of the lumbar spine. Available treatment options have limited effectiveness and prognosis is unfavorable. We conducted an international randomized, double-blind, sham-controlled trial at 26 multidisciplinary centers to determine safety and efficacy of an implantable, restorative neurostimulator designed to restore multifidus neuromuscular control and facilitate relief of symptoms (clinicaltrials.gov identifier: NCT02577354). Two hundred four eligible participants with refractory mechanical (musculoskeletal) chronic LBP and a positive prone instability test indicating impaired multifidus control were implanted and randomized to therapeutic (N = 102) or low-level sham (N = 102) stimulation of the medial branch of the dorsal ramus nerve (multifidus nerve supply) for 30 minutes twice daily. The primary endpoint was the comparison of responder proportions (≥30% relief on the LBP visual analogue scale without analgesics increase) at 120 days. After the primary endpoint assessment, participants in the sham-control group switched to therapeutic stimulation and the combined cohort was assessed through 1 year for long-term outcomes and adverse events. The primary endpoint was inconclusive in terms of treatment superiority (57.1% vs 46.6%; difference: 10.4%; 95% confidence interval, -3.3% to 24.1%, P = 0.138). Prespecified secondary outcomes and analyses were consistent with a modest but clinically meaningful treatment benefit at 120 days. Improvements from baseline, which continued to accrue in all outcome measures after conclusion of the double-blind phase, were clinically important at 1 year. The incidence of serious procedure- or device-related adverse events (3.9%) compared favorably with other neuromodulation therapies for chronic pain.
Collapse
Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, United States
| | - Vivek Mehta
- Barts Neuromodulation Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, United States
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre,Leeds Teaching Hopsitals NHS Trust, Leeds, United Kingdom
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, United States
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, United States
| | - Edgar Ross
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | - Alexios Carayannopoulos
- Departments of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, United States
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Antoine Tohmeh
- Multicare Neuroscience Institute, Spokane, WA, United States
| | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, United States
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, United States
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, United States
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, United States
| | - James Rathmell
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | - Robert Levy
- Anesthesia Pain Care Consultant, Tamarac, FL, United States
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| |
Collapse
|
17
|
Goebel A, Birklein F, Brunner F, Clark JD, Gierthmühlen J, Harden N, Huygen F, Knudsen L, McCabe C, Lewis J, Maihöfner C, Magerl W, Moseley GL, Terkelsen A, Thomassen I, Bruehl S. The Valencia consensus-based adaptation of the IASP complex regional pain syndrome diagnostic criteria. Pain 2021; 162:2346-2348. [PMID: 33729210 PMCID: PMC8374712 DOI: 10.1097/j.pain.0000000000002245] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Andreas Goebel
- Department of Pain Medicine, Pain Research Institute, University of Liverpool and Walton Centre NHS Foundation Trust Liverpool, United Kingdom
| | - Frank Birklein
- Department of Neurology, University of Mainz, Mainz, Germany
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Clinic, Zurich, Switzerland
| | - J. David Clark
- Stanford University School of Medicine, Stanford, CA, United States
| | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | | | - Frank Huygen
- Rotterdam University, Rotterdam, the Netherlands
| | - Lone Knudsen
- The National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Candy McCabe
- School for Health and Social Wellbeing, University of the West of England, Bristol, United Kingdom
| | - Jenny Lewis
- School for Health and Social Wellbeing, University of the West of England, Bristol, United Kingdom
- Royal United Hospitals Bath NHS Trust, Bath University, Bath, United Kingdom
| | | | | | | | - Astrid Terkelsen
- Department of Neurology, Danish Pain Research Center, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
18
|
Affiliation(s)
- Rikke Krüger Jensen
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | | | - Frank Huygen
- Department of Anaesthesiology, Pain Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Bart Koes
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
| |
Collapse
|
19
|
Christelis N, Simpson B, Russo M, Stanton-Hicks M, Barolat G, Thomson S, Schug S, Baron R, Buchser E, Carr DB, Deer TR, Dones I, Eldabe S, Gallagher R, Huygen F, Kloth D, Levy R, North R, Perruchoud C, Petersen E, Rigoard P, Slavin K, Turk D, Wetzel T, Loeser J. Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11. Pain Med 2021; 22:807-818. [PMID: 33779730 PMCID: PMC8058770 DOI: 10.1093/pm/pnab015] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective For many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS. Methods This article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established. Results 14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option—Persistent spinal pain syndrome—was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification. Conclusions This project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.
Collapse
Affiliation(s)
| | - Brian Simpson
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Marc Russo
- Hunter Pain Specialists, Broadmeadow, New South Wales, Australia
| | | | | | - Simon Thomson
- Basildon and Thurrock University Hospitals, Basildon, UK
| | - Stephan Schug
- Anaesthesiology and Pain Medicine, Medical School, University of Western Australia and Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ralf Baron
- Department of Neurology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | | | - Daniel B Carr
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | | | - Ivano Dones
- Department of Neurosurgery, Fondazione Istituto Neurologico "C. Besta," Milano, Italy
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Rollin Gallagher
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Frank Huygen
- Center for Pain Medicine, Erasmus MC Pijnbehandelcentrum, Rotterdam, Zuid-Holland, Netherlands
| | - David Kloth
- Department of Anesthesiology, Danbury Hospital, Danbury, Connecticut, USA
| | - Robert Levy
- Marcus Neuroscience Institute, Boca Raton, Florida, USA
| | - Richard North
- Department of Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Philippe Rigoard
- Spine-Neurostimulation Functional Unit, PRISMATICS, Poitiers Hospital University, Poitiers, France
| | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Dennis Turk
- University of Washington Seattle, Washington, USA
| | - Todd Wetzel
- Department of Orthopedics, Bassett Medical Center, Coopersown, New York, USA
| | - John Loeser
- Departments of Neurological Surgery & Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
20
|
de Rooij J, Harhangi B, Aukes H, Groeneweg G, Stronks D, Huygen F. The Effect of Percutaneous Nucleoplasty vs Anterior Discectomy in Patients with Cervical Radicular Pain due to a Single-Level Contained Soft-Disc Herniation: A Randomized Controlled Trial. Pain Physician 2020; 23:553-564. [PMID: 33185372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Cervical radicular pain (CRP) is a common problem in the adult population. When conservative treatment fails and the severe pain persist, surgical treatment is considered. However, surgery is associated with some serious risks. To reduce these risks, new minimally invasive techniques have been developed, such as percutaneous nucleoplasty. Several studies have shown that percutaneous nucleoplasty is a safe and effective technique for the treatment of CRP, but until now no randomized controlled trials have been conducted that compare percutaneous cervical nucleoplasty (PCN) to anterior cervical discectomy (ACD) in patients with a single-level contained soft-disc herniation. OBJECTIVES To compare the effects of PCN and ACD in a group of patients with CRP caused by a single-level contained soft-disc herniation. STUDY DESIGN A randomized, controlled, multi-center trial. SETTING Medical University Center and local hospitals. METHODS Forty-eight patients with CRP as a result of a single-level contained soft-disc herniation were randomized to one of the following 2 treatments: PCN or ACD. The primary outcome measure was arm pain intensity, measured with a Visual Analog Scale (VAS). Secondary outcomes were arm pain intensity during heavy effort, neck pain, global perceived effect, Neck Disability Index (NDI), and the patients' general health (Short Form Generated Health Survey [SF-36]). All parameters were measured at baseline (T0), 3 months after intervention (T2), and one year after intervention (T3). One week after the intervention (T1), an intermediate assessment of arm pain, arm pain during heavy effort, neck pain, satisfaction, and improvement were performed. RESULTS At 3 months, the intention to treat analyses revealed a statistical significant interaction between the groups on the primary outcome, arm pain intensity, and on the secondary outcome of the SF-36 item pain, in favor of the ACD group. On the other secondary outcomes, no statistical significant differences were found between the groups over time. At 12 months, there was a trend for more improvement of arm pain in favor of the ACD group and no statistical interactions were found on the secondary outcomes. LIMITATIONS Firstly, the inclusion by the participating hospitals was limited. Secondly, the trial was ended before reaching the required sample size. Thirdly, at baseline, after the inclusion by the neurosurgeon, 13 patients scored less than 50.0 mm on the VAS. Fourthly, the withdrawal of the physiotherapy (PT) group and finally, the patients and interventionists could not be blinded for the treatment. CONCLUSIONS At 3 months, the ACD group performed significantly better on arm pain reduction than the PCN group in patients with CRP as a result of a single-level contained soft-disc hernia. However, the clinical relevancy of this treatment effect can be debated. For all parameters, after one year, no significant differences between the groups were found. When it comes to the longer-term effectiveness, we conclude that PCN can be a good alternative for ACD.
Collapse
Affiliation(s)
- Judith de Rooij
- Department of Anaesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Orthopaedics, Physiotherapy Unit, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Biswadjiet Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hans Aukes
- Department of Anaesthesiology, Unit of Pain Medicine, Albert Schweitzer Hospital, Sliedrecht, The Netherlands
| | - George Groeneweg
- Department of Anaesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dirk Stronks
- Department of Anaesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Frank Huygen
- Department of Anaesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Huygen F, Kern KU, Pérez C. Expert Opinion: Exploring the Effectiveness and Tolerability of Capsaicin 179 mg Cutaneous Patch and Pregabalin in the Treatment of Peripheral Neuropathic Pain. J Pain Res 2020; 13:2585-2597. [PMID: 33116801 PMCID: PMC7569173 DOI: 10.2147/jpr.s263054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background and Objective Treatment of peripheral neuropathic pain (PNP) remains a challenge. In the absence of clear predictors of response, clinical decision-making involves trial and error. While many classes of pharmacological agent are used and have shown efficacy, one of the most commonly used first-line treatments is pregabalin. However, in the 60% of PNP cases in which the pain is localized, a local treatment may be more suitable. This article will summarize the evidence for the relative effectiveness and tolerability of the capsaicin 179 mg patch and pregabalin in the treatment of PNP and highlight the expert opinion of the authors based on their own clinical experiences. Results When compared in a head-to-head trial in patients with PNP, capsaicin 179 mg patch provided non-inferior pain relief compared with an optimized dose of pregabalin, as well as a reduction in dynamic mechanical allodynia, faster onset of action, fewer systemic side effects, and greater treatment satisfaction. Adverse events associated with capsaicin patch are mainly application site reactions, compared with systemic and central nervous system effects with pregabalin. Studies indicate that capsaicin 179 mg patch is associated with a lower burden of therapy than pregabalin in terms of improved tolerability, lack of a daily pill burden, lack of drug-drug interactions, and increased regimen flexibility. Conclusion In localized neuropathic pain, evidence supports a pragmatic approach of using a local treatment before considering a systemic treatment. For treatment selection, the patient profile (eg, concomitant medication use, age) and the treatments' efficacy and tolerability profiles should be considered.
Collapse
Affiliation(s)
- Frank Huygen
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Kai-Uwe Kern
- Institute for Pain Medicine/Pain Practice Wiesbaden, Wiesbaden, Germany
| | | |
Collapse
|
22
|
Thomson S, Huygen F, Prangnell S, De Andrés J, Baranidharan G, Belaïd H, Berry N, Billet B, Cooil J, De Carolis G, Demartini L, Eldabe S, Gatzinsky K, Kallewaard JW, Meier K, Paroli M, Stark A, Winkelmüller M, Stoevelaar H. Appropriate referral and selection of patients with chronic pain for spinal cord stimulation: European consensus recommendations and e-health tool. Eur J Pain 2020; 24:1169-1181. [PMID: 32187774 PMCID: PMC7318692 DOI: 10.1002/ejp.1562] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022]
Abstract
Background Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic, neuropathic‐like and ischaemic pain. However, the heterogeneity of patients in daily clinical practice makes it often challenging to determine which patients are eligible for this treatment, resulting in undesirable practice variations. This study aimed to establish patient‐specific recommendations for referral and selection of SCS in chronic pain. Methods A multidisciplinary European panel used the RAND/UCLA Appropriateness Method (RUAM) to assess the appropriateness of (referral for) SCS for 386 clinical scenarios in four pain areas: chronic low back pain and/or leg pain, complex regional pain syndrome, neuropathic pain syndromes and ischaemic pain syndromes. In addition, the panel identified a set of psychosocial factors that are relevant to the decision for SCS treatment. Results Appropriateness of SCS was strongly determined by the neuropathic or neuropathic‐like pain component, location and spread of pain, anatomic abnormalities and previous response to therapies targeting pain processing (e.g. nerve block). Psychosocial factors considered relevant for SCS selection were as follows: lack of engagement, dysfunctional coping, unrealistic expectations, inadequate daily activity level, problematic social support, secondary gain, psychological distress and unwillingness to reduce high‐dose opioids. An educational e‐health tool was developed that combines clinical and psychosocial factors into an advice on referral/selection for SCS. Conclusions The RUAM was useful to establish a consensus on patient‐specific criteria for referral/selection for SCS in chronic pain. The e‐health tool may help physicians learn to apply an integrated approach of clinical and psychosocial factors. Significance Determining the eligibility of SCS in patients with chronic pain requires careful consideration of a variety of clinical and psychosocial factors. Using a systematic approach to combine evidence from clinical studies and expert opinion, a multidisciplinary European expert panel developed detailed recommendations to support appropriate referral and selection for SCS in chronic pain. These recommendations are available as an educational e‐health tool (https://www.scstool.org/).
Collapse
Affiliation(s)
- Simon Thomson
- Department of Anaesthesiology, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Frank Huygen
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Prangnell
- Clinical Neuropsychology Service, Oxford University Hospitals, Oxford, UK
| | - José De Andrés
- Valencia University Medical School Anesthesia Unit - Surgical Specialties Department, Department of Anaesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | | | - Hayat Belaïd
- Department of Neurosurgery, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Neil Berry
- Neuromodulation Team, Wessex Neurological Centre, Southampton, UK
| | - Bart Billet
- Department of Anaesthesiology, AZ Delta, Roeselare, Belgium
| | - Jan Cooil
- Department of Physiotherapy, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Giuliano De Carolis
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Laura Demartini
- Pain Unit, Clinical Scientific Institutes Maugeri, Pavia, Italy
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Kliment Gatzinsky
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan W Kallewaard
- Department of Anaesthesiology and Pain Management, Rijnstate Hospital, Velp, The Netherlands
| | - Kaare Meier
- Department of Neurosurgery and Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mery Paroli
- Anaesthesiology & Pain Therapy Unit, Santa Chiara University Hospital, Pisa, Italy
| | - Angela Stark
- Pain Management Service, Basildon and Thurrock University Hospitals, Basildon, UK
| | | | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium
| |
Collapse
|
23
|
Huygen F, Kallewaard JW, van Tulder M, Van Boxem K, Vissers K, van Kleef M, Van Zundert J. "Evidence-Based Interventional Pain Medicine According to Clinical Diagnoses": Update 2018. Pain Pract 2019; 19:664-675. [PMID: 30957944 PMCID: PMC6850128 DOI: 10.1111/papr.12786] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 01/01/2023]
Abstract
Introduction Between 2009 and 2011 a series of 26 articles on evidence‐based medicine for interventional pain medicine according to clinical diagnoses were published. The high number of publications since the last literature search justified an update. Methods For the update an independent 3rd party, specialized in systematic reviews was asked in 2015 to perform the literature search and summarize relevant evidence using Cochrane and GRADE methodology to compile guidelines on interventional pain management. The guideline committee reviewed the information and made a last update on March 1st 2018. The information from new studies published after the research performed by the 3th party and additional observational studies was used to incorporate other factors such as side effects and complications, invasiveness, costs and ethical factors, which influence the ultimate recommendations. Results For the different indications a total of 113 interventions were evaluated. Twenty‐seven (24%) interventions were new compared to the previous guidelines and the recommendation changed for only 3 (2.6%) of the interventions. Discussion This article summarizes the evolution of the quality of evidence and the strength of recommendations for the interventional pain treatment options for 28 clinical pain diagnoses.
Collapse
Affiliation(s)
- Frank Huygen
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Maurits van Tulder
- Department of Epidemiology and Biostatistics, Vrije Universiteit Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Kris Vissers
- Department of Pain and Palliative Pain Medicine, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium.,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
24
|
Eldabe S, Tariq A, Nath S, Gulve A, Antrobus H, Baloch M, Buczkowski P, Collighan N, Fernandez T, Fritz AK, Humble S, Huygen F, Krishnan M, Mehta V, Mishra S, Muthukrishnan S, Snidvongs S, Tamosauskas R, Underwood M. Best practice in radiofrequency denervation of the lumbar facet joints: a consensus technique. Br J Pain 2019; 14:47-56. [PMID: 32110398 DOI: 10.1177/2049463719840053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Radiofrequency denervation is used to treat selected people with low back pain. Recent trials have been criticised for using a sub-optimal intervention technique. Objectives To achieve consensus on a best practice technique for administering radiofrequency denervation of the lumbar facet joints to selected people with low back pain. Study design A consensus of expert professionals in the area of radiofrequency denervation of the lumbar facet joints. Methods We invited a clinical member from the 30 most active UK departments in radiofrequency pain procedures and two overseas clinicians with specific expertise to a 1 day consensus meeting. Drawing on the known anatomy of the medial branch, the theoretical basis of radiofrequency procedures, a survey of current practice and collective expertise, delegates were facilitated to reach consensus on the best practice technique. Results The day was attended by 24 UK and international clinical experts. Attendees agreed a best practice technique for the conduct of radiofrequency denervation of the lumbar facet joints. Limitations This consensus was based on a 1 day meeting of 24 clinical experts who attended and took part in the discussions. The agreed technique has not been subject to input from a wider community of experts. Conclusions Current best practice for radiofrequency denervation has been agreed for use in a UK trial. Group members intend immediate implementation in their respective trusts. We propose using this in a planned Randomised Controlled Trial (RCT) of radiofrequency denervation for selected people with low back pain.
Collapse
Affiliation(s)
- Sam Eldabe
- Pain Management, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Anisah Tariq
- Pain Management, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | - Ashish Gulve
- Pain Management, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | | | | | - Piotr Buczkowski
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Neil Collighan
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | | | - Ann-Katrin Fritz
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | | | - Vivek Mehta
- Pain and Anaesthesia Research Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Sailesh Mishra
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Saz Snidvongs
- Barts Health NHS Trust, Pain and Anaesthesia Research Centre, London, UK
| | | | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
25
|
Kallewaard JW, Nijhuis H, Huygen F, Wille F, Zuidema X, van de Minkelis J, Raza A. Prospective Cohort Analysis of DRG Stimulation for Failed Back Surgery Syndrome Pain Following Lumbar Discectomy. Pain Pract 2018; 19:204-210. [PMID: 30269439 DOI: 10.1111/papr.12734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/30/2018] [Accepted: 08/05/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Surgical lumbar discectomy is a commonly performed routine spinal procedure that is usually undertaken to alleviate lumbar radicular symptoms caused by a herniated intervertebral disc. Surgical lumbar discectomy can also lead to chronic postsurgical leg and/or back pain (failed back surgery syndrome [FBSS]), a condition that can be refractory to conventional medical management. Early clinical results on the use of dorsal root ganglion (DRG) stimulation for FBSS have supported the use of this treatment alternative. METHODS A multicenter, single-arm, observational cohort study enrolled patients who had chronic pain following surgical lumbar discectomy, had failed conservative treatments, and reported pain intensity of at least 6 out of 10 in the primary region of pain. Data were collected on pain, quality of life, disability, and mood at baseline and through 12 months. RESULTS Thirteen patients underwent a trial of DRG stimulation; 11 (84.6%; 95% confidence interval = 57.8% to 95.7%) had good outcomes and underwent permanent device placement. Pain was reduced from a score of 8.64 (±0.92) at baseline to 2.40 (±2.38; n = 9) after 12 months of treatment, a 72.05% average reduction (P < 0.001). Similar improvements were observed across the secondary clinical measures, and safety data were in line with published rates. DISCUSSION These results suggest that DRG stimulation induces pain relief in subjects diagnosed with FBSS. These reductions in pain were also associated with improvements in quality of life and disability. Additional prospective studies are warranted to further investigate this potential application of DRG stimulation, as well as to optimize patient selection, lead placement, and programming strategies.
Collapse
Affiliation(s)
| | | | | | - Frank Wille
- Diakonessenhuis Utrecht, Zeist, The Netherlands.,Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Xander Zuidema
- Diakonessenhuis Utrecht, Zeist, The Netherlands.,Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Adil Raza
- Abbott Laboratories, Plano, Texas, U.S.A
| |
Collapse
|
26
|
Deer TR, Pope JE, Lamer TJ, Grider JS, Provenzano D, Lubenow TR, FitzGerald JJ, Hunter C, Falowski S, Sayed D, Baranidharan G, Patel NK, Davis T, Green A, Pajuelo A, Epstein LJ, Harned M, Liem L, Christo PJ, Chakravarthy K, Gilmore C, Huygen F, Lee E, Metha P, Nijhuis H, Patterson DG, Petersen E, Pilitsis JG, Rowe JJ, Rupert MP, Skaribas I, Sweet J, Verrills P, Wilson D, Levy RM, Mekhail N. The Neuromodulation Appropriateness Consensus Committee on Best Practices for Dorsal Root Ganglion Stimulation. Neuromodulation 2018; 22:1-35. [PMID: 30246899 DOI: 10.1111/ner.12845] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/03/2018] [Accepted: 05/29/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) is dedicated to improving the safety and efficacy of neuromodulation and thus improving the lives of patients undergoing neuromodulation therapies. With continued innovations in neuromodulation comes the need for evolving reviews of best practices. Dorsal root ganglion (DRG) stimulation has significantly improved the treatment of complex regional pain syndrome (CRPS), among other conditions. Through funding and organizational leadership by the International Neuromodulation Society (INS), the NACC reconvened to develop the best practices consensus document for the selection, implantation and use of DRG stimulation for the treatment of chronic pain syndromes. METHODS The NACC performed a comprehensive literature search of articles about DRG published from 1995 through June, 2017. A total of 2538 article abstracts were then reviewed, and selected articles graded for strength of evidence based on scoring criteria established by the US Preventive Services Task Force. Graded evidence was considered along with clinical experience to create the best practices consensus and recommendations. RESULTS The NACC achieved consensus based on peer-reviewed literature and experience to create consensus points to improve patient selection, guide surgical methods, improve post-operative care, and make recommendations for management of patients treated with DRG stimulation. CONCLUSION The NACC recommendations are intended to improve patient care in the use of this evolving therapy for chronic pain. Clinicians who choose to follow these recommendations may improve outcomes.
Collapse
Affiliation(s)
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - James J FitzGerald
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nikunj K Patel
- Institute of Clinical Neurosciences, Department of Neurosurgery, Southmead Hospital, University of Bristol, Bristol, UK
| | | | - Alex Green
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | | | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, KY, USA
| | - Liong Liem
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | | | - Frank Huygen
- Erasmus University Hospital, Rotterdam, The Netherlands
| | - Eric Lee
- Summit Pain Alliance, Santa Rosa, CA, USA
| | | | | | | | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Julie G Pilitsis
- Neurosurgery and Neuroscience & Experimental Therapeutics, Albany Medical College, Albany, NY, USA
| | | | | | | | - Jennifer Sweet
- Case Western Reserve University, Stereotactic & Functional Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Derron Wilson
- Goodman Campbell Brain and Spine, Indiana University School of Medicine Department of Neurological Surgery, Indianapolis, IN, USA
| | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
27
|
Abstract
A 68-year-old man classified as III on the American Society of Anaesthesiologists (ASA) physical status classification system, with a high-grade papillary urothelial cell carcinoma of the left distal ureter, underwent open retroperitoneal distal ureterectomy followed by a ureteroneocystostomy with a vesico-psoas hitch. Postoperatively, the patient complained of left proximal lower limb weakness, severe pain and hypaesthesia of the ventral left thigh suggestive of femoral neuropathy. After excluding common causes for postsurgical pain, a surgical re-exploration was eventually performed during which the sutures used in the vesicopexy were removed, resulting in almost complete resolution of the symptoms. Electromyographic analysis 4 weeks after discharge confirmed the diagnosis of femoral neuropathy, most likely caused by the sutures used in the vesicopexy. This is a rare complication with major consequences for postoperative recovery.
Collapse
Affiliation(s)
| | | | - Frank Huygen
- Department of Anaesthesiology, erasmusMC, Rotterdam, The Netherlands
| |
Collapse
|
28
|
Meissner W, Huygen F, Neugebauer EAM, Osterbrink J, Benhamou D, Betteridge N, Coluzzi F, De Andres J, Fawcett W, Fletcher D, Kalso E, Kehlet H, Morlion B, Montes Pérez A, Pergolizzi J, Schäfer M. Management of acute pain in the postoperative setting: the importance of quality indicators. Curr Med Res Opin 2018; 34:187-196. [PMID: 29019421 DOI: 10.1080/03007995.2017.1391081] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite the introduction of evidence-based recommendations for postoperative pain management (POPM), the consensus is that pain control remains suboptimal. Barriers to achieving patient-satisfactory analgesia include deficient knowledge regarding POPM among staff, lack of instructions, insufficient pain assessments and sub-optimal treatment. Effective monitoring of POPM is essential to enable policy makers and healthcare providers to improve the quality of care. Quality indicators (QIs) are quantitative measures of clinical practice that can monitor, evaluate and guide the quality of care provided to patients. QIs can be used to assess various aspects relating to the care process and they have proven useful in improving health outcomes in diseases such as myocardial infarction. In this commentary we critically analyze the evidence regarding the use of QIs in acute POPM based upon the experience of pain specialists from Europe and the USA who are members of the Change Pain Advisory Board. We also undertook a literature review to see what has been published on QIs in acute pain with the goal of assessing which QIs have been developed and used, and which ones have been successful/unsuccessful. In the hospital sector the development and implementation of QIs is complex. The nature of POPM requires a highly trained, multidisciplinary team and it is at this level that major improvements can be made. Greater involvement of patients regarding pain management is also seen as a priority area for improving clinical outcomes. Changes in structure and processes to deliver high-level quality care need to be regularly audited to ensure translation into better outcomes. QIs can help drive this process by providing an indicator of current levels of performance. In addition, outcomes QIs can be used to benchmark levels of performance between different healthcare providers.
Collapse
Affiliation(s)
- Winfried Meissner
- a Dept. of Anesthesiology and Intensive Care , Jena University Hospital , Jena , Germany
| | - Frank Huygen
- b University Hospital , Rotterdam , The Netherlands
| | - Edmund A M Neugebauer
- c Brandenburg Medical School - Theodor Fontane , Neuruppin , Germany
- d Faculty of Health - School of Medicine , Witten/Herdecke University , Witten , Germany
| | - Jürgen Osterbrink
- e Institute of Nursing Science and Practice, WHO Collaborating Centre for Nursing Research and Education, Paracelsus Medical University , Salzburg , Austria
- f Brooks College of Health , University of North Florida, Jacksonville , Florida , USA
| | - Dan Benhamou
- g Département d'Anesthésie-Réanimation, Groupe Hospitalier Paris Sud , Hôpital Bicêtre , Le Kremlin-Bicêtre , France
- h SOS Regional Anaesthesia (SOS-RA) Service , Le Kremlin-Bicêtre , France
| | | | - Flaminia Coluzzi
- j Dept. Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesia, Intensive Care and Pain Medicine , Sapienza University of Rome - Polo Pontino , Latina , Italy
| | - José De Andres
- k Anesthesia Critical Care and Pain Management Department , General University Hospital , Valencia , Spain
| | - William Fawcett
- l Department of Anaesthesia , Royal Surrey County Hospital , Guildford , UK
- m Faculty of Health and Medical Sciences , University of Surrey , Guildford , UK
| | - Dominique Fletcher
- n Department of Anesthesiology and Critical Care , Hôpital Raymond-Poincaré , Garches , France
| | - Eija Kalso
- o Pain Clinic, Department of Anaesthesiology, Intensive Care, and Pain Medicine , Helsinki University Hospital and University of Helsinki , Helsinki , Finland
| | - Henrik Kehlet
- p Section for Surgical Pathophysiology, Rigshospitalet , Copenhagen , Denmark
| | - Bart Morlion
- q The Leuven Centre for Algology & Pain Management , University of Leuven , Leuven , Belgium
| | - Antonio Montes Pérez
- r Department of Anesthesiology , Hospitales Mar-Esperanza, Universitat Autònoma Barcelona , Barcelona , Spain
| | | | | |
Collapse
|
29
|
Affiliation(s)
- Esther Maas
- Department of Health Sciences, VU University Amsterdam, Amsterdam, the Netherlands
| | - Johan Juch
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Frank Huygen
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
30
|
Huygen F, Liem L, Cusack W, Kramer J. Stimulation of the L2-L3 Dorsal Root Ganglia Induces Effective Pain Relief in the Low Back. Pain Pract 2017; 18:205-213. [PMID: 28486758 DOI: 10.1111/papr.12591] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic low back pain affects millions of people worldwide and can arise through a variety of clinical origins. In the case of failed back surgery syndrome (FBSS), previous surgical procedures can contribute to low back pain that is often unresponsive to intervention. Although spinal cord stimulation (SCS) can be an effective treatment modality, it does not provide sufficient pain relief for some intractable cases. Recently, alternative neuromodulation options have been developed, including dorsal root ganglion (DRG) stimulation. The objective of this report is to further investigate these clinical observations. METHODS Twelve patients with significant chronic discogenic low back pain due to FBSS were included. All subjects underwent implantation of DRG stimulation systems that had at least 1 lead placed at L2 or L3. Subjects' pain ratings, mood, and quality of life were tracked prospectively for up to 12 months. RESULTS More than half of subjects reported 50% or better pain relief in the low back, and the average low back pain relief was 45.5% at 12 months. Concomitant reductions in overall pain, leg pain, pain interference, mood, and quality of life were also found. DISCUSSION For the studied population, DRG stimulation at the L2-L3 levels was effective at relieving low back pain. These reductions in pain were associated with improvements in quality of life. Thus, DRG stimulation at these levels may be effective for low back pain by recruiting both segmental and nonsegmental neural pathways that are not otherwise accessible via traditional SCS.
Collapse
Affiliation(s)
- Frank Huygen
- Erasmus University, Rotterdam, Maastricht, The Netherlands
| | - Liong Liem
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | |
Collapse
|
31
|
Koopmans-Klein G, Van Op den Bosch J, van Megen Y, Prenen H, Huygen F, Mancini I. Prolonged release oxycodone and naloxone treatment counteracts opioid-induced constipation in patients with severe pain compared to previous analgesic treatment. Curr Med Res Opin 2017; 33:2217-2227. [PMID: 28805471 DOI: 10.1080/03007995.2017.1367276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Treatment with prolonged-release oxycodone/naloxone (PR OXN) has been shown to improve opioid induced constipation (OIC) in constipated patients. This publication reports on a real-life observational study investigating the efficacy of PR OXN with regard to bowel function in patients switching to PR OXN from WHO step 1, step 2 and step 3 opioids. METHODS Patients with chronic pain experiencing insufficient pain relief and/or unacceptable side effects were switched to PR OXN and monitored in this observational study with respect to efficacy regarding bowel function and efficacy regarding pain relief in comparison with previous analgesic therapy. A patient was considered a responder with respect to efficacy if this assessment was "slightly better", "better" or "much better" compared with previous therapy. Bowel function index, pain intensity, quality of life, laxative medication use, and safety analgesic were also evaluated. RESULTS A total of 1338 patients (mean [SD] age 64.3 [14.9], 63% female) were observed for 43 [3-166] days (median [range]) during treatment with PR OXN. Overall response rate regarding bowel function efficacy was 82.5%. Patients with symptoms of constipation at study entry obtained a clinically relevant improvement of the bowel function index (BFI) within the first 2 weeks of PR OXN treatment. Non-constipated patients at study entry maintained normal bowel function despite switching to treatment with the opioid PR OXN. CONCLUSION In conclusion, treatment with PR OXN results in a significant and clinically relevant improvement of bowel function. During the observation of the treatment with PR OXN patients reported an improvement of quality of life (QoL). More interestingly, non-constipated patients maintained a normal bowel function, showing prevention of constipation despite the use of an opioid.
Collapse
Affiliation(s)
- Gineke Koopmans-Klein
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
| | | | - Yvonne van Megen
- a Mundipharma Pharmaceuticals BV , Medical Department , Leusden , The Netherlands
| | - Hans Prenen
- d Digestive Oncology Unit , University Hospital Leuven , Leuven , Belgium
| | - Frank Huygen
- b Center for Pain Medicine, Erasmus MC , Rotterdam , The Netherlands
| | | |
Collapse
|
32
|
Andrés JD, Pogatzki-Zahn E, Huygen F, Neugebauer E, Fawcett W. Controlling acute pain to improve the quality of postoperative pain management: an update from the European Society of Regional Anesthesia meeting held in Maastricht (September 2016). Pain Manag 2017; 7:513-522. [PMID: 28793825 DOI: 10.2217/pmt-2017-0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Improvement in postoperative pain management remains a global concern with a significant unmet need for patients. This was the focus of a 'Change Pain' session at the 35th European Society of Regional Anesthesia meeting (Maastricht, September 2016). Awareness of the size and nature of the problem is important to improve postoperative pain management strategies. Optimal treatment of acute pain should aim to avoid long-term sequelae such as the development of chronic pain disorders (e.g., phantom limb pain). Cases highlighting unsuccessful and successful strategies to manage individuals undergoing surgery were presented. The benefits of personalized care, encouraging patients to be more involved in decisions regarding their treatment and their preferred clinical outcomes were discussed and considered to be a step forward in acute pain management.
Collapse
Affiliation(s)
- Jose De Andrés
- Departments of Anesthesia & Surgery, Critical Care & Multidisciplinary Pain Management, Valencia University General Hospital, Anesthesia Division, Valencia School of Medicine, Valencia, Spain
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care & Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Frank Huygen
- Erasmus MC, University Hospital, Rotterdam, The Netherlands
| | - Edmund Neugebauer
- Brandenburg Medical School Theodor Fontane & Health Services Research, Witten/Herdecke University, Campus Neuruppin, Neuruppin, Germany
| | - William Fawcett
- Department of Anesthesia, Royal Surrey County Hospital, Egerton Road, Royal Surrey, Guildford, UK.,Faculty of Health & Medical Sciences, Duke of Kent Building, University of Surrey, Guildford, UK
| |
Collapse
|
33
|
Müller-Schwefe G, Morlion B, Ahlbeck K, Alon E, Coaccioli S, Coluzzi F, Huygen F, Jaksch W, Kalso E, Kocot-Kępska M, Kress HG, Mangas AC, Margarit Ferri C, Mavrocordatos P, Nicolaou A, Hernández CP, Pergolizzi J, Schäfer M, Sichère P. Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms. Curr Med Res Opin 2017; 33:1199-1210. [PMID: 28277866 DOI: 10.1080/03007995.2017.1298521] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed. DIAGNOSIS Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects. CONCLUSIONS This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.
Collapse
Affiliation(s)
| | | | | | - Eli Alon
- d Universitätsspital Zurich , Zurich , Switzerland
| | | | - Flaminia Coluzzi
- f Department of Medical and Surgical Sciences and Biotechnologies , Sapienza University of Rome , Italy
| | - Frank Huygen
- g University Hospital , Rotterdam , The Netherlands
| | | | - Eija Kalso
- i Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki, and Helsinki University Hospital , Finland
| | - Magdalena Kocot-Kępska
- j Department of Pain Research and Treatment , Collegium Medicum Jagiellonian University , Kraków , Poland
| | - Hans-Georg Kress
- k Department of Special Anaesthesia and Pain Therapy , Medizinische Universität/AKH Wien , Vienna , Austria
| | | | | | | | | | | | | | - Michael Schäfer
- r Department of Anaesthesiology and Intensive Care Medicine , Charité University Berlin, Campus Virchow Klinikum , Berlin , Germany
| | | |
Collapse
|
34
|
Abstract
Low back pain in general and specifically chronic low back pain forms a major burden for the patient and society. Recently studies demonstrated that up to 65% of patients evolve to chronic pain as opposed to the previously accepted 8%. As low back pain patients present first with their general practitioner, the latter should establish a treatment plan, including the appropriate referrals. There are, however, no clear guidelines as to how to refer low back pain patients. The process of trial and error of different specialties and treatment possibilities often results in a long and costly trajectory. A better understanding of the subtypes of chronic low back pain, the risks for chronification and fast adequate referral may result in higher patient satisfaction and cost reduction. Proposed solutions: We propose a classification system based on the clinical and anatomical characteristics of axial low back pain, separated from radicular pain. It is important to recognize the risks for chronification, such as degenerative and/or herniated disk, a smaller cross-sectional area of the multifidus, erector spinae, and psoas muscles and psychological and social factors, to be able to provide appropriate management. Also stratification of the patients according to the degree of disability may help in defining the correct treatment approach. A one-and-a-half line approach, where a spine physician assistant works under the supervision of the general practitioner to establish the sub-diagnosis, the risk factors for chronicity and to explain the proposed management plan to the patient, may be helpful for an early appropriate treatment selection for the patient with chronic low back pain.
Collapse
Affiliation(s)
- Coen Itz
- a Department of Anesthesiology and Pain Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
- b Health Insurance Company VGZ Eindhoven , Eindhoven , The Netherlands
| | - Frank Huygen
- c Department of Anesthesiology , Centre of Pain Medicine, Erasmus Medical Center , Rotterdam , the Netherlands
| | - Maarten van Kleef
- a Department of Anesthesiology and Pain Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
| |
Collapse
|
35
|
Delhaas E, Froberg A, Verzijlbergen F, van der Lugt A, Harhangi B, Huygen F. Isotopic Scintigraphy Coupled With Computed Tomography for the Investigation of Intrathecal Baclofen Device Malfunction. Arch Phys Med Rehabil 2016; 97:1595. [DOI: 10.1016/j.apmr.2016.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 11/30/2022]
|
36
|
Meissner W, Coluzzi F, Fletcher D, Huygen F, Morlion B, Neugebauer E, Montes A, Pergolizzi J. Improving the management of post-operative acute pain: priorities for change. Curr Med Res Opin 2015; 31:2131-43. [PMID: 26359332 DOI: 10.1185/03007995.2015.1092122] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Poor management of post-operative acute pain can contribute to medical complications including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the development of chronic pain. It is therefore important that all patients undergoing surgery should receive adequate pain management. However, evidence suggests this is not currently the case; between 10% and 50% of patients develop chronic pain after various common operations, and one recent US study recorded >80% of patients experiencing post-operative pain. At the first meeting of the acute chapter of the Change Pain Advisory Board, key priorities for improving post-operative pain management were identified in four different areas. Firstly, patients should be more involved in decisions regarding their own treatment, particularly when fateful alternatives are being considered. For this to be meaningful, relevant information should be provided so they are well informed about the various options available. Good physician/patient communication is also essential. Secondly, better professional education and training of the various members of the multidisciplinary pain management team would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain at different points along pain pathways, more widespread adoption of patient-controlled analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational change could provide similar benefits; introducing acute pain services and increasing their availability towards the 24 hours/day ideal, greater adherence to protocols, increased use of patient-reported outcomes, and greater receptivity to technological advances would all help to enhance performance and increase patient satisfaction. It must be acknowledged that implementing these recommendations would incur a considerable cost that purchasers of healthcare may be unwilling or unable to finance. Nevertheless, change is under way and the political will exists for it to continue.
Collapse
Affiliation(s)
- Winfried Meissner
- a a Leiter der Sektion Schmerz, Klinik für Anaesthesiologie und Intensivmedizin, Universitätsklinikum der FSU Jena , Germany
| | - Flaminia Coluzzi
- b b Department of Medical and Surgical Sciences and Biotechnologies , Sapienza University of Rome , Italy
| | - Dominique Fletcher
- c c Service Anesthésie Réanimation, Hôpital Raymond Poincare , Garches , France
| | - Frank Huygen
- d d University Hospital , Rotterdam , The Netherlands
| | | | - Edmund Neugebauer
- f f Faculty of Health , School of Medicine, Witten/Herdecke University , Cologne , Germany
| | | | - Joseph Pergolizzi
- h h Department of Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
- i i Naples Anesthesia and Pain Associates , Naples , FL , USA
| |
Collapse
|
37
|
Huygen F, Verschueren K, McCabe C, Stegmann JU, Zima J, Mahaux O, Van Holle L, Angelo MG. Investigating Reports of Complex Regional Pain Syndrome: An Analysis of HPV-16/18-Adjuvanted Vaccine Post-Licensure Data. EBioMedicine 2015; 2:1114-21. [PMID: 26501109 PMCID: PMC4587999 DOI: 10.1016/j.ebiom.2015.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/30/2015] [Accepted: 07/01/2015] [Indexed: 12/03/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain disorder that typically follows trauma or surgery. Suspected CRPS reported after vaccination with human papillomavirus (HPV) vaccines led to temporary suspension of proactive recommendation of HPV vaccination in Japan. We investigated the potential CRPS signal in relation to HPV-16/18-adjuvanted vaccine (Cervarix®) by database review of CRPS cases with independent expert confirmation; a disproportionality analysis and analyses of temporality; an observed versus expected analysis using published background incidence rates; systematic reviews of aggregate safety data, and a literature review. The analysis included 17 case reports of CRPS: 10 from Japan (0.14/100,000 doses distributed) and seven from the United Kingdom (0.08/100,000). Five cases were considered by independent experts to be confirmed CRPS. Quantitative analyses did not suggest an association between CRPS and HPV-16/18-adjuvanted vaccine. Observed CRPS incidence after HPV-16/18 vaccination was statistically significantly below expected rates. Systematic database reviews using search terms varying in specificity and sensitivity did not identify new cases. No CRPS was reported during clinical development and no unexpected results found in the literature. There is not sufficient evidence to suggest an increased risk of developing CRPS following vaccination with HPV-16/18-adjuvanted vaccine. Post-licensure safety surveillance confirms the acceptable benefit-risk of HPV-16/18 vaccination. GSK investigated a potential safety signal after suspected CRPS cases were reported following HPV vaccination in Japan Little is known of CRPS. We used database reviews and statistical methods to maximise case detection and reduce uncertainty There is not sufficient evidence to suggest an increased risk of CRPS following HPV-16/18-adjuvanted vaccine
In 2013 the Japanese health authority temporarily suspended proactive recommendation of HPV vaccination after reports of a chronic pain condition (CRPS) in Japan. GSK, who manufactures one of the two available HPV vaccines (Cervarix®), investigated this potential safety issue by reviewing its safety database for all cases of CRPS ever reported after HPV vaccination, and by various statistical analyses. None of the reviews or analyses suggested a safety concern. The observed rate of CRPS after vaccination was lower than what might be expected by chance. At this time there is not enough evidence to suggest that Cervarix® causes CRPS.
Collapse
Affiliation(s)
- Frank Huygen
- Center for Pain Medicine, Erasmus MC, University Hospital, Rotterdam 3000CA, The Netherlands
- Corresponding author at: Center for Pain Medicine, Erasmus MC, University Hospital, PO Box 2040, Rotterdam 3000CA, The Netherlands.
| | - Kristin Verschueren
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Candida McCabe
- Bath Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, BA1 1RL, United Kingdom
- University of the West of England, Bristol, BS16 1DD, United Kingdom
| | - Jens-Ulrich Stegmann
- Vaccines Clinical Safety and Pharmacovigilance, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Julia Zima
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Olivia Mahaux
- Vaccines Safety and Research Group, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Lionel Van Holle
- Vaccines Safety and Research Group, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Maria-Genalin Angelo
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| |
Collapse
|
38
|
Kress HG, Aldington D, Alon E, Coaccioli S, Collett B, Coluzzi F, Huygen F, Jaksch W, Kalso E, Kocot-Kępska M, Mangas AC, Ferri CM, Mavrocordatos P, Morlion B, Müller-Schwefe G, Nicolaou A, Hernández CP, Sichère P. A holistic approach to chronic pain management that involves all stakeholders: change is needed. Curr Med Res Opin 2015; 31:1743-54. [PMID: 26172982 DOI: 10.1185/03007995.2015.1072088] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Chronic pain affects a large proportion of the population, imposing significant individual distress and a considerable burden on society, yet treatment is not always instituted and/or adequate. Comprehensive multidisciplinary management based on the biopsychosocial model of pain has been shown to be clinically effective and cost-efficient, but is not widely available. A literature review of stakeholder groups revealed many reasons for this, including: i) many patients believe healthcare professionals lack relevant knowledge, and consultations are rushed, ii) general practitioners consider that pain management has a low priority and is under-resourced, iii) pain specialists cite non-adherence to evidence-based treatment, sub-optimal prescribing, and chronic pain not being regarded as a disease in its own right, iv) nurses', pharmacists' and physiotherapists' skills are not fully utilized, and v) psychological therapy is employed infrequently and often too late. Many of the issues relating to physicians could be addressed by improving medical training, both at undergraduate and postgraduate levels - for example, by making pain medicine a compulsory core subject of the undergraduate medical curriculum. This would improve physician/patient communication, increase the use of standardized pain assessment tools, and allow more patients to participate in treatment decisions. Patient care would also benefit from improved training for other multidisciplinary team members; for example, nurses could provide counseling and follow-up support, psychologists offer coping skills training, and physiotherapists have a greater role in rehabilitation. Equally important measures include the widespread adoption of a patient-centered approach, chronic pain being recognized as a disease in its own right, and the development of universal guidelines for managing chronic non-cancer pain. Perhaps the greatest barrier to improvement is lack of political will at both national and international level. Some powerful initiatives and collaborations are currently lobbying policy-making bodies to raise standards and reduce unnecessary pain - it is vital they continue.
Collapse
Affiliation(s)
- Hans-Georg Kress
- a a Department of Special Anaesthesia and Pain Therapy , Medizinische Universität/AKH Wien , Vienna , Austria
| | | | - Eli Alon
- c c Universitätsspital Zurich , Zurich , Switzerland
| | | | - Beverly Collett
- e e University Hospitals of Leicester NHS Trust , Leicester , UK
| | - Flaminia Coluzzi
- f f Department of Medical and Surgical Sciences and Biotechnologies , Sapienza University of Rome , Italy
| | - Frank Huygen
- g g University Hospital , Rotterdam , The Netherlands
| | | | - Eija Kalso
- i i Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki, and Helsinki University Hospital , Finland
| | - Magdalena Kocot-Kępska
- j j Department of Pain Research and Treatment , Collegium Medicum Jagiellonian University , Kraków , Poland
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Müller-Schwefe G, Ahlbeck K, Aldington D, Alon E, Coaccioli S, Coluzzi F, Huygen F, Jaksch W, Kalso E, Kocot-Kępska M, Kress HG, Mangas AC, Ferri CM, Morlion B, Nicolaou A, Hernández CP, Pergolizzi J, Schäfer M, Sichère P. Pain in the cancer patient: different pain characteristics CHANGE pharmacological treatment requirements. Curr Med Res Opin 2014; 30:1895-908. [PMID: 24841174 DOI: 10.1185/03007995.2014.925439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Twenty years ago, the main barriers to successful cancer pain management were poor assessment by physicians, and patients' reluctance to report pain and take opioids. Those barriers are almost exactly the same today. Cancer pain remains under-treated; in Europe, almost three-quarters of cancer patients experience pain, and almost a quarter of those with moderate to severe pain do not receive any analgesic medication. Yet it has been suggested that pain management could be improved simply by ensuring that every consultation includes the patient's rating of pain, that the physician pays attention to this rating, and a plan is agreed to increase analgesia when it is inadequate. After outlining current concepts of carcinogenesis in some detail, this paper describes different methods of classifying and diagnosing cancer pain and the extent of current under-treatment. Key points are made regarding cancer pain management. Firstly, the pain may be caused by multiple different mechanisms and therapy should reflect those underlying mechanisms - rather than being simply based on pain intensity as recommended by the WHO three-step ladder. Secondly, a multidisciplinary approach is required which combines both pharmacological and non-pharmacological treatment, such as psychotherapy, exercise therapy and electrostimulation. The choice of analgesic agent and its route of administration are considered, along with various interventional procedures and the requirements of palliative care. Special attention is paid to the treatment of breakthrough pain (particularly with fast-acting fentanyl formulations, which have pharmacokinetic profiles that closely match those of breakthrough pain episodes) and chemotherapy-induced neuropathic pain, which affects around one third of patients who receive chemotherapy. Finally, the point is made that medical education should place a greater emphasis on pain therapy, both at undergraduate and postgraduate level.
Collapse
|
40
|
Kramer J, Liem L, Russo M, Smet I, Van Buyten JP, Huygen F. Lack of Body Positional Effects on Paresthesias When Stimulating the Dorsal Root Ganglion (DRG) in the Treatment of Chronic Pain. Neuromodulation 2014; 18:50-7; discussion 57. [DOI: 10.1111/ner.12217] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 04/04/2014] [Accepted: 05/13/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Jeffery Kramer
- Spinal Modulation, Inc.; Menlo Park CA USA
- University of Illinois College of Medicine; Peoria IL USA
| | - Liong Liem
- Sint Antonius; Nieuwegein The Netherlands
| | - Marc Russo
- Hunter Pain Clinic; Broadmeadow NSW Australia
| | | | | | | |
Collapse
|
41
|
Kress HG, Ahlbeck K, Aldington D, Alon E, Coaccioli S, Coluzzi F, Huygen F, Jaksch W, Kalso E, Kocot-Kępska M, Mangas AC, Margarit Ferri C, Morlion B, Müller-Schwefe G, Nicolaou A, Pérez Hernández C, Pergolizzi J, Schäfer M, Sichère P. Managing chronic pain in elderly patients requires a CHANGE of approach. Curr Med Res Opin 2014; 30:1153-64. [PMID: 24450746 DOI: 10.1185/03007995.2014.887005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In many countries, the number of elderly people has increased rapidly in recent years and this is expected to continue; it has been predicted that almost a quarter of the population in the European Union will be over 65 years of age in 2035. Many elderly people suffer from chronic pain but it is regularly under-treated, partly because managing these patients is often complex. This paper outlines the extent of untreated pain in this population and the consequent reduction in quality of life, before articulating the reasons why it is poorly or inaccurately diagnosed. These include the patient's unwillingness to complain, atypical pain presentations, multiple morbidities and cognitive decline. Successful pain management depends upon accurate diagnosis, which is based upon a complete history and thorough physical examination, as well as an assessment of psychosocial functioning. Poor physician/patient communication can be improved by using standardized instruments to establish individual treatment targets and measure progress towards them. User-friendly observational instruments may be valuable for patients with dementia. In line with the widely accepted biopsychosocial model of pain, a multidisciplinary approach to pain management is recommended, with pharmacotherapy, psychological support, physical rehabilitation and interventional procedures available if required. Declining organ function and other physiological changes require lower initial doses of analgesics and less frequent dosing intervals, and the physician must be aware of all medications that the patient is taking, in order to avoid drug/drug interactions. Non-adherence to treatment is common, and various strategies can be employed to improve it; involving the elderly patient's caregivers and family, using medication systems such as pill-boxes, or even sending text messages. In the long term, the teaching of pain medicine needs to be improved--particularly in the use of opioids--both at undergraduate level and after qualification.
Collapse
|
42
|
Van Buyten JP, Smet I, Liem L, Russo M, Huygen F. Stimulation of dorsal root ganglia for the management of complex regional pain syndrome: a prospective case series. Pain Pract 2014; 15:208-16. [PMID: 24451048 DOI: 10.1111/papr.12170] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 11/01/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic and progressive pain condition usually involving the extremities and characterized by sensorimotor, vascular, and trophic changes. Spinal cord stimulation (SCS) is an effective intervention for this condition, but is hampered by the technical challenges associated with precisely directing stimulation to distal extremities. Dorsal root ganglia (DRG) may be more effective as a physiological target for electrical modulation due to recruitment of the primary sensory neurons that innervate the painful distal anatomical regions. METHODS Eleven subjects diagnosed with uni- or bilateral lower-extremity CRPS were recruited as part of a larger study involving chronic pain of heterogeneous etiologies. Quadripolar epidural leads of a newly developed neurostimulation system were placed near lumbar DRGs using conventional percutaneous techniques. The neurostimulators were trialed; 8 were successful and permanently implanted and programed to achieve optimal pain-paresthesia overlap. RESULTS All 8 subjects experienced some degree of pain relief and subjective improvement in function, as measured by multiple metrics. One month after implantation of the neurostimulator, there was significant reduction in average self-reported pain to 62% relative to baseline values. Pain relief persisted through 12 months in most subjects. In some subjects, edema and trophic skin changes associated with CRPS were also mitigated and function improved. Neuromodulation of the DRG was able to provide excellent pain-paresthesia concordance in locations that are typically hard to target with traditional SCS, and the stimulation reduced the area of pain distributions. CONCLUSIONS Neuromodulation of the DRG appears to be a promising option for relieving chronic pain and other symptoms associated with CRPS. The capture of discrete painful areas such as the feet, combined with stable paresthesia intensities independent of body position, suggests this stimulation modality may allow more selective and consistent targeting of painful areas than traditional SCS.
Collapse
|
43
|
Affiliation(s)
- Panagiota Sykioti
- 1st Anaesthesiology Clinic; Pain Relief and Palliative Care Unit; Aretaieion University Hospital; University of Athens; Athens Greece
| | - Panagiotis Zis
- Department of Neurology; Evangelismos General Hospital; Athens Greece
| | - Athina Vadalouca
- 1st Anaesthesiology Clinic; Pain Relief and Palliative Care Unit; Aretaieion University Hospital; University of Athens; Athens Greece
| | | | | |
Collapse
|
44
|
van Seventer R, Huygen F. Reply by the authors. Pain Pract 2014; 14:95-96. [PMID: 24551884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
|
45
|
Pergolizzi J, Ahlbeck K, Aldington D, Alon E, Coluzzi F, Dahan A, Huygen F, Kocot-Kępska M, Mangas AC, Mavrocordatos P, Morlion B, Müller-Schwefe G, Nicolaou A, Pérez Hernández C, Sichère P, Schäfer M, Varrassi G. The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment. Curr Med Res Opin 2013; 29:1127-35. [PMID: 23786498 PMCID: PMC3793283 DOI: 10.1185/03007995.2013.810615] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chronic pain is currently under-diagnosed and under-treated, partly because doctors' training in pain management is often inadequate. This situation looks certain to become worse with the rapidly increasing elderly population unless there is a wider adoption of best pain management practice. This paper reviews current knowledge of the development of chronic pain and the multidisciplinary team approach to pain therapy. The individual topics covered include nociceptive and neuropathic pain, peripheral sensitization, central sensitization, the definition and diagnosis of chronic pain, the biopsychosocial model of pain and the multidisciplinary approach to pain management. This last section includes an example of the implementation of a multidisciplinary approach in Belgium and describes the various benefits it offers; for example, the early multidimensional diagnosis of chronic pain and rapid initiation of evidence-based therapy based on an individual treatment plan. The patient also receives continuity of care, while pain relief is accompanied by improvements in physical functioning, quality of life and emotional stress. Other benefits include decreases in catastrophizing, self-reported patient disability, and depression. Improved training in pain management is clearly needed, starting with the undergraduate medical curriculum, and this review is intended to encourage further study by those who manage patients with chronic pain.
Collapse
Affiliation(s)
- Joseph Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Jongen JLM, Hans G, Benzon HT, Huygen F, Hartrick CT. Neuropathic Pain and Pharmacological Treatment. Pain Pract 2013; 14:283-95. [DOI: 10.1111/papr.12085] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 04/26/2013] [Indexed: 12/27/2022]
Affiliation(s)
- Joost L. M. Jongen
- Department of Neurology; Erasmus MC; Rotterdam The Netherlands
- Department of Anesthesiology; Erasmus MC; Rotterdam The Netherlands
| | - Guy Hans
- Department of Anesthesiology and Multidisciplinary Pain Center; Antwerp University Hospital; Edegem Belgium
| | - Honorio T. Benzon
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago Illinois
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine; Erasmus MC; Rotterdam The Netherlands
| | - Craig T. Hartrick
- Departments of Biomedical Sciences and Anesthesiology; Oakland University William Beaumont School of Medicine; Rochester Michigan U.S.A
| |
Collapse
|
47
|
van Seventer R, Vos C, Giezeman M, Meerding WJ, Arnould B, Regnault A, van Eerd M, Martin C, Huygen F. Validation of the Dutch Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain. Pain Pract 2012; 13:390-8. [DOI: 10.1111/papr.12006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 08/19/2012] [Indexed: 01/21/2023]
Affiliation(s)
| | - Cornelis Vos
- Department of General Practice; Erasmus Medical Center; Rotterdam; The Netherlands
| | | | | | | | | | - Maarten van Eerd
- Department of Anaesthesiology; Amphia Ziekenhuis; Breda; The Netherlands
| | - Carola Martin
- Department of Anaesthesiology Pain treatment centre; Erasmus Medical Center; Rotterdam; The Netherlands
| | - Frank Huygen
- Department of Anaesthesiology Pain treatment centre; Erasmus Medical Center; Rotterdam; The Netherlands
| |
Collapse
|
48
|
Pergolizzi J, Ahlbeck K, Aldington D, Alon E, Collett B, Coluzzi F, Huygen F, Jaksch W, Kocot-Kępska M, Mangas AC, Margarit C, Mavrocordatos P, Morlion B, Müller-Schwefe G, Nicolaou A, Pérez Hernández C, Sichere P, Varrassi G. The chronic pain conundrum: should we CHANGE from relying on past history to assessing prognostic factors? Curr Med Res Opin 2012; 28:249-56. [PMID: 22181344 DOI: 10.1185/03007995.2011.651525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite limited empirical support, chronic pain has traditionally been defined mainly on the basis of its duration, which takes no account of the causative mechanisms or its clinical significance. SCOPE For this commentary on current pain management practice, the CHANGE PAIN Advisory Board considered the evidence for adopting a prognostic definition of chronic pain. The rationale underlying this approach is to take psychological and behavioural factors into account, as well as the multidimensional nature of pain. Measures of pain intensity, interference with everyday activities, role disability, depression, duration and number of pain sites are used to calculate a risk score, which indicates the likelihood of a patient having pain in the future. The consistency of a prognostic definition with the concept of integrated patient care was also considered. FINDINGS When this method was compared with the number of pain days experienced over the previous 6 months--in patients with back pain, headache or orofacial pain--it was a better predictor of clinically significant pain 6 months later for all three pain conditions. Further evidence supporting this approach is that several factors other than the duration of pain have been shown to be important prognostic indicators, including unemployment, functional disability, anxiety and self-rated health. The use of a multifactorial risk score may also suggest specific measures to improve outcomes, such as addressing emotional distress. These measures should be undertaken as part of an integrated pain management strategy; chronic pain is a biopsychosocial phenomenon and all aspects of the patient's pain must be dealt with appropriately and simultaneously for treatment to be effective. CONCLUSION The implementation of a prognostic definition and wider adoption of integrated care could bring significant advantages. However, these measures require improved training in pain management and structural revision of specialist facilities, for which political support is essential.
Collapse
Affiliation(s)
- Joseph Pergolizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
van Eijs F, Huygen F, Van Zundert J. In Response: Intravenous Regional Guanethidine for Complex Regional Pain Syndrome. Pain Pract 2011. [DOI: 10.1111/j.1533-2500.2011.00483.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
50
|
Van Zundert J, Hartrick C, Patijn J, Huygen F, Mekhail N, van Kleef M. Evidence-Based Interventional Pain Medicine According to Clinical Diagnoses. Pain Pract 2011; 11:423-9. [DOI: 10.1111/j.1533-2500.2011.00490.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|