Interventional pain management for chronic pain: a survey of physicians in Canada

Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era

BACKGROUND

Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation.

METHODS

A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey.

RESULTS

The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options.

CONCLUSIONS

Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.

Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management

PURPOSE

Chronic pain is a common condition affecting almost one in five Canadians. One of the methods used to treat chronic pain is injection therapies. While they are considered relatively safe procedures, they do carry inherent risk that can result in adverse events. Our goal was to investigate these patient safety events to identify themes that could be used to shape practice guidelines and standards and improve patient safety.

METHODS

We looked at closed civil legal actions and regulatory college complaints associated with injection therapies for chronic pain in the Canadian Medical Protection Association database from 2015 to 2019. Injury was defined as that arising from, or associated with, plans or actions taken during the provision of health care, rather than an underlying disease or injury.

RESULTS

Of the 91 cases identified, the most common reported complications were neurologic-related symptoms, injury, and infection. Fifty-eight percent (53/91) of patients experienced health care-related harm that had a negative effect on their health or quality of life. Peer experts were critical of the clinical care provided in 74% (67/91) of the cases. Provider-related (60%, 40/67), team-related (75%, 50/67), and system-related factors (21%, 14/67) were identified as contributing factors in these cases. Common examples of provider-related factors were deficiencies in clinical decision-making (48%, 19/40), failure to follow established procedures (43%, 17/40), and situational awareness (38%, 15/40). Common examples of team-related factors were deficiencies in medical record keeping (80%, 40/50) and communication breakdowns (56%, 28/50). All system-related factors were related to inadequate office procedures.

CONCLUSION

We recommend that clinicians conduct appropriate physical examinations, keep up-to-date with clinical standards, and ensure their documentation reflects their assessment, the patient's condition, and the treatment rationale.

Role of peripheral nerve stimulation in treating chronic neuropathic pain: an international focused survey of pain medicine experts

Interventional pain management (IPM) options for refractory neuropathic pain (NP) have recently increased with availability of peripheral nerve stimulation (PNS) equipment and expertise. Given a lack of high-quality evidence and guidelines on this topic, we sought to understand the perception of physicians with expertise in treating NP regarding IPM and the role of PNS. We emailed a survey in March 2022 to international NP experts including pain medicine physicians, researchers, and leaders of 11 professional pain societies. No representatives from vendors of PNS systems were included in the design of the survey nor as respondents. Among 24 respondents (67% of those contacted), the distal common peroneal, tibial, and sural nerves were most frequently targeted (60%) with PNS. Persistent postsurgical pain of more than 3 months was the most common indication for PNS (84%). The aggregate NP treatment algorithm in order of median rank was non-opioid medications as first line, IPM including epidural/perineural steroid injections tied with transcutaneous electrical nerve stimulation as second line, pulsed radiofrequency (RF) tied with RF ablation/denervation as third line, temporary then permanent PNS as fourth line, followed by spinal cord stimulation, opioids, cryoablation, botulinum, peripheral nerve field stimulation, intrathecal targeted drug delivery, and others. Before offering PNS, 12 respondents (50%) indicated their preference for trialing non-neuromodulation treatments for 1-3 months. Twenty-two respondents (92%) agreed PNS should be offered early in the treatment of neuropathic pain. The most common barriers to PNS use were cost, lack of high-quality evidence in support of its use, lack of exposure to PNS in training programs, and lack of familiarity with the use of ultrasound guidance. PNS appears to have an increasing role in the treatment of NP but more research is needed on the outcomes of PNS to elucidate its role.

Interventional treatments for chronic, axial or radicular, non-cancer, spinal pain: a protocol for a systematic review and network meta-analysis of randomised trials

INTRODUCTION

Chronic, non-cancer, axial or radicular spinal pain is a common condition associated with considerable socioeconomic burden. Clinicians frequently offer patients various interventional procedures for the treatment of chronic spine pain; however, the comparative effectiveness and safety of available procedures remains uncertain.

METHODS

We will conduct a systematic review of randomised controlled trials that explores the effectiveness and harms of interventional procedures for the management of axial or radicular, chronic, non-cancer, spine pain. We will identify eligible studies through a systematic search of Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science from inception without language restrictions. Eligible trials will: (1) enrol primarily adult patients (≥18 years old) with axial or radicular, chronic, non-cancer, spine pain, (2) randomise patients to different, currently available, interventional procedures or to an interventional procedure and a placebo/sham procedure or usual care, and (3) measure outcomes at least 1 month after randomisation.Pairs of reviewers will independently screen articles identified through searches and extract information and assess risk of bias of eligible trials. We will use a modified Cochrane instrument to evaluate risk of bias. We will use frequentist random-effects network meta-analyses to assess the relative effects of interventional procedures, and five a priori hypotheses to explore between studies subgroup effects. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome, including direct, indirect and network estimates.

ETHICS AND DISSEMINATION

No research ethics approval is required for this systematic review, as no confidential patient data will be used. We will disseminate our findings through publication in a peer-reviewed journal and conference presentations, and our review will support development of a BMJ Rapid Recommendations providing contextualised clinical guidance based on this body of evidence.

PROSPERO REGISTRATION NUMBER

CRD42020170667.

Impacts of COVID-19 Pandemic on Psychological Well-Being of Older Chronic Kidney Disease Patients

COVID-19 pandemic has been a major global issue, its eventual influences on the population welfare, global markets, public security, and everyday activities remain uncertain. Indeed, the pandemic has arisen a significant global threat. Its psychological impact is predicted to be severe and enduring, but the absolute magnitude is still largely unclear. Chronic kidney disease (CKD) is a complication markedly contributes to the mortality of COVID-19 cases, meanwhile several studies have demonstrated the high frequency and seriousness of the COVID-19 in CKD patients receiving dialysis. Importantly, the influence of COVID-19 among CKD patients without dialysis is still largely unexplored. Thus, we systemically summarized how mental health affects the spreading of COVID-19 to virtually worldwide, covering perspectives from several countries across a wide range of fields and clinical contexts. This review aims to provide the latest details and reveal potential concerns on the public health including psychological well-being of the older patients with CKD.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

Reliability and Validity of Performance Evaluations of Pain Medicine Clinical Faculty by Residents and Fellows Using a Supervision Scale

BACKGROUND

Annual and/or semiannual evaluations of pain medicine clinical faculty are mandatory for multiple organizations in the United States. We evaluated the validity and psychometric reliability of a modified version of de Oliveira Filho et al clinical supervision scale for this purpose.

METHODS

Six years of weekly evaluations of pain medicine clinical faculty by resident physicians and pain medicine fellows were studied. A 1-4 rating (4 = "Always") was assigned to each of 9 items (eg, "The faculty discussed with me the management of patients before starting a procedure or new therapy and accepted my suggestions, when appropriate").

RESULTS

Cronbach α of the 9 items equaled .975 (95% confidence interval [CI], 0.974-0.976). A G coefficient of 0.90 would be expected with 18 raters; the N = 12 six-month periods had mean 18.8 ± 5.9 (standard deviation [SD]) unique raters in each period (median = 20).Concurrent validity was shown by Kendall τb = 0.45 (P < .0001) pairwise by combination of ratee and rater between the average supervision score and the average score on a 21-item evaluation completed by fellows in pain medicine. Concurrent validity also was shown by τb = 0.36 (P = .0002) pairwise by combination of ratee and rater between the average pain medicine supervision score and the average operating room supervision score completed by anesthesiology residents.Average supervision scores differed markedly among the 113 raters (η = 0.485; CI, 0.447-0.490). Pairings of ratee and rater were nonrandom (Cramér V = 0.349; CI, 0.252-0.446).Mixed effects logistic regression was performed with rater leniency as covariates and the dependent variable being an average score equaling the maximum 4 vs <4. There were 3 of 13 ratees with significantly more averages <4 than the other ratees, based on P < .01 criterion; that is, their supervision was reliably rated as below average. There were 3 of 13 different ratees who provided supervision reliably rated as above average.Raters did not report higher supervision scores when they had the opportunity to perform more interventional pain procedures.

CONCLUSIONS

Evaluations of pain medicine clinical faculty are required. As found when used for evaluating operating room anesthesiologists, a supervision scale has excellent internal consistency, achievable reliability using 1-year periods of data, concurrent validity with other ratings, and the ability to differentiate among ratees. However, to be reliable, routinely collected supervision scores must be adjusted for rater leniency.

The efficacy of extracorporeal shock wave for chronic musculoskeletal pain conditions: A protocol of systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This systematic review is the first one to assess the effectiveness and safety of extracorporeal shock-wave therapy (ESWT) for patients with chronic musculoskeletal pain conditions (CMPC).

METHODS

Seven electronic databases were searched for all relevant literature from inception to December 2019, including PubMed, the Web of Science, EMBASE, Cochrane library, China National Knowledge Infrastructure Database (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang database. Only randomized controlled trials (RCTs) of ESWT for chronic musculoskeletal pain will be included. Two reviewers will independently select eligible studies and collected the detailed information, assessed the methodological quality. A third reviewer will join in discussion to solve disagreements. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) will be presented to demonstrate the effectiveness of ESWT for patients with chronic MSK pain conditions. RevMan 5.4 software will be used for statistical analysis.

RESULTS

This systematic review will explore the effectiveness and safety of ESWT for patients with CMPC. The primary outcome includes pain level, and secondary outcome includes function limitation and adverse events.

CONCLUSION

It can provide the updated evidence which is of great importance for patients, clinical practice and health related policy maker in ESWT treating CMPC.