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Nishtar M, Mark R, Langford DJ, McDermott MP, Markman JD, Evans SR, France FO, Park M, Sharma S, Turk DC, Dworkin RH, Gewandter JS. Evaluating the balance of benefits and harms in chronic pain clinical trials: prioritizing individual participants over individual outcomes. Reg Anesth Pain Med 2024; 49:363-367. [PMID: 37963675 PMCID: PMC11081843 DOI: 10.1136/rapm-2023-104809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/26/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) generally assess efficacy and safety separately, with the conclusion of whether a treatment is beneficial based solely on the efficacy endpoint. However, assessing and combining efficacy and safety domains, using a single composite outcome measure, can provide a more comprehensive assessment of the overall effect of a treatment. Furthermore, composite outcomes can incorporate information regarding the relationship between the individual outcomes. In fact, such outcomes have been suggested in the clinical trials literature for at least 15 years. OBJECTIVES To (1) identify whether recent primary publications of chronic pain RCTs from major pain journals included a composite outcome measure of benefits and harms and (2) discuss the potential benefits of such outcomes in various stages of treatment development, including as outcome measures in RCTs, and to support decisions of Data and Safety Monitoring Boards and ordering of treatments in the context of treatment guidelines. EVIDENCE REVIEW RCTs published in 6 major pain journals published between 2016 and 2021 that investigated interventions for chronic pain were reviewed. FINDINGS Of 73 RCTs identified, only 2 included a composite outcome measure of benefits and harms. Both of these articles compared 2 active treatments. CONCLUSIONS Composite outcomes of benefits and harms are underutilized in chronic pain RCTs. The advantages and challenges of using such outcomes are discussed.
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Affiliation(s)
- Mahd Nishtar
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Remington Mark
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Dale J Langford
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | - Scott R Evans
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Fallon O France
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Meghan Park
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Sonia Sharma
- School of Medicine and Biomedical Sciences, University at Buffalo Jacobs, Buffalo, New York, USA
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Jennifer S Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Abraham L, Dworkin RH, Turk DC, Markman JD, Williams DA, Bushmakin AG, Hall JA, Semel DC, Cappelleri JC, Yang R. Examining the Relationships Among Treatment, Pain, and Physical Function in Patients With Osteoarthritis: A Mediation-Modeling Approach. Clin J Pain 2023; 39:159-165. [PMID: 36806283 PMCID: PMC10022660 DOI: 10.1097/ajp.0000000000001095] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/26/2022] [Accepted: 01/06/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVES To better understand the relationships among treatment, pain, and physical function (PF). METHODS Data were collected from 2 published randomized clinical trials of osteoarthritis patients who received tanezumab or a placebo. PF was measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) PF domain. Pain (WOMAC pain domain) was a mediator of the effect of treatment on PF. A set of mediation models were investigated. Variables were treatment (tanezumab vs placebo), WOMAC pain domain, and WOMAC PF domain. Cross-sectional mediation models were assessed separately at different weeks. Longitudinal mediation models used data from all weeks simultaneously. Results could identify a steady-state period. RESULTS The cross-sectional and longitudinal mediation models showed a stable indirect effect of treatment through the pain on PF across time, indicating that a pseudo-steady-state model was appropriate. Therefore, the longitudinal steady-state mediation models were used with all available data assuming relationships among variables in the model being the same at all time points; results showed that the indirect effect of the treatment on PF was 77.8% in study 1 (NCT02697773) and 74.1% in study 2 (NCT02709486), both P <0.0001, whereas the direct effect was 22.2% for study 1 ( P = 0.0003) and 25.9% for study 2 ( P = 0.0019). DISCUSSION At least 75% of the treatment effect of tanezumab on physical functioning can be explained by the improvements in pain. However, tanezumab had an additional effect on physical functioning (~25%) that, was independent of improvements in pain. Such independent effects are of considerable interest and require further research to determine their mechanisms.
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Edwards RR, Schreiber KL, Dworkin RH, Turk DC, Baron R, Freeman R, Jensen TS, Latremoliere A, Markman JD, Rice ASC, Rowbotham M, Staud R, Tate S, Woolf CJ, Andrews NA, Carr DB, Colloca L, Cosma-Roman D, Cowan P, Diatchenko L, Farrar J, Gewandter JS, Gilron I, Kerns RD, Marchand S, Niebler G, Patel KV, Simon LS, Tockarshewsky T, Vanhove GF, Vardeh D, Walco GA, Wasan AD, Wesselmann U. Optimizing and Accelerating the Development of Precision Pain Treatments for Chronic Pain: IMMPACT Review and Recommendations. J Pain 2023; 24:204-225. [PMID: 36198371 PMCID: PMC10868532 DOI: 10.1016/j.jpain.2022.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/01/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
Large variability in the individual response to even the most-efficacious pain treatments is observed clinically, which has led to calls for a more personalized, tailored approach to treating patients with pain (ie, "precision pain medicine"). Precision pain medicine, currently an aspirational goal, would consist of empirically based algorithms that determine the optimal treatments, or treatment combinations, for specific patients (ie, targeting the right treatment, in the right dose, to the right patient, at the right time). Answering this question of "what works for whom" will certainly improve the clinical care of patients with pain. It may also support the success of novel drug development in pain, making it easier to identify novel treatments that work for certain patients and more accurately identify the magnitude of the treatment effect for those subgroups. Significant preliminary work has been done in this area, and analgesic trials are beginning to utilize precision pain medicine approaches such as stratified allocation on the basis of prespecified patient phenotypes using assessment methodologies such as quantitative sensory testing. Current major challenges within the field include: 1) identifying optimal measurement approaches to assessing patient characteristics that are most robustly and consistently predictive of inter-patient variation in specific analgesic treatment outcomes, 2) designing clinical trials that can identify treatment-by-phenotype interactions, and 3) selecting the most promising therapeutics to be tested in this way. This review surveys the current state of precision pain medicine, with a focus on drug treatments (which have been most-studied in a precision pain medicine context). It further presents a set of evidence-based recommendations for accelerating the application of precision pain methods in chronic pain research. PERSPECTIVE: Given the considerable variability in treatment outcomes for chronic pain, progress in precision pain treatment is critical for the field. An array of phenotypes and mechanisms contribute to chronic pain; this review summarizes current knowledge regarding which treatments are most effective for patients with specific biopsychosocial characteristics.
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Affiliation(s)
| | | | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Arnold-Heller-Straße 3, House D, 24105 Kiel, Germany
| | - Roy Freeman
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | - Nick A Andrews
- Salk Institute for Biological Studies, San Diego, California
| | | | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | - Luda Diatchenko
- Department of Anesthesia and Faculty of Dentistry, McGill University, Montreal, California
| | - John Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Robert D Kerns
- Yale University, Departments of Psychiatry, Neurology, and Psychology, New Haven, Connecticut
| | | | | | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | | | | | | | | | - Gary A Walco
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Ajay D Wasan
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ursula Wesselmann
- Department of Anesthesiology/Division of Pain Medicine, Neurology and Psychology, The University of Alabama at Birmingham, Birmingham, Alabama
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Gewandter JS, Sohn MB, De Guzman R, Frazer ME, Chiodo V, Sharma S, Geha P, Markman JD. Predicting Treatment Response with Sensory Phenotyping in Post-Traumatic Neuropathic Pain. Pain Med 2022; 23:1726-1732. [PMID: 35312012 PMCID: PMC9527609 DOI: 10.1093/pm/pnac045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Currently available treatments for neuropathic pain are only modestly efficacious when assessed in randomized clinical trials and work for only some patients in the clinic. Induced-pain or gain-of-function phenotypes have been shown to predict response to analgesics (vs placebos) in patients with neuropathic pain. However, the predictive value of these phenotypes has never been studied in post-traumatic neuropathic pain. METHODS Mixed-effects models for repeated measures were used to evaluate the efficacy of pregabalin vs placebo in subgroups with induced-pain phenotypes (i.e., hyperalgesia or allodynia) in data from a recent, multinational randomized clinical trial (N = 539) that identified phenotypic subgroups through the use of a structured clinical exam. RESULTS The difference in mean pain score between the active and placebo groups (i.e., delta) after 15 weeks of treatment for the subgroup with hyperalgesia was -0.76 (P = 0.001), compared with 0.19 (P = 0.47) for the subgroup that did not have hyperalgesia. The treatment-by-phenotype interaction, which tests whether subgroups have statistically different treatment responses, was significant (P = 0.0067). The delta for the subgroup with allodynia was -0.31 (P = 0.22), compared with -0.30 (P = 0.22) for the subgroup that did not have allodynia (treatment-by-phenotype interaction P = 0.98). CONCLUSIONS These data suggest that hyperalgesia, but not allodynia, predicts response to pregabalin in patients with chronic post-traumatic neuropathic pain. This study extends the growing data supporting the utility of induced-pain phenotypes to predict response to analgesics in post-traumatic neuropathic pain. Sensory phenotyping in large, multisite trials through the use of a structured clinical exam has the potential to accelerate the development of new analgesics and improve the generalizability of clinical trial results.
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Affiliation(s)
- Jennifer S Gewandter
- Correspondence to: Jennifer S. Gewandter, PhD, MPH, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 604, Rochester, NY 14642, USA. Tel: 585-276-5661; Fax: 585-244-7271; E-mail:
| | - Michael B Sohn
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Rachel De Guzman
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Maria E Frazer
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Valerie Chiodo
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Sonia Sharma
- Department of Oral Diagnostic Sciences, University at Buffalo School of Dental Medicine, Buffalo, New York
| | - Paul Geha
- Department of Psychiatry, University of Rochester, Rochester, New York, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, New York
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Markman JD, Schnitzer TJ, Perrot S, Beydoun SR, Ohtori S, Viktrup L, Yang R, Bramson C, West CR, Verburg KM. Clinical Meaningfulness of Response to Tanezumab in Patients with Chronic Low Back Pain: Analysis From a 56-Week, Randomized, Placebo- and Tramadol-Controlled, Phase 3 Trial. Pain Ther 2022; 11:1267-1285. [PMID: 35962939 PMCID: PMC9633876 DOI: 10.1007/s40122-022-00424-7] [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: 05/05/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION A recent phase 3, randomized, placebo- and tramadol-controlled trial (56-week treatment/24-week safety follow-up) demonstrated efficacy of tanezumab 10 mg in patients with chronic low back pain (CLBP) and a history of inadequate response to standard-of-care analgesics. Here, we report on the clinical meaningfulness of treatment response in this study, focused on secondary measures of pain, interference with daily functions, overall disease status, and satisfaction with treatment. METHODS Patients received placebo (up to week 16; n = 406), subcutaneously administered (SC) tanezumab 5 mg (every 8 weeks; n = 407), SC tanezumab 10 mg (every 8 weeks; n = 407), or orally administered tramadol prolonged-release (100-300 mg/day; n = 605) for 56 weeks. Patient's global assessment of low back pain (PGA-LBP), Brief Pain Inventory-short form (BPI-sf), Treatment Satisfaction Questionnaire for Medication (TSQM), and modified Patient-Reported Treatment Impact (mPRTI) were assessed at weeks 16 and 56. RESULTS At week 16, significant (p < 0.05) improvements over placebo were evident with tanezumab for the PGA-LBP (10 mg) and most BPI-sf (both doses), TSQM (both doses), and mPRTI (both doses) items assessed. Improvements over baseline persisted for the PGA-LBP and BPI-sf at week 56. However, the magnitude of improvements was modestly lower at week 56 relative to week 16. Tramadol did not improve PGA-LBP or BPI-sf scores versus placebo at week 16. Most differences between tanezumab and tramadol at week 56 did not reach the level of statistical significance for all endpoints. CONCLUSIONS The totality of the evidence as captured by measures of pain, interference with daily function, patient overall assessment of disease status, and satisfaction with treatment demonstrates the clinically meaningful benefit of tanezumab for some patients with CLBP compared with placebo. CLINICALTRIALS gov: NCT02528253.
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Affiliation(s)
- John D Markman
- University of Rochester School of Medicine and Dentistry, 2180 S. Clinton Ave, Rochester, NY, 14618, USA.
| | - Thomas J Schnitzer
- Northwestern University Feinberg School of Medicine, 710 N Lake Shore Drive, Room 1020, Chicago, IL, 60611, USA
| | - Serge Perrot
- Pain Center, Cochin Hospital, INSERM U 987, Paris University, Paris, France
| | - Said R Beydoun
- University of Southern California, 1520 San Pablo Street, Suite 3000, Los Angeles, CA, 90033, USA
| | - Seiji Ohtori
- Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Lars Viktrup
- Eli Lilly & Company, 893 Delaware St, Indianapolis, IN, 46225, USA
| | - Ruoyong Yang
- Pfizer Inc, 235 E 42nd St, New York, NY, 10017, USA
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7
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Kleykamp BA, Dworkin RH, Turk DC, Bhagwagar Z, Cowan P, Eccleston C, Ellenberg SS, Evans SR, Farrar JT, Freeman RL, Garrison LP, Gewandter JS, Goli V, Iyengar S, Jadad AR, Jensen MP, Junor R, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, McDermott MP, Mease PJ, O'Connor AB, Patel KV, Raja SN, Rowbotham MC, Sampaio C, Singh JA, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations. Pain 2022; 163:1006-1018. [PMID: 34510135 PMCID: PMC8904641 DOI: 10.1097/j.pain.0000000000002475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.
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Affiliation(s)
- Bethea A Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, CT, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | | | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy L Freeman
- Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders, Boston, MA, United States
| | - Louis P Garrison
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Veeraindar Goli
- Pfizer, Inc, New York, NY, United States. Dr. Goli is now with the Emeritus Professor, Duke University School of Medicine, Durham, NC, United States
| | - Smriti Iyengar
- Division of Translational Research, NINDS, NIH, Rockville, MD, United States
| | - Alejandro R Jadad
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Beati, Inc, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Wayland, MA, United States
| | | | | | - Dmitri Lissin
- DURECT Corporation, Cupertino, CA, United States. Dr. Lissin is now woth the Scilex Pharmaceuticals, Inc., San Diego, CA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Philip J Mease
- Division of Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C Rowbotham
- Department of Anesthesia, UCSF School of Medicine, Research Institute, CPMC Sutter Health, San Francisco, CA, United States
| | - Cristina Sampaio
- Clinical Pharmacology Lab, Faculdade de Medicina de Lisboa, University Lisbon, Lisbon, Portugal
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, United States
- Department of Medicine at the School of Medicine, University of Alabama (UAB) at Birmingham, Birmingham, AL, United States
- Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, United States
| | - Ilona Steigerwald
- Chief Medical Officer SVP Neumentum, Inc, Morristown NJ, United States
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, United States
| | - Leslie A Tive
- Department of Biopharmaceuticals, Pfizer, Inc, New York, NY, United States
| | | | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, United States
| | - Hilary D Wilson
- Patient Affairs and Engagement, Boehringer Ingelheim, Ridgefield, CT, United States
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8
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Konno SI, Nikaido T, Markman JD, Ohta M, Machida T, Isogawa N, Yoshimatsu H, Viktrup L, Brown MT, West CR, Verburg KM. Tanezumab for chronic low back pain: a long-term, randomized, celecoxib-controlled Japanese Phase III safety study. Pain Manag 2021; 12:323-335. [PMID: 34786956 DOI: 10.2217/pmt-2021-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim & methods: This trial investigated long-term (56-week treatment/24-week follow-up) use of subcutaneous tanezumab (5 or 10 mg every 8 weeks) or oral celecoxib (200 mg/day) in Japanese patients with chronic low back pain. Results & conclusion: Tanezumab safety was consistent with previous studies, except overall adverse events (tanezumab 5 mg = 63.0%, tanezumab 10 mg = 54.8%, celecoxib = 67.4%) and events of abnormal peripheral sensation (tanezumab 5 mg = 9.8%, tanezumab 10 mg = 4.3%, celecoxib = 4.3%) were more frequent with 5 mg than 10 mg tanezumab. Joint safety event rates were 1.1% for tanezumab 5 mg, 2.2% for tanezumab 10 mg and 0% for celecoxib. All treatments improved pain and function throughout the treatment period. Clinical trial registration number: NCT02725411.
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Affiliation(s)
- Shin-Ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - Takuya Nikaido
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima, 960-1295, Japan
| | - John D Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY 14618, USA
| | | | | | - Naoki Isogawa
- Pfizer R&D Japan, Tokyo, 151-8589, Japan.,Current affiliation: UCB Japan Co., Ltd., Tokyo, 160-0023, Japan
| | | | - Lars Viktrup
- Neuroscience Business Unit, Eli Lilly & Company, Indianapolis, IN 46225, USA
| | - Mark T Brown
- Pfizer Global Product Development, Pfizer Inc., Groton, CT 06340, USA
| | - Christine R West
- Pfizer Global Product Development, Pfizer Inc., Groton, CT 06340, USA
| | - Kenneth M Verburg
- Pfizer Global Product Development, Pfizer Inc., Groton, CT 06340, USA
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9
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Gewandter JS, Smith SM, Dworkin RH, Turk DC, Gan TJ, Gilron I, Hertz S, Katz NP, Markman JD, Raja SN, Rowbotham MC, Stacey BR, Strain EC, Ward DS, Farrar JT, Kroenke K, Rathmell JP, Rauck R, Brown C, Cowan P, Edwards RR, Eisenach JC, Ferguson M, Freeman R, Gray R, Giblin K, Grol-Prokopczyk H, Haythornthwaite J, Jamison RN, Martel M, McNicol E, Oshinsky M, Sandbrink F, Scholz J, Scranton R, Simon LS, Steiner D, Verburg K, Wasan AD, Wentworth K. Research approaches for evaluating opioid sparing in clinical trials of acute and chronic pain treatments: Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials recommendations. Pain 2021; 162:2669-2681. [PMID: 33863862 PMCID: PMC8497633 DOI: 10.1097/j.pain.0000000000002283] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Randomized clinical trials have demonstrated the efficacy of opioid analgesics for the treatment of acute and chronic pain conditions, and for some patients, these medications may be the only effective treatment available. Unfortunately, opioid analgesics are also associated with major risks (eg, opioid use disorder) and adverse outcomes (eg, respiratory depression and falls). The risks and adverse outcomes associated with opioid analgesics have prompted efforts to reduce their use in the treatment of both acute and chronic pain. This article presents Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus recommendations for the design of opioid-sparing clinical trials. The recommendations presented in this article are based on the following definition of an opioid-sparing intervention: any intervention that (1) prevents the initiation of treatment with opioid analgesics, (2) decreases the duration of such treatment, (3) reduces the total dosages of opioids that are prescribed for or used by patients, or (4) reduces opioid-related adverse outcomes (without increasing opioid dosages), all without causing an unacceptable increase in pain. These recommendations are based on the results of a background review, presentations and discussions at an IMMPACT consensus meeting, and iterative drafts of this article modified to accommodate input from the co-authors. We discuss opioid sparing definitions, study objectives, outcome measures, the assessment of opioid-related adverse events, incorporation of adequate pain control in trial design, interpretation of research findings, and future research priorities to inform opioid-sparing trial methods. The considerations and recommendations presented in this article are meant to help guide the design, conduct, analysis, and interpretation of future trials.
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Affiliation(s)
| | | | | | | | - Tong Joo Gan
- Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Ian Gilron
- Queens University, Kingston, Ontario, Canada
| | - Sharon Hertz
- (Formally) U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | - Denham S. Ward
- University of Rochester Medical Center, Rochester, NY, USA
| | | | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - James P. Rathmell
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, USA
| | - Robert R. Edwards
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | - Roy Freeman
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | - Roy Gray
- GW Pharmaceuticals, Carlsbad, CA, USA
| | | | | | | | - Robert N. Jamison
- Brigham and Women’s Hospital / Harvard Medical School, Boston, MA, USA
| | | | | | | | - Friedhelm Sandbrink
- U.S. Department of Veterans Affairs / George Washington University, Washington, DC, USA
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10
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Gewandter JS, McDermott MP, Evans S, Katz NP, Markman JD, Simon LS, Turk DC, Dworkin RH. Composite outcomes for pain clinical trials: considerations for design and interpretation. Pain 2021; 162:1899-1905. [PMID: 33449513 PMCID: PMC8991304 DOI: 10.1097/j.pain.0000000000002188] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Michael P McDermott
- Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Scott Evans
- Department of Biostatistics and Bioinformatics, George Washington University, Rochville, MD, United States
| | - Nathaniel P Katz
- Analgesic Solutions, Natick, MA, United States
- Tufts University, Boston, MA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, NY, United States
| | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
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11
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Smith SM, Dworkin RH, Turk DC, McDermott MP, Eccleston C, Farrar JT, Rowbotham MC, Bhagwagar Z, Burke LB, Cowan P, Ellenberg SS, Evans SR, Freeman RL, Garrison LP, Iyengar S, Jadad A, Jensen MP, Junor R, Kamp C, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, Mease PJ, O'Connor AB, Patel KV, Raja SN, Sampaio C, Schoenfeld D, Singh J, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Interpretation of chronic pain clinical trial outcomes: IMMPACT recommended considerations. Pain 2020; 161:2446-2461. [PMID: 32520773 PMCID: PMC7572524 DOI: 10.1097/j.pain.0000000000001952] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Interpreting randomized clinical trials (RCTs) is crucial to making decisions regarding the use of analgesic treatments in clinical practice. In this article, we report on an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) consensus meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, the purpose of which was to recommend approaches that facilitate interpretation of analgesic RCTs. We review issues to consider when drawing conclusions from RCTs, as well as common methods for reporting RCT results and the limitations of each method. These issues include the type of trial, study design, statistical analysis methods, magnitude of the estimated beneficial and harmful effects and associated precision, availability of alternative treatments and their benefit-risk profile, clinical importance of the change from baseline both within and between groups, presentation of the outcome data, and the limitations of the approaches used.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P McDermott
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | | | - John T Farrar
- Departments of Epidemiology, Neurology, and Anesthesia, University of Pennsylvania, Philadelphia, PA, United States
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
- Rallybio, New Haven, CT, United States
| | - Laurie B Burke
- School of Pharmacy, University of Maryland, Baltimore, MD, United States
- LORA Group, LLC, Royal Oak, MD, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Susan S Ellenberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Epidemiology and Biostatistics, The George Washington University, Washington, DC, United States
| | - Roy L Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Louis P Garrison
- Department of Pharmacy, University of Washington, Seattle, WA, United States
| | | | - Alejandro Jadad
- Department of Anesthesia, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Cornelia Kamp
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
- Clinical Materials Services Unit, University of Rochester Medical Center, Rochester, NY, United States
| | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Natick, MA, United States
| | | | | | - Dmitri Lissin
- Scilex Pharmaceuticals, Palo Alto, CA, United States
| | - John D Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Philip J Mease
- Rheumatology Clinical Research, Swedish Medical Center, Seattle, WA, United States
- University of Washington School of Medicine, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Cristina Sampaio
- Faculdade Medicinda de Lisboa, Universidade de Lisboa, Lisboa, Portugal
- CHDI Foundation, Princeton, NJ, United States
| | - David Schoenfeld
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jasvinder Singh
- Departments of Medicine and Epidemiology, University of Alabama at Birmingham School of Medicine, Birmingham, AB, United States
| | | | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto, CA, United States
| | | | - Jeffrey Tobias
- Aquila Consulting Group, LLC, Petaluma, CA, United States
| | - Ajay D Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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12
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Markman JD, Rhyne AL, Sasso RC, Patel AA, Hsu WK, Fischgrund JS, Edidin AA, Vajkoczy P. Association Between Opioid Use and Patient-Reported Outcomes in a Randomized Trial Evaluating Basivertebral Nerve Ablation for the Relief of Chronic Low Back Pain. Neurosurgery 2020; 86:343-347. [PMID: 31034561 DOI: 10.1093/neuros/nyz093] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/05/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic low back pain (CLBP) is a primary indication for opioid therapy. OBJECTIVE To evaluate the hypothesis that CLBP patients reporting reduced opioid use have superior functional outcomes following basivertebral nerve (BVN) radiofrequency ablation. METHODS This post hoc analysis from a sham-controlled trial examined short-acting opioid use from baseline through 1 yr. Opioid use was stratified into 3 groups by two blinded external reviewers. Two-sample t-tests were used to compare Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) measurements between those patients who increased or decreased their opioid usage compared to baseline. RESULTS Actively treated patients with decreased opioid use at 12 mo had a mean ODI improvement of 24.9 ± 16.0 (n = 27) compared to 7.3 ± 9.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in ODI were 17.4 ± 16.1 (n = 19) and 1.2 ± 14.3 (n = 5; P = .053) for the patients reporting decreased vs increased opioid usage, respectively. Actively treated patients reporting decreased opioid use had a mean improvement in VAS of 3.3 ± 2.5 (n = 27) compared to 0.6 ± 1.8 (n = 18) for patients reporting increased opioid use (P < .001). In the sham arm, the improvements in VAS were 2.5 ± 2.6 (n = 19) and 1.4 ± 1.9 (n = 5; P = .374) for patients reporting decreased vs increased opioid use, respectively. CONCLUSION Subjects undergoing BVN ablation who decreased opioid use had greater improvement in ODI and VAS scores compared with those reporting increased opioid usage. There is an association between functional benefit from BVN ablation and reduced opioid use.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | - Rick C Sasso
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alpesh A Patel
- Department of Orthopaedic Surgery and Department of Neurosurgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Wellington K Hsu
- Department of Orthopaedic Surgery and Department of Neurosurgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Fischgrund
- Department of Orthopedic Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | | | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
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13
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Abstract
This cohort study evaluates whether the incorporation of a pain tolerability question augments the information gathered from a numeric rating scale.
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Affiliation(s)
- John D. Markman
- Translational Pain Research, Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Maria E. Frazer
- Translational Pain Research, Department of Neurosurgery, University of Rochester, Rochester, New York
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14
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Markman JD, Czerniecka-Foxx K, Khalsa PS, Hayek SM, Asher AL, Loeser JD, Chou R. AAPT Diagnostic Criteria for Chronic Low Back Pain. J Pain 2020; 21:1138-1148. [PMID: 32036046 DOI: 10.1016/j.jpain.2020.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
Chronic low back pain (CLBP) conditions are highly prevalent and constitute the leading cause of disability worldwide. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS), have combined to create the ACTTION-APS Pain Taxonomy (AAPT). The AAPT initiative convened a working group to develop diagnostic criteria for CLBP. The working group identified 3 distinct low back pain conditions which result in a vast public health burden across the lifespan. This article focuses on: 1) the axial predominant syndrome of chronic musculoskeletal low back pain, 2) the lateralized, distally-radiating syndrome of chronic lumbosacral radicular pain 3) and neurogenic claudication associated with lumbar spinal stenosis. This classification of CLBP is organized according to the AAPT multidimensional framework, specifically 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. PERSPECTIVE: An evidence-based classification of CLBP conditions was constructed for the AAPT initiative. This multidimensional diagnostic framework includes: 1) core diagnostic criteria; 2) common features; 3) medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester, Rochester, New York.
| | | | - Partap S Khalsa
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Salim Michel Hayek
- Division of Pain Medicine, Department of Anesthesiology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Atrium Health, Charlotte, North Carolina
| | - John D Loeser
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
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15
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Gewandter JS, Dworkin RH, Turk DC, Devine EG, Hewitt D, Jensen MP, Katz NP, Kirkwood AA, Malamut R, Markman JD, Vrijens B, Burke L, Campbell JN, Carr DB, Conaghan PG, Cowan P, Doyle MK, Edwards RR, Evans SR, Farrar JT, Freeman R, Gilron I, Juge D, Kerns RD, Kopecky EA, McDermott MP, Niebler G, Patel KV, Rauck R, Rice ASC, Rowbotham M, Sessler NE, Simon LS, Singla N, Skljarevski V, Tockarshewsky T, Vanhove GF, Wasan AD, Witter J. Improving Study Conduct and Data Quality in Clinical Trials of Chronic Pain Treatments: IMMPACT Recommendations. J Pain 2019; 21:931-942. [PMID: 31843583 DOI: 10.1016/j.jpain.2019.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/30/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Abstract
The estimated probability of progressing from phase 3 analgesic clinical trials to regulatory approval is approximately 57%, suggesting that a considerable number of treatments with phase 2 trial results deemed sufficiently successful to progress to phase 3 do not yield positive phase 3 results. Deficiencies in the quality of clinical trial conduct could account for some of this failure. An Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting was convened to identify potential areas for improvement in trial conduct in order to improve assay sensitivity (ie, ability of trials to detect a true treatment effect). We present recommendations based on presentations and discussions at the meeting, literature reviews, and iterative revisions of this article. The recommendations relate to the following areas: 1) study design (ie, to promote feasibility), 2) site selection and staff training, 3) participant selection and training, 4) treatment adherence, 5) data collection, and 6) data and study monitoring. Implementation of these recommendations may improve the quality of clinical trial data and thus the validity and assay sensitivity of clinical trials. Future research regarding the effects of these strategies will help identify the most efficient use of resources for conducting high quality clinical trials. PERSPECTIVE: Every effort should be made to optimize the quality of clinical trial data. This manuscript discusses considerations to improve conduct of pain clinical trials based on research in multiple medical fields and the expert consensus of pain researchers and stakeholders from academia, regulatory agencies, and industry.
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Affiliation(s)
| | | | | | | | | | | | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts; Tufts University, Boston, Massachusetts
| | - Amy A Kirkwood
- CR UK and UCL Cancer Trials Centre, UCL Cancer Institute, London, UK
| | | | - John D Markman
- University of Rochester Medical Center, Rochester, New York
| | | | | | | | - Daniel B Carr
- Tufts University School of Medicine, Boston, Massachusetts
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | | | | | - Scott R Evans
- George Washington University, Washington, District of Columbia
| | - John T Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roy Freeman
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Ian Gilron
- Queen's University, Kingston, Ontario, Canada
| | - Dean Juge
- Horizon Pharma, Lake Forest, Illinois
| | | | | | | | | | | | - Richard Rauck
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Neil Singla
- Lotus Clinical Research, Pasadena, California
| | | | | | | | - Ajay D Wasan
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James Witter
- National Institutes of Health, Bethesda, Maryland
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16
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Gewandter JS, McDermott MP, He H, Gao S, Cai X, Farrar JT, Katz NP, Markman JD, Senn S, Turk DC, Dworkin RH. Demonstrating Heterogeneity of Treatment Effects Among Patients: An Overlooked but Important Step Toward Precision Medicine. Clin Pharmacol Ther 2019; 106:204-210. [PMID: 30661240 DOI: 10.1002/cpt.1372] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 01/06/2019] [Indexed: 01/11/2023]
Abstract
Although heterogeneity in the observed outcomes in clinical trials is often assumed to reflect a true heterogeneous response, it could actually be due to random variability. This retrospective analysis of four randomized, double-blind, placebo-controlled multiperiod (i.e., episode) crossover trials of fentanyl for breakthrough cancer pain illustrates the use of multiperiod crossover trials to examine heterogeneity of treatment response. A mixed-effects model, including fixed effects for treatment and episode and random effects for patient and treatment-by-patient interaction, was used to assess the heterogeneity in patients' responses to treatment during each episode. A significant treatment-by-patient interaction was found for three of four trials (P < 0.05), suggesting heterogeneity of the effect of fentanyl among different patients in each trial. Similar analyses in other therapeutic areas could identify conditions and therapies that should be investigated further for predictors of treatment response in efforts to maximize the efficiency of developing precision medicine strategies.
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Affiliation(s)
- Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Hua He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana, USA
| | - Shan Gao
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - John T Farrar
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts, USA.,Tufts University School of Medicine, Boston, Massachusetts, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Stephen Senn
- Luxembourg Institute of Health, Strassen, Luxembourg
| | - Dennis C Turk
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York, USA
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17
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Kudel I, Hopps M, Cappelleri JC, Sadosky A, King-Concialdi K, Liebert R, Parsons B, Hlavacek P, Alexander AH, DiBonaventura MD, Markman JD, Farrar JT, Stacey BR. Characteristics of patients with neuropathic pain syndromes screened by the painDETECT questionnaire and diagnosed by physician exam. J Pain Res 2019; 12:255-268. [PMID: 30662281 PMCID: PMC6327912 DOI: 10.2147/jpr.s160513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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] [Indexed: 11/28/2022] Open
Abstract
Background The aim of this study was to identify the clinical characteristics, treatment usage, and health outcomes of US adults diagnosed with neuropathic pain (NeP) by experienced physicians. Methods Adults with scores exceeding the threshold for probable NeP (painDETECT ≥19) and diagnosed with NeP by a qualified physician completed a questionnaire that included comorbid conditions, pain symptoms and experiences, medication use, health status (3-level EuroQol 5 Dimensions (EQ-5D-3L]: health utilities index and visual analog scale), pain severity and interference with functioning (Brief Pain Inventory), and work and activity impairment (Work Productivity and Activity Impairment questionnaire). Descriptive analyses were performed for each NeP subtype. Results Participants (n=295) were predominantly female (64.4%), middle-aged (53.9%), and white (51.5%). Chronic low back pain was the most frequently diagnosed major NeP syndrome (n=166), followed by diabetic peripheral neuropathy (n=58), post-trauma neuropathy (n=47), post-surgical neuropathy (n=28), and central NeP (n=23). An additional 45 participants were diagnosed, but did not meet the criteria for the aforementioned subtypes. Participants could be diagnosed with multiple subtypes. Across each NeP subtype, patients reported high rates of comorbid disease, including arthritis (range: 39.1%–64.3%) and high blood pressure (range: 26.1%–69.0%), as well as symptomology that included numbness (range: 68.1%–91.4%) and changes in muscular strength (range: 24.1%–65.2%). The majority of patients reported back pain (range: 77.8%–95.7%) and arthritis/joint pain (range: 68.1%–78.6%). The most commonly reported types of NeP pain medication were non-steroidal anti-inflammatory drugs (range: 43.1%–70.2%), weak opioids (range: 22.2%–39.3%), and strong opioids (range: 8.7%–28.6%). All six NeP groups generally reported similar levels of dysfunction on all self-report measures. The most notable finding was that the EuroQol-5D-3L health utilities index scores for each of the six groups were lower than the US norms by a clinically important amount. Conclusion These exploratory findings indicate that patients with NeP across different etiologies are medically complex and experience impaired function across multiple domains.
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Affiliation(s)
- Ian Kudel
- Health Outcomes Practice, Kantar Health, New York, NY, USA,
| | | | | | | | | | - Ryan Liebert
- Health Outcomes Practice, Kantar Health, New York, NY, USA,
| | | | | | | | | | - John D Markman
- University of Rochester Medical Center School of Medicine and Dentistry, Rochester, NY, USA
| | - John T Farrar
- Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Brett R Stacey
- UW Center for Pain Relief, University of Washington, Seattle, WA, USA
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Sandwell S, Montoya S, Towner JE, Markman JD, Schell MC, Bhalla T. Anatomical Study of Percutaneous Trigeminal Compressive Balloon Positioning on Merged 3-D Rotational X-Ray and Preprocedural Magnetic Resonance Imaging. Stereotact Funct Neurosurg 2018; 96:182-189. [PMID: 30032150 DOI: 10.1159/000489947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/28/2017] [Accepted: 05/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Percutaneous trigeminal rhizotomy or balloon compression for trigeminal neuralgia carries a potential risk for the brainstem, the carotid artery, and the basilar artery. OBJECTIVE To detail the relation of critical neural and vascular structures to expanded balloons used for percutaneous compression of the trigeminal ganglion. METHOD A retrospective analysis of preprocedural magnetic resonance imaging (MRI) and procedural X-ray-based imaging for 9 patients detailed balloon proximity to the brainstem, carotid artery, and basilar artery. RESULTS Balloons extended 10.96 ± 5.54 mm (mean ± SD) posterior to the clival line. The average distance from the balloon to the brainstem was 6.89 mm, and that to the basilar artery was 12.12 mm (range: 0-18.2). The medial edge of the balloon was an average distance of 1.39 mm from the baseline position of the carotid lumen. CONCLUSION Preprocedural MRI, merged with 3-D rotational angiography suite imaging, detailed the proximity of the balloon to critical neural and vascular structures. Our study found that the standard technique for percutaneous trigeminal compression, with balloon placement at an average depth of 10.96 mm posterior to the clival line, on average, provided an additional 6.89 mm of space before the brainstem would have been encountered, demonstrating safe positioning.
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Affiliation(s)
- Stephen Sandwell
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Simone Montoya
- Department of Radiology, University of Rochester Medical Center, Rochester, New York, USA
| | - James E Towner
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - John D Markman
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, New York, USA.,Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Michael C Schell
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurological Surgery, University of Rochester Medical Center, Rochester, New York, USA.,Department of Radiology, University of Rochester Medical Center, Rochester, New York, USA.,Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
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Markman JD, Baron R, Gewandter JS. Why are there no drugs indicated for sciatica, the most common chronic neuropathic syndrome of all? Drug Discov Today 2018; 23:1904-1909. [PMID: 29894812 DOI: 10.1016/j.drudis.2018.06.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/16/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
This review examines the stark contrast between the successes and failures of the clinical development of analgesics for different types of chronic low back pain (CLBP) syndrome over the past three decades. Multiple drugs with differing mechanisms of action have been developed for nonspecific axial-predominant low back syndromes and yet not a single therapy is indicated for any neuropathic low back pain syndrome (e.g., sciatica). Clinician findings have informed the entry criteria for neuropathic low back pain clinical trials, whereas entry criteria of axial CLBP trials have prioritized only patient reports of pain. This key difference could account for the lack of success in developing therapies for neuropathic low back pain in an era marked by successful development of analgesics for other types of CLBP as well as many chronic pain syndromes associated with nerve injury, such as post-herpetic neuralgia (PHN).
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Affiliation(s)
- John D Markman
- Department of Neurosurgery, Translational Pain Research Program, University of Rochester, 2180 South Clinton Avenue, Rochester, NY, USA.
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Universitaetsklinikum Schleswig-Holstein, Campus Kiel, Haus 41, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY, USA
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20
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Zimering JH, Stone JJ, Paulzak A, Markman JD, Johnson MD, Vates GE. Ectopic brain tissue in the trigeminal nerve presenting as rapid-onset trigeminal neuralgia: case report. J Neurosurg 2017; 129:1063-1066. [PMID: 29192861 DOI: 10.3171/2017.6.jns17811] [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] [Indexed: 11/06/2022]
Abstract
The authors report the case of a 52-year-old man who presented with rapid-onset lancinating facial pain consistent with trigeminal neuralgia. Magnetic resonance imaging revealed a nonenhancing small lesion on the right trigeminal nerve concerning for an atypical schwannoma or neuroma. The patient underwent resection of the mass via a right retrosigmoid approach. His facial pain completely resolved immediately postoperatively and had not recurred at 6 months after surgery. The mass was consistent with normal brain tissue (neurons and glial cells) without evidence of mitoses. A final histopathological diagnosis of ectopic brain tissue with neural tissue demonstrating focal, chronic T-cell inflammation was made. The partial rhizotomy during resection was curative for the facial pain. To the authors' knowledge, this is the first report of neuroglial ectopia causing trigeminal neuralgia.
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Affiliation(s)
| | | | | | | | - Mahlon D Johnson
- 4Department of Pathology, Division of Neuropathology, University of Rochester Medical Center, Rochester, New York
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21
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DiBonaventura MD, Sadosky A, Concialdi K, Hopps M, Kudel I, Parsons B, Cappelleri JC, Hlavacek P, Alexander AH, Stacey BR, Markman JD, Farrar JT. The prevalence of probable neuropathic pain in the US: results from a multimodal general-population health survey. J Pain Res 2017; 10:2525-2538. [PMID: 29138590 PMCID: PMC5677393 DOI: 10.2147/jpr.s127014] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [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] [Indexed: 11/23/2022] Open
Abstract
Background The prevalence of neuropathic pain (NeP) has been estimated within specific health conditions; however, there are no published data on its broad prevalence in the US. The current exploratory study addresses this gap using the validated PainDetect questionnaire as a screener for probable NeP in a general-population health survey conducted with a multimodal recruitment strategy to maximize demographic representativeness. Materials and methods Adult respondents were recruited from a combination of Internet panels, telephone lists, address lists, mall-based interviews, and store-receipt invitations using a random stratified-sampling framework, with strata defined by age, sex, and race/ethnicity. Older persons and minorities were oversampled to improve prevalence estimates. Results were weighted to match the total adult US population using US Census data. Demographic information was collected, and respondents who experienced physical pain in the past 12 months completed the PainDetect and provided additional pain history. A cutoff score of 19 or greater on the PainDetect was used to define probable NeP. Results A total of 24,925 respondents (average response rate 2.5%) provided demographic data (52.2% female, mean age 51.5 years); 15,751 respondents reported pain (63.7%), of which 2,548 (15.7%, 95% confidence interval 14.9%-16.5%) had probable NeP based on the PainDetect, which was 10% (95% confidence interval 9.5%-10.5%) of all respondents. Among those reporting pain, the prevalence of probable NeP among Blacks and Hispanics was consistently higher than Whites in each age- and sex group. The highest prevalence among those with pain was among male Hispanics 35-44 years (32.4%) and 45-54 years (24.2%) old. The most commonly used medications reported by those with probable NeP were nonsteroidal anti-inflammatory drugs (44.2%), followed by weak opioids (31.7%), antiepileptics (10.9%), and strong opioids (10.9%). Conclusion This is the first study to provide an estimate of the prevalence of probable NeP in the US, showing significant variation by age and ethnicity.
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Affiliation(s)
| | | | | | | | - Ian Kudel
- Health Outcomes Practice, Kantar Health
| | | | | | | | | | | | - John D Markman
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - John T Farrar
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, US
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22
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Gewandter JS, McDermott MP, Kitt RA, Chaudari J, Koch JG, Evans SR, Gross RA, Markman JD, Turk DC, Dworkin RH. Interpretation of CIs in clinical trials with non-significant results: systematic review and recommendations. BMJ Open 2017; 7:e017288. [PMID: 28720618 PMCID: PMC5726092 DOI: 10.1136/bmjopen-2017-017288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Interpretation of CIs in randomised clinical trials (RCTs) with treatment effects that are not statistically significant can distinguish between results that are 'negative' (the data are not consistent with a clinically meaningful treatment effect) or 'inconclusive' (the data remain consistent with the possibility of a clinically meaningful treatment effect). This interpretation is important to ensure that potentially beneficial treatments are not prematurely abandoned in future research or clinical practice based on invalid conclusions. DESIGN Systematic review of RCT reports published in 2014 in Annals of Internal Medicine, New England Journal of Medicine, JAMA, JAMA Internal Medicine and The Lancet (n=247). RESULTS 85 of 99 articles with statistically non-significant results reported CIs for the treatment effect. Only 17 of those 99 articles interpreted the CI. Of the 22 articles in which CIs indicated an inconclusive result, only four acknowledged that the study could not rule out a clinically meaningful treatment effect. CONCLUSIONS Interpretation of CIs is important but occurs infrequently in study reports of trials with treatment effects that are not statistically significant. Increased author interpretation of CIs could improve application of RCT results. Reporting recommendations are provided.
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Affiliation(s)
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Rachel A Kitt
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA
| | - Jenna Chaudari
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA
| | - James G Koch
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA
| | - Scott R Evans
- Department of Biostatistics, Harvard University, Boston, Massachusetts, USA
| | - Robert A Gross
- Department of Neurology, University of Rochester, Rochester, New York, USA
- Department of Pharmacology and Physiology, University of Rochester, Rochester, New York, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, Rochester, New York, USA
| | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester, Rochester, New York, USA
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Smith SM, Dworkin RH, Turk DC, Baron R, Polydefkis M, Tracey I, Borsook D, Edwards RR, Harris RE, Wager TD, Arendt-Nielsen L, Burke LB, Carr DB, Chappell A, Farrar JT, Freeman R, Gilron I, Goli V, Haeussler J, Jensen T, Katz NP, Kent J, Kopecky EA, Lee DA, Maixner W, Markman JD, McArthur JC, McDermott MP, Parvathenani L, Raja SN, Rappaport BA, Rice ASC, Rowbotham MC, Tobias JK, Wasan AD, Witter J. The Potential Role of Sensory Testing, Skin Biopsy, and Functional Brain Imaging as Biomarkers in Chronic Pain Clinical Trials: IMMPACT Considerations. J Pain 2017; 18:757-777. [PMID: 28254585 PMCID: PMC5484729 DOI: 10.1016/j.jpain.2017.02.429] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/19/2017] [Accepted: 02/16/2017] [Indexed: 02/08/2023]
Abstract
Valid and reliable biomarkers can play an important role in clinical trials as indicators of biological or pathogenic processes or as a signal of treatment response. Currently, there are no biomarkers for pain qualified by the U.S. Food and Drug Administration or the European Medicines Agency for use in clinical trials. This article summarizes an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting in which 3 potential biomarkers were discussed for use in the development of analgesic treatments: 1) sensory testing, 2) skin punch biopsy, and 3) brain imaging. The empirical evidence supporting the use of these tests is described within the context of the 4 categories of biomarkers: 1) diagnostic, 2) prognostic, 3) predictive, and 4) pharmacodynamic. Although sensory testing, skin punch biopsy, and brain imaging are promising tools for pain in clinical trials, additional evidence is needed to further support and standardize these tests for use as biomarkers in pain clinical trials. PERSPECTIVE The applicability of sensory testing, skin biopsy, and brain imaging as diagnostic, prognostic, predictive, and pharmacodynamic biomarkers for use in analgesic treatment trials is considered. Evidence in support of their use and outlining problems is presented, as well as a call for further standardization and demonstrations of validity and reliability.
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24
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Smith SM, Gewandter JS, Kitt RA, Markman JD, Vaughan JA, Cowan P, Kopecky EA, Malamut R, Sadosky A, Tive L, Turk DC, Dworkin RH. Participant Preferences for Pharmacologic Chronic Pain Treatment Trial Characteristics: An ACTTION Adaptive Choice-Based Conjoint Study. J Pain 2016; 17:1198-1206. [PMID: 27555429 DOI: 10.1016/j.jpain.2016.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/20/2016] [Accepted: 07/26/2016] [Indexed: 12/01/2022]
Abstract
Barriers to clinical trial recruitment can delay study completion, potentially resulting in increased costs and an unrepresentative sample. In the current study of 150 participants with chronic pain, we used a computerized adaptive choice-based conjoint survey that included 8 characteristics that may affect enrollment in pharmacologic pain treatment trials (ie, treatment allocation, frequency of pain ratings, treatment administration method, current medications, number of study visits, availability of evening and weekend visits, invasiveness of laboratory procedures, payment). These data were analyzed using Sawtooth Software ver. 8.4.8 (Sawtooth Software, Inc, Orem, UT), which identifies the characteristics that dominate participants' decisions across multiple sets of potential trials. Three characteristics had the largest relative importance in participants' trial preferences: 1) invasiveness of required laboratory procedures (ie, 22%), with no procedures or blood tests preferred over ice-water sensory testing or skin biopsy; 2) ability to continue current pain medications (21%); and 3) payment for study participation (21%), with higher payment preferred. The fourth most important characteristic was number of study visits (13%), with participants preferring fewer in-person visits and more phone contacts. Understanding the preferences of potential participants is an important step toward enhancing enrollment in pain treatment trials. PERSPECTIVE This article presents the preferences of individuals with chronic pain conditions regarding modifiable pain treatment trial characteristics (eg, number of study visits, payment, treatment allocation). These findings may help to improve enrollment into analgesic clinical trials and in turn accelerate the development of new pain treatments.
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Affiliation(s)
- Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
| | - Jennifer S Gewandter
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Rachel A Kitt
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - John D Markman
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Janet A Vaughan
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, California
| | | | | | | | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, and Psychiatry, and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
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26
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Markman JD, Gewandter JS, Frazer ME, Pittman C, Cai X, Patel KV, Jahromi BS, Dworkin RH, Burke LB, Farrar JT. Evaluation of outcome measures for neurogenic claudication: A patient-centered approach. Neurology 2015; 85:1250-6. [PMID: 26354988 DOI: 10.1212/wnl.0000000000002000] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 06/11/2015] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To determine whether patients with neurogenic claudication associated with lumbar spinal stenosis would prefer a treatment that makes it possible for them to walk farther or walk with less pain; to examine associations between this treatment preference and patient-reported and in-clinic treadmill testing measures of walking ability and walking-associated pain. METHODS In this cross-sectional study, 269 patients with neurogenic claudication were asked to report their pain intensity when walking, complete the Swiss Spinal Stenosis Questionnaire, rank their outcome preferences for treatment, and undergo standardized treadmill testing, including measures of final pain rating and time to first pain of moderate intensity (Tfirst). Descriptive statistics were used to characterize patient preferences for treatment outcome. Associations between self-report questionnaires and standardized treadmill testing outcomes were evaluated using Spearman correlations. RESULTS Seventy-nine percent of patients expressed a preference for treatment that allowed them to walk with less pain. Preference for reduced pain was associated with higher pain during daily walking, along with a shorter Tfirst and higher final pain severity on treadmill testing. In contrast, patient preference for treatment outcome was not associated with self-reported measures of daily walking capacity or walking distance on the treadmill. CONCLUSIONS A majority of patients with neurogenic claudication prioritized walking with reduced pain over walking farther. Reduction in pain while walking may therefore constitute a sufficient patient-focused treatment outcome for the majority of these patients. These results have implications for clinical trial design and assessment of treatment efficacy in neurogenic claudication.
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Affiliation(s)
- John D Markman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia.
| | - Jennifer S Gewandter
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Maria E Frazer
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Christine Pittman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Xueya Cai
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Kushang V Patel
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Babak S Jahromi
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Robert H Dworkin
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - Laurie B Burke
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
| | - John T Farrar
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., C.P., B.S.J.), and Departments of Anesthesiology (J.S.G., R.H.D.) and Biostatistics and Computational Biology (X.C.), University of Rochester School of Medicine and Dentistry, NY; Department of Anesthesiology and Pain Medicine (K.V.P.), University of Washington, Seattle; LORA Group, LLC (L.B.B.), Royal Oak, MD; and Department of Biostatistics and Epidemiology (J.T.F.), University of Pennsylvania, Philadelphia
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Markman JD, Barbosa WA, Gewandter JS, Frazer M, Rast S, Dugan M, Nandigam K, Villareal A, Kwong TC. Interpretation of Urine Drug Testing Results in Patients Using Transdermal Buprenorphine Preparations for the Treatment of Chronic Noncancer Pain: Table 1. Pain Med 2015; 16:1132-6. [DOI: 10.1111/pme.12740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Markman JD, Nandigam K. Lumbar Spinal Stenosis. Pain Medicine 2015. [DOI: 10.1093/med/9780199931484.003.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Markman JD, Kress BT, Frazer M, Hanson R, Kogan V, Huang JH. Screening for neuropathic characteristics in failed back surgery syndromes: challenges for guiding treatment. Pain Med 2014; 16:520-30. [PMID: 25530081 DOI: 10.1111/pme.12612] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Neuropathic pain screening tools have shown promise in identifying common neuropathic pain characteristics that derive from diverse etiologies (e.g., diabetic peripheral neuropathy, postherpetic neuralgia). However, no prior studies have specifically assessed whether these tools are capable of discerning the underlying pain mechanisms in the vast, heterogeneous group of patients diagnosed with failed back surgery syndrome (FBSS). DESIGN In this clinical observational study, two tests for neuropathic pain characteristics, the Douleur Neuropathique en 4 (DN4) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaires, were performed on 43 subjects with FBSS. Subjects underwent physical or neurosensory exam components of the DN4 and LANSS in the region of most severe pain (e.g., axial low back or lower extremities). DN4 and LANSS scores were correlated with clinical history and neurologic exam, pain-related quality of life questionnaires, and compared to an independent assessment of pain distribution. RESULTS The presence of neuropathic characteristics, determined by the DN4 (62% sensitivity, 44% specificity), LANSS (38% sensitivity, 75% specificity; cut-offs of 4 and 12, respectively), or their combination (20% sensitivity, 58% specificity) was associated with higher pain intensity as measured by the visual analog scale (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.042), modified Brief Pain Inventory-Short Form (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.082), and Neuropathic Pain Symptom Inventory (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.001), and greater pain-related functional impairment as measured by the Roland-Morris Disability Questionnaire (DN4 > 4, P = 0.006; LANSS ≥ 12, P = 0.018). The percentage of subjects characterized as neuropathic by the DN4 and LANSS lacked concordance (67.4 vs. 25.6), and the distribution of most severe symptoms (i.e., axial vs radicular) did not correlate with subjects determined to have neuropathic pain. CONCLUSIONS Unlike other neuropathic syndromes, the neuropathic component of FBSS is less reliably identified by the LANSS and DN4.
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Affiliation(s)
- John D Markman
- Translational Pain Research, Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA; Department of Neurosurgery, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
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Markman JD, Frazer ME, Rast SA, McDermott MP, Gewandter JS, Chowdhry AK, Czerniecka K, Pilcher WH, Simon LS, Dworkin RH. Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication. Neurology 2014; 84:265-72. [PMID: 25503625 PMCID: PMC4335998 DOI: 10.1212/wnl.0000000000001168] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [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] [Indexed: 12/23/2022] Open
Abstract
Objectives: To test the effects of pregabalin on the induction of neurogenic claudication. Methods: This study was a randomized, double-blind, active placebo-controlled, 2-period, crossover trial. Twenty-nine subjects were randomized to receive pregabalin followed by active placebo (i.e., diphenhydramine) or active placebo followed by pregabalin. Each treatment period lasted 10 days, including a 2-step titration. Periods were separated by a 10-day washout period, including a 3-day taper phase after the first period. The primary outcome variable was the time to first moderate pain symptom (Numeric Rating Scale score ≥4) during a 15-minute treadmill test (Tfirst). Secondary outcome measures included pain intensity at rest, pain intensity at the end of the treadmill test, distance walked, and validated self-report measures of pain and functional limitation including the Roland-Morris Disability Questionnaire, modified Brief Pain Inventory–Short Form, Oswestry Disability Index, and Swiss Spinal Stenosis Questionnaire. Results: No significant difference was found between pregabalin and active placebo for the time to first moderate pain symptom (difference in median Tfirst = −1.08 [95% confidence interval −2.25 to 0.08], p = 0.61). In addition, none of the secondary outcome measures of pain or functional limitation were significantly improved by pregabalin compared with active placebo. Conclusions: Pregabalin was not more effective than active placebo in reducing painful symptoms or functional limitations in patients with neurogenic claudication associated with lumbar spinal stenosis. Classification of evidence: This study provides Class I evidence that for patients with neurogenic claudication, compared with diphenhydramine, pregabalin does not increase the time to moderate pain during a treadmill test.
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Affiliation(s)
- John D Markman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA.
| | - Maria E Frazer
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Shirley A Rast
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Michael P McDermott
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Jennifer S Gewandter
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Amit K Chowdhry
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Kate Czerniecka
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Webster H Pilcher
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Lee S Simon
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Robert H Dworkin
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
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Dayawansa S, Wang EW, Liu W, Markman JD, Gelbard HA, Huang JH. Allotransplanted DRG neurons or Schwann cells affect functional recovery in a rodent model of sciatic nerve injury. Neurol Res 2014; 36:1020-1027. [PMID: 24836462 DOI: 10.1179/1743132814y.0000000386] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE In this study, the functional recoveries of Sprague-Dawley rats following repair of a complete sciatic nerve transection using allotransplanted dorsal root ganglion (DRG) neurons or Schwann cells were examined using a number of outcome measures. METHODS Four groups were compared: (1) repair with a nerve guide conduit seeded with allotransplanted Schwann cells harvested from Wistar rats, (2) repair with a nerve guide conduit seeded with DRG neurons, (3) repair with solely a nerve guide conduit, and (4) sham-surgery animals where the sciatic nerve was left intact. The results corroborated our previous reported histology findings and measures of immunogenicity. RESULTS The Wistar-DRG-treated group achieved the best recovery, significantly outperforming both the Wistar-Schwann group and the nerve guide conduit group in the Von Frey assay of touch response (P < 0.05). Additionally, Wistar-DRG and Wistar-Schwann seeded repairs showed lower frequency and severity in an autotomy measure of the self-mutilation of the injured leg because of neuralgia. CONCLUSION These results suggest that in complete peripheral nerve transections, surgical repair using nerve guide conduits with allotransplanted DRG and Schwann cells may improve recovery, especially DRG neurons, which elicit less of an immune response.
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Affiliation(s)
- Samantha Dayawansa
- Department of Neurosurgery, University of Rochester, NY, USA.,Department of Pathology, University of Buffalo, NY, USA
| | - Ernest W Wang
- Department of Neurosurgery, University of Rochester, NY, USA.,Center for Neural Development and Disease, University of Rochester, NY, USA
| | - Weimin Liu
- Department of Neurosurgery, University of Rochester, NY, USA.,Center for Neural Development and Disease, University of Rochester, NY, USA
| | - John D Markman
- Department of Neurosurgery, University of Rochester, NY, USA.,Center for Neural Development and Disease, University of Rochester, NY, USA.,Department of Neurology, University of Rochester, NY, USA
| | - Harris A Gelbard
- Center for Neural Development and Disease, University of Rochester, NY, USA.,Department of Neurology, University of Rochester, NY, USA
| | - Jason H Huang
- Department of Neurosurgery, University of Rochester, NY, USA.,Center for Neural Development and Disease, University of Rochester, NY, USA.,Department of Neurosurgery, Scott & White Health System, Temple, TX, USA
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Smith SM, Dart RC, Katz NP, Paillard F, Adams EH, Comer SD, Degroot A, Edwards RR, Haddox JD, Jaffe JH, Jones CM, Kleber HD, Kopecky EA, Markman JD, Montoya ID, O’Brien C, Roland CL, Stanton M, Strain EC, Vorsanger G, Wasan AD, Weiss RD, Turk DC, Dworkin RH. Classification and definition of misuse, abuse, and related events in clinical trials: ACTTION systematic review and recommendations. Pain 2013; 154:2287-2296. [PMID: 23792283 PMCID: PMC5460151 DOI: 10.1016/j.pain.2013.05.053] [Citation(s) in RCA: 163] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 04/29/2013] [Accepted: 05/17/2013] [Indexed: 11/25/2022]
Abstract
As the nontherapeutic use of prescription medications escalates, serious associated consequences have also increased. This makes it essential to estimate misuse, abuse, and related events (MAREs) in the development and postmarketing adverse event surveillance and monitoring of prescription drugs accurately. However, classifications and definitions to describe prescription drug MAREs differ depending on the purpose of the classification system, may apply to single events or ongoing patterns of inappropriate use, and are not standardized or systematically employed, thereby complicating the ability to assess MARE occurrence adequately. In a systematic review of existing prescription drug MARE terminology and definitions from consensus efforts, review articles, and major institutions and agencies, MARE terms were often defined inconsistently or idiosyncratically, or had definitions that overlapped with other MARE terms. The Analgesic, Anesthetic, and Addiction Clinical Trials, Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership convened an expert panel to develop mutually exclusive and exhaustive consensus classifications and definitions of MAREs occurring in clinical trials of analgesic medications to increase accuracy and consistency in characterizing their occurrence and prevalence in clinical trials. The proposed ACTTION classifications and definitions are designed as a first step in a system to adjudicate MAREs that occur in analgesic clinical trials and postmarketing adverse event surveillance and monitoring, which can be used in conjunction with other methods of assessing a treatment's abuse potential.
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Affiliation(s)
- Shannon M. Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Richard C. Dart
- University of Colorado School of Medicine and Rocky Mountain Poison & Drug Center, Denver Health, Denver, CO
| | - Nathaniel P. Katz
- Analgesic Solutions, Natick, MA, and Tufts University, Boston, MA, USA
| | | | | | - Sandra D. Comer
- Columbia University; New York State Psychiatric Institute, New York, NY, USA
| | | | | | - J. David Haddox
- Purdue Pharma L.P., Stamford, CT, and Tufts University, Boston, MA, USA
| | - Jerome H. Jaffe
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Herbert D. Kleber
- Columbia University; New York State Psychiatric Institute, New York, NY, USA
| | | | - John D. Markman
- Department of Neurosurgery, University of Rochester, Rochester, NY, USA
| | | | | | | | | | - Eric C. Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Roger D. Weiss
- Harvard Medical School, Boston, MA, USA and Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, MA, USA
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Robert H. Dworkin
- Departments of Anesthesiology and Neurology and Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Dworkin RH, Turk DC, Peirce-Sandner S, Burke LB, Farrar JT, Gilron I, Jensen MP, Katz NP, Raja SN, Rappaport BA, Rowbotham MC, Backonja MM, Baron R, Bellamy N, Bhagwagar Z, Costello A, Cowan P, Fang WC, Hertz S, Jay GW, Junor R, Kerns RD, Kerwin R, Kopecky EA, Lissin D, Malamut R, Markman JD, McDermott MP, Munera C, Porter L, Rauschkolb C, Rice ASC, Sampaio C, Skljarevski V, Sommerville K, Stacey BR, Steigerwald I, Tobias J, Trentacosti AM, Wasan AD, Wells GA, Williams J, Witter J, Ziegler D. Considerations for improving assay sensitivity in chronic pain clinical trials: IMMPACT recommendations. Pain 2012; 153:1148-1158. [PMID: 22494920 DOI: 10.1016/j.pain.2012.03.003] [Citation(s) in RCA: 213] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/23/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022]
Abstract
A number of pharmacologic treatments examined in recent randomized clinical trials (RCTs) have failed to show statistically significant superiority to placebo in conditions in which their efficacy had previously been demonstrated. Assuming the validity of previous evidence of efficacy and the comparability of the patients and outcome measures in these studies, such results may be a consequence of limitations in the ability of these RCTs to demonstrate the benefits of efficacious analgesic treatments vs placebo ("assay sensitivity"). Efforts to improve the assay sensitivity of analgesic trials could reduce the rate of falsely negative trials of efficacious medications and improve the efficiency of analgesic drug development. Therefore, an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting was convened in which the assay sensitivity of chronic pain trials was reviewed and discussed. On the basis of this meeting and subsequent discussions, the authors recommend consideration of a number of patient, study design, study site, and outcome measurement factors that have the potential to affect the assay sensitivity of RCTs of chronic pain treatments. Increased attention to and research on methodological aspects of clinical trials and their relationships with assay sensitivity have the potential to provide the foundation for an evidence-based approach to the design of analgesic clinical trials and expedite the identification of analgesic treatments with improved efficacy and safety.
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Affiliation(s)
- Robert H Dworkin
- Departments of Anesthesiology and Neurology and Center for Human Experimental Therapeutics, University of Rochester, Rochester, NY 14642, USA University of Washington, Seattle, WA, USA University of Rochester, Rochester, NY, USA United States Food and Drug Administration, Silver Spring, MD, USA University of Pennsylvania, Philadelphia, PA, USA Queen's University, Kingston, ON, Canada Analgesic Solutions, Natick, MA, USA Tufts University, Boston, MA, USA Johns Hopkins University, Baltimore, MD, USA California Pacific Medical Center Research Institute, San Francisco, CA, USA University of Wisconsin, Madison, WI, USA University of Kiel, Kiel, Germany University of Queensland, Brisbane, Australia Bristol-Myers Squibb, Wallingford, CT, USA American Chronic Pain Association, Rocklin, CA, USA DePuy Spine, Raynham, MA, USA Pfizer, New London, CT, USA Eisai Limited, Mosquito Way, Hatfield, UK Department of Veterans Affairs, West Haven, CT, USA Yale University, New Haven, CT, USA Nuvo Research, West Chester, PA, USA Endo Pharmaceuticals Inc., Chadds Ford, PA, USA Durect Corporation, Cupertino, CA, USA AstraZeneca, Wilmington, DE, USA Purdue Pharma, Stamford, CT, USA National Institutes of Health, Bethesda, MD, USA Johnson & Johnson Pharmaceutical Research & Development, Titusville, NJ, USA Imperial College, London, UK Faculdade de Medicina de Lisboa, Lisbon, Portugal Eli Lilly & Co., Indianapolis, IN, USA King Pharmaceuticals (currently Pfizer), Cary, NC, USA Oregon Health and Science University, Portland, OR, USA Grünenthal GmbH, Aachen, Germany NeurogesX, Inc., San Carlos, CA, USA Harvard Medical School, Boston, MA, USA University of Ottawa, Ottawa, ON, Canada Smith & Nephew, Durham, NC, USA German Diabetes Center, Heinrich Heine University, Düsseldorf, Germany
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Markman JD, Hanson RS. THE ROLE OF INTERVENTIONAL THERAPY IN THE TREATMENT OF NEUROPATHIC PAIN. Continuum (Minneap Minn) 2009. [DOI: 10.1212/01.con.0000348857.43136.fb] [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: 11/15/2022]
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Markman JD. Not so fast: the reformulation of fentanyl and breakthrough chronic non-cancer pain. Pain 2008; 136:227-229. [PMID: 18384960 DOI: 10.1016/j.pain.2008.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Revised: 03/07/2008] [Accepted: 03/10/2008] [Indexed: 11/25/2022]
Affiliation(s)
- John D Markman
- Director, Neuromedicine Pain Management Center and Translational Pain Research, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 670 Rochester, NY 14642, USA
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Abstract
This article reviews the evidence for several common interventional techniques for the treatment of chronic pain, including: intraspinal delivery of analgesics, reversible blockade with local anesthetics, augmentation with spinal cord stimulation, and ablation with radiofrequency energy or neurolytic agents. The role of these techniques is defined within the framework of a multidisciplinary approach to the neurobehavioral syndrome of chronic pain. Challenges to the study of the analgesic efficacy of procedural interventions are explored, as are the practical issues raised by their clinical implementation, with the aim of helping nonspecialist physicians identify the patients most likely to benefit from these approaches.
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Affiliation(s)
- John D Markman
- Neuromedicine Pain Management Center, Department of Neurosurgery and Neurology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 670 Rochester, New York 14642, USA.
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Abstract
This article reviews the evidence for several common interventional techniques for the treatment of chronic pain, including: intraspinal delivery of analgesics, reversible blockade with local anesthetics, augmentation with spinal cord stimulation, and ablation with radiofrequency energy or neurolytic agents. The role of these techniques is defined within the framework of a multidisciplinary approach to the neurobehavioral syndrome of chronic pain. Challenges to the study of the analgesic efficacy of procedural interventions are explored, as are the practical issues raised by their clinical implementation, with the aim of helping nonspecialist physicians identify the patients most likely to benefit from these approaches.
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Affiliation(s)
- John D Markman
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Abstract
UNLABELLED Chronic neuropathic pain due to injury or dysfunction of the nervous system remains a formidable treatment challenge in spite of a growing range of medication choices. We review current clinical research supporting the use of ion channel modulators for neuropathic pain states. New modes of local drug delivery, novel Ca2+ channel targets, and increased choices for drugs with activity at Na+channels are transforming this longstanding therapeutic strategy. Clinical decision making is increasingly informed by a more nuanced understanding of the role of voltage-gated Na+channels (VGSCs) and Ca2+ channels (VGCCs) in the pathophysiology of nerve injury. Although holding great promise for the future, mechanism-based approaches to treatment will require greater understanding of the analgesic mechanisms of drug action and of the relationships between pathophysiologic mechanisms and clinical presentation. PERSPECTIVE Treatment options for neuropathic pain targeting ion channels have grown rapidly in the past decade. An evolving body of clinical research supports the widespread use of this longstanding therapeutic strategy. Improved efficacy of ion channel modulators hinges upon further elucidation of the relationship between signs and symptoms of pain and underlying pathophysiology.
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Affiliation(s)
- John D Markman
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Abstract
OBJECTIVES To determine if joint kinetic gait alterations in fallers persist when they attempt to walk at a faster speed that is more comparable with nonfallers' comfortable walking speed. DESIGN Retrospective, case-control study. Stereophotogrammetric and force platform data were collected. SETTING A gait laboratory. PARTICIPANTS Sixteen elderly subjects who had at least 2 falls in the last 6 months from an unclear cause and 23 elderly subjects with no history of repeated falls. MAIN OUTCOME MEASURES Differences in all major peak joint kinetic (moment and power) values during the gait cycle between elderly nonfallers walking at comfortable speed and elderly fallers walking at (1) comfortable and (2) fast speed. RESULTS Statistically significant differences present at both comfortable and fast walking speeds were present in 4 sagittal plane parameters. There was an increase in peak external hip flexion moment in stance, a reduction in peak hip extension moment, a reduction in knee flexion moment in preswing, and a reduction in knee power absorption in preswing. CONCLUSION The presence and persistence of 4 specific alterations in sagittal plane joint kinetics at both comfortable and fast walking speeds imply specific intrinsic pattern differences and allow for new insights into the mechanics of gait in elderly people who fall. The presence of these alterations also suggests they may serve as potential identifiable markers to detect those who may be at risk for falls.
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Affiliation(s)
- D C Kerrigan
- Harvard Medical School Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA 02114, USA
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Kerrigan DC, Lee LW, Nieto TJ, Markman JD, Collins JJ, Riley PO. Kinetic alterations independent of walking speed in elderly fallers. Arch Phys Med Rehabil 2000. [DOI: 10.1053/apmr.2000.5581] [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: 11/11/2022]
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