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Nielsen A, Dyer NL, Lechuga C, McKee MD, Dusek JA. Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines. Integr Med Res 2024; 13:101048. [PMID: 38841077 PMCID: PMC11151162 DOI: 10.1016/j.imr.2024.101048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024] Open
Abstract
Background Acupuncture shows promise as an effective nonpharmacologic option for reduction of acute pain in the emergency department (ED). Following CONSORT and STRICTA guidelines, randomized controlled trials (RCTs) generally report intervention details and acupoint options, but fidelity to acupuncture interventions, critical to reliability in intervention research, is rarely reported. Methods ACUITY is an NCCIH-funded, multi-site feasibility RCT of acupuncture in 3 EDs (Cleveland, Nashville, and San Diego). ACUITY acupuncturists were trained in study design, responsive acupuncture manualization protocol, logistics and real-time recording of session details via REDCap forms created to track fidelity. Results Across 3 recruiting sites, 79 participants received acupuncture: 51 % women, 43 % Black/African American, with heterogeneous acute pain sites at baseline: 32 % low back, 22 % extremity, 20 % abdominal, 10 % head. Pragmatically, participants were treated in ED common areas (52 %), private rooms (39 %), and semi-private rooms (9 %). Objective tracking found 98 % adherence to the six components of the acupuncture manualization protocol: staging, number of insertion points (M = 13.2, range 2-22), needle retention time (M = 23.5 min, range 4-52), session length (M = 40.3 min, range 20-66), whether general recommendations were provided and completion of the session form. Conclusion To the best of our knowledge, this is the first RCT to assess and report fidelity to an acupuncture protocol. Fidelity monitoring will be fundamental for ACUITY2, which would be a future definitive, multi-site RCT. Furthermore, we recommend that fidelity to acupuncture interventions be added to CONSORT and STRICTA reporting guidelines in future RCTs. Protocol registration The protocol of this study is registered at clinicaltrials.gov: NCT04880733.
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Affiliation(s)
- Arya Nielsen
- Icahn School of Medicine at Mount Sinai, Department of Family Medicine and Community Health, New York, NY, USA
| | - Natalie L. Dyer
- Susan Samueli Integrative Health Institute, University of California- Irvine, Irvine, CA, USA
| | - Claudia Lechuga
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, NY, USA
| | - M. Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Jeffery A. Dusek
- Susan Samueli Integrative Health Institute, University of California- Irvine, Irvine, CA, USA
- Department of Medicine, General Internal Medicine, University of California- Irvine, Irvine, CA, USA
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2
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Fritz JM, Ford I, George SZ, Vinci de Vanegas L, Cope T, Burke CA, Goode AP. Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials. FRONTIERS IN PAIN RESEARCH 2024; 5:1324096. [PMID: 38706872 PMCID: PMC11066221 DOI: 10.3389/fpain.2024.1324096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.
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Affiliation(s)
- Julie M. Fritz
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Isaac Ford
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Steven Z. George
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Laura Vinci de Vanegas
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Tyler Cope
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Colleen A. Burke
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
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3
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Ter Meulen BC, Maas ET, van der Vegt R, Haumann J, Weinstein HC, Ostelo RWJG, van Dongen JM. Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25:247. [PMID: 38561748 PMCID: PMC10983727 DOI: 10.1186/s12891-024-07366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION Dutch National trial register: NTR4457 (March, 6th, 2014).
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands.
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
| | - Rien van der Vegt
- Department of Pain Medicine and Anesthesiology Zaans MC, Zaandam, The Netherlands
| | - Johan Haumann
- Department of Pain Medicine and Anesthesiology, OLVG, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam and the Amsterdam Movement Sciences Research Institute, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
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Faulk DJ, Karlik JB, Strupp KM, Tran SM, Twite M, Brull SJ, Yaster M, Austin TM. The Incidence of Residual Neuromuscular Block in Pediatrics: A Prospective, Pragmatic, Multi-institutional Cohort Study. Cureus 2024; 16:e56408. [PMID: 38638790 PMCID: PMC11024486 DOI: 10.7759/cureus.56408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Residual neuromuscular block, defined as a quantitatively measured train-of-four ratio (TOFr) <0.9, is common postoperatively. Using a pragmatic trial design, we hypothesized that qualitative and/or clinical assessment of neuromuscular block would inadequately detect residual block following antagonism with neostigmine or sugammadex. Method After IRB approval and written informed consent, 74 children (aged 2-17 years), undergoing elective surgery and receiving rocuronium, were prospectively enrolled in the study at Children's Hospital Colorado and Children's Healthcare of Atlanta. Routine clinical practice at both institutions consisted of clinical signs and/or qualitative assessment with peripheral nerve stimulators. Children at the Colorado hospital routinely received sugammadex antagonism; whereas children at the Atlanta hospital received neostigmine. Residual neuromuscular block was assessed postoperatively using quantitative electromyography. If TOFr was <0.9, patients received sugammadex until TOFr ≥0.9. Result Qualitative and clinical assessment failed to detect residual block in 29.7% of patients in the neostigmine reversal cohort (adjusted odds ratio (aOR) 29.8, 95% confidence interval (CI): 2.7 to 5,559.5, p-value = 0.002). No residual block was detected in the sugammadex reversal cohort. A correlation between increasing patient weight and incidence of postoperative residual block was observed in the neostigmine cohort (aOR 1.05, 95% CI: 1.02 to 1.10, p-value = 0.002). Conclusion Qualitative and/or clinical assessment of neuromuscular block inadequately detects residual block following neostigmine antagonism.
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Affiliation(s)
- Debra J Faulk
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Joelle B Karlik
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Kim M Strupp
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Stephanie M Tran
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Mark Twite
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Sorin J Brull
- Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, USA
| | - Myron Yaster
- Anesthesiology, Children's Hospital Colorado, Denver, USA
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Gunsilius CZ, Heffner J, Bruinsma S, Corinha M, Cortinez M, Dalton H, Duong E, Lu J, Omar A, Owen LLW, Roarr BN, Tang K, Petzschner FH. SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment. JMIR Mhealth Uhealth 2024; 12:e47177. [PMID: 38214952 PMCID: PMC10818247 DOI: 10.2196/47177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/03/2023] [Accepted: 11/30/2023] [Indexed: 01/13/2024] Open
Abstract
Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.
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Affiliation(s)
- Chloe Zimmerman Gunsilius
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI, United States
- Neuroscience Graduate Program, Department of Neuroscience, Brown University, Providence, RI, United States
- Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Joseph Heffner
- Department of Cognitive, Linguistic, and Psychological Sciences, Brown University, Providence, RI, United States
| | - Sienna Bruinsma
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
| | - Madison Corinha
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI, United States
| | - Maria Cortinez
- Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Hadley Dalton
- Center for Computation and Visualization, Brown University, Providence, RI, United States
| | - Ellen Duong
- Center for Computation and Visualization, Brown University, Providence, RI, United States
| | - Joshua Lu
- Center for Computation and Visualization, Brown University, Providence, RI, United States
| | - Aisulu Omar
- Center for Computation and Visualization, Brown University, Providence, RI, United States
| | - Lucy Long Whittington Owen
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI, United States
| | - Bradford Nazario Roarr
- Center for Computation and Visualization, Brown University, Providence, RI, United States
| | - Kevin Tang
- Industrial Design, Rhode Island School of Design, Providence, RI, United States
| | - Frederike H Petzschner
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, United States
- Center for Digital Health, Brown University, Lifespan, Providence, RI, United States
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6
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Tracy BA, Soncrant J, Rhon DI, Young JL. Trials Investigating Exercise for Low Back Pain Lack Pragmatic Application: A Systematic Review. Arch Phys Med Rehabil 2024; 105:157-165. [PMID: 38042245 DOI: 10.1016/j.apmr.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE To systematically review the orientation of trials analyzing exercise for low back pain (LBP) on the efficacy-effectiveness spectrum. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Ovid MEDLINE were searched for trials published between January 1, 2010, and August 13, 2022. STUDY SELECTION Randomized controlled trials investigating exercise for adults with LBP. DATA EXTRACTION Two reviewers independently used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to determine the efficacy-effectiveness orientation. The same 2 reviewers assessed the risk of bias for all studies using the Cochrane Collaboration risk of bias 2.0 tool. DATA SYNTHESIS The search identified 2975 records. Full-text review was conducted on 674 studies, and 159 studies were included. The proportion of trials with a strong or rather strong efficacy orientation (RITES rating=1 or 2), balanced emphasis (RITES rating=3), or strong or rather strong effectiveness (RITES rating=4 or 5) orientation on the efficacy-effectiveness spectrum within each RITES domain were reported. A greater proportion of trials had an efficacy orientation when compared with effectiveness or a balanced emphasis within 4 domains: participant characteristics: efficacy 43.9%, 41.9% effectiveness, balanced 14.5%; trial setting: 69.0% efficacy, effectiveness 15.8% balanced 15.2%; flexibility of interventions: 74.2% efficacy, effectiveness 8.8%, balanced 17.0%; clinical relevance of experimental and comparison interventions: 50.3% efficacy, 33.3% effectiveness 33.3%, balanced 16.4%. A high risk of bias was found in 42.1% (n=67) of trials. CONCLUSION Trials investigating the effect of exercise for LBP have a greater orientation toward efficacy across multiple trial design domains. Researchers should consider pragmatic designs in future trials to improve generalizability. Clinicians should consider the efficacy-effectiveness orientation when translating evidence into clinical practice.
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Affiliation(s)
- Brad A Tracy
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, WI.
| | - Jason Soncrant
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, WI; South College, Doctor of Physical Therapy Program, Knoxville, TN
| | - Daniel I Rhon
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, WI; Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Jodi L Young
- Bellin College, Doctor of Science in Physical Therapy Program, Green Bay, WI
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7
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Ozek B, Lu Z, Pouromran F, Radhakrishnan S, Kamarthi S. Analysis of pain research literature through keyword Co-occurrence networks. PLOS DIGITAL HEALTH 2023; 2:e0000331. [PMID: 37676880 PMCID: PMC10484461 DOI: 10.1371/journal.pdig.0000331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/18/2023] [Indexed: 09/09/2023]
Abstract
Pain is a significant public health problem as the number of individuals with a history of pain globally keeps growing. In response, many synergistic research areas have been coming together to address pain-related issues. This work reviews and analyzes a vast body of pain-related literature using the keyword co-occurrence network (KCN) methodology. In this method, a set of KCNs is constructed by treating keywords as nodes and the co-occurrence of keywords as links between the nodes. Since keywords represent the knowledge components of research articles, analysis of KCNs will reveal the knowledge structure and research trends in the literature. This study extracted and analyzed keywords from 264,560 pain-related research articles indexed in IEEE, PubMed, Engineering Village, and Web of Science published between 2002 and 2021. We observed rapid growth in pain literature in the last two decades: the number of articles has grown nearly threefold, and the number of keywords has grown by a factor of 7. We identified emerging and declining research trends in sensors/methods, biomedical, and treatment tracks. We also extracted the most frequently co-occurring keyword pairs and clusters to help researchers recognize the synergies among different pain-related topics.
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Affiliation(s)
- Burcu Ozek
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, United States of America
| | - Zhenyuan Lu
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, United States of America
| | - Fatemeh Pouromran
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, United States of America
| | - Srinivasan Radhakrishnan
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, United States of America
| | - Sagar Kamarthi
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, Massachusetts, United States of America
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8
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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] [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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Saesen R, Depreytere K, Krupianskaya K, Langeweg J, Verheecke J, Lacombe D, Huys I. Analysis of the characteristics and the degree of pragmatism exhibited by pragmatic-labelled trials of antineoplastic treatments. BMC Med Res Methodol 2023; 23:148. [PMID: 37355603 PMCID: PMC10290324 DOI: 10.1186/s12874-023-01975-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Pragmatic clinical trials (PCTs) are designed to reflect how an investigational treatment would be applied in clinical practice. As such, unlike their explanatory counterparts, they measure therapeutic effectiveness and are capable of generating high-quality real-world evidence. However, the conduct of PCTs remains extremely rare. The scarcity of such studies has contributed to the emergence of the efficacy-effectiveness gap and has led to calls for launching more of them, including in the field of oncology. This analysis aimed to identify self-labelled pragmatic trials of antineoplastic interventions and to evaluate whether their use of this label was justified. METHODS We searched PubMed® and Embase® for publications corresponding with studies that investigated antitumor therapies and that were tagged as pragmatic in their titles, abstracts and/or index terms. Subsequently, we consulted all available source documents for the included trials and extracted relevant information from them. The data collected were then used to appraise the degree of pragmatism displayed by the PCTs with the help of the validated PRECIS-2 tool. RESULTS The literature search returned 803 unique records, of which 46 were retained upon conclusion of the screening process. This ultimately resulted in the identification of 42 distinct trials that carried the 'pragmatic' label. These studies examined eight different categories of neoplasms and were mostly randomized, open-label, multicentric, single-country trials sponsored by non-commercial parties. On a scale of one (very explanatory) to five (very pragmatic), the median PCT had a PRECIS-2 score per domain of 3.13 (interquartile range: 2.57-3.53). The most and least pragmatic studies in the sample had a score of 4.44 and 1.57, respectively. Only a minority of trials were described in sufficient detail to allow them to be graded across all domains of the PRECIS-2 instrument. Many of the studies examined also had features that arguably precluded them from being pragmatic altogether, such as being monocentric or placebo-controlled in nature. CONCLUSION PCTs of antineoplastic treatments are generally no more pragmatic than they are explanatory.
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Affiliation(s)
- Robbe Saesen
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
- European Organisation for Research and Treatment of Cancer (EORTC), Avenue E. Mounier 83, 1200, Brussels, Belgium.
| | - Kevin Depreytere
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karyna Krupianskaya
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Joël Langeweg
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Julie Verheecke
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Denis Lacombe
- European Organisation for Research and Treatment of Cancer (EORTC), Avenue E. Mounier 83, 1200, Brussels, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy Research Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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10
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Kerns RD, Davis AF, Fritz JM, Keefe FJ, Peduzzi P, Rhon DI, Taylor SL, Vining R, Yu Q, Zeliadt SB, George SZ. Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence. THE JOURNAL OF PAIN 2023; 24:568-574. [PMID: 36574858 PMCID: PMC10079571 DOI: 10.1016/j.jpain.2022.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.
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Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, Connecticut, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Alison F Davis
- Pain Management Collaboratory, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Julie M Fritz
- Department of Physical Therapy & Athletic Training, College of Health, The University of Utah, Salt Lake City, Utah
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Peter Peduzzi
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, , New Haven, Connecticut
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Health Administration, Greater Los Angeles VA Health Care System, Los Angeles, California; Department of Medicine and Department of Health Policy and Management, UCLA, Los Angeles, California
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | - Qilu Yu
- Office of Clinical and Regulatory Affairs, National Institutes of Health, National Center for Complementary and Integrative Health, Bethesda, Maryland
| | - Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington; Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Steven Z George
- Laszlo Ormandy Distinguished Professor, Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham North Carolina
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11
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Hohenschurz-Schmidt D, Draper-Rodi J, Vase L, Scott W, McGregor A, Soliman N, MacMillan A, Olivier A, Cherian CA, Corcoran D, Abbey H, Freigang S, Chan J, Phalip J, Sørensen LN, Delafin M, Baptista M, Medforth NR, Ruffini N, Andresen SS, Ytier S, Ali D, Hobday H, Ngurah Agung Adhiyoga Santosa AA, Vollert J, Rice AS. Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article II): a meta-analysis relating methods to trial results. Pain 2023; 164:509-533. [PMID: 36271798 PMCID: PMC9916063 DOI: 10.1097/j.pain.0000000000002730] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/16/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Sham interventions in randomized clinical trials (RCTs) of physical, psychological, and self-management (PPS) therapies for pain are highly variable in design and believed to contribute to poor internal validity. However, it has not been formally tested whether the extent to which sham controls resemble the treatment under investigation consistently affects trial outcomes, such as effect sizes, differential attrition, participant expectancy, and blinding effectiveness. Placebo- or sham-controlled RCTs of PPS interventions of clinical pain populations were searched in 12 databases. The similarity of control interventions to the experimental treatment was rated across 25 features. Meta-regression analyses assessed putative links between employed control interventions, observed effect sizes in pain-related outcomes, attrition, and blinding success. The sample included 198 unique control interventions, dominated by manual therapy and chronic musculoskeletal pain research. Meta-analyses indicated small-to-moderate benefits of active treatments over control interventions, across subgroups of manual therapies, exercise, and rehabilitation, and psychological intervention trials. Multiple meta-regression modelling demonstrated that similarity between sham control and tested interventions predicted variability in pain-related outcomes, attrition, and blinding effectiveness. Influential variables were differences relating to the extent of intervention exposure, participant experience, and treatment environments. The results support the supposed link between blinding methods and effect sizes, based on a large and systematically sourced overview of methods. However, challenges to effective blinding are complex and often difficult to discern from trial reports. Nonetheless, these insights have the potential to change trial design, conduct, and reporting and will inform guideline development.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Jerry Draper-Rodi
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Section for Psychology and Neuroscience, Aarhus University, Aarhus, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alison McGregor
- Human Performance Group, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Nadia Soliman
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Andrew MacMillan
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Axel Olivier
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Cybill Ann Cherian
- Chemical Engineering Department, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Hilary Abbey
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Sascha Freigang
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Lea Nørgaard Sørensen
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Maite Delafin
- The Penn Clinic, Hertfordshire, Hatfield, United Kingdom
| | - Margarida Baptista
- Wolfson Centre for Age Related Diseases, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Nuria Ruffini
- National Centre Germany, Foundation C.O.M.E. Collaboration, Berlin, Germany
| | | | | | - Dorota Ali
- Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Harriet Hobday
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Jan Vollert
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, 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, Münster,Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Andrew S.C. Rice
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
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12
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Hohenschurz-Schmidt D, Draper-Rodi J, Vase L, Scott W, McGregor A, Soliman N, MacMillan A, Olivier A, Cherian CA, Corcoran D, Abbey H, Freigang S, Chan J, Phalip J, Nørgaard Sørensen L, Delafin M, Baptista M, Medforth NR, Ruffini N, Skøtt Andresen S, Ytier S, Ali D, Hobday H, Santosa AANAA, Vollert J, Rice AS. Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods. Pain 2023; 164:469-484. [PMID: 36265391 PMCID: PMC9916059 DOI: 10.1097/j.pain.0000000000002723] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/17/2022] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Jerry Draper-Rodi
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Lene Vase
- Section for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus C, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alison McGregor
- Human Performance Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Nadia Soliman
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Andrew MacMillan
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Axel Olivier
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Cybill Ann Cherian
- Chemical Engineering Department, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Hilary Abbey
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Sascha Freigang
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Lea Nørgaard Sørensen
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Maite Delafin
- The Penn Clinic, Hertfordshire, Hatfield, United Kingdom
| | - Margarida Baptista
- Department of Psychology, Wolfson Centre for Age Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Nuria Ruffini
- National Centre Germany, Foundation C.O.M.E. Collaboration, Berlin, Germany
| | | | | | - Dorota Ali
- Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Harriet Hobday
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
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13
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Real-world data and evidence in pain research: a qualitative systematic review of methods in current practice. Pain Rep 2023; 8:e1057. [PMID: 36741790 PMCID: PMC9891449 DOI: 10.1097/pr9.0000000000001057] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 02/05/2023] Open
Abstract
The use of routinely collected health data (real-world data, RWD) to generate real-world evidence (RWE) for research purposes is a growing field. Computerized search methods, large electronic databases, and the development of novel statistical methods allow for valid analysis of data outside its primary clinical purpose. Here, we systematically reviewed the methodology used for RWE studies in pain research. We searched 3 databases (PubMed, EMBASE, and Web of Science) for studies using retrospective data sources comparing multiple groups or treatments. The protocol was registered under the DOI:10.17605/OSF.IO/KGVRM. A total of 65 studies were included. Of those, only 4 compared pharmacological interventions, whereas 49 investigated differences in surgical procedures, with the remaining studying alternative or psychological interventions or epidemiological factors. Most 39 studies reported significant results in their primary comparison, and an additional 12 reported comparable effectiveness. Fifty-eight studies used propensity scores to account for group differences, 38 of them using 1:1 case:control matching. Only 17 of 65 studies provided sensitivity analyses to show robustness of their findings, and only 4 studies provided links to publicly accessible protocols. RWE is a relevant construct that can provide evidence complementary to randomized controlled trials (RCTs), especially in scenarios where RCTs are difficult to conduct. The high proportion of studies reporting significant differences between groups or comparable effectiveness could imply a relevant degree of publication bias. RWD provides a potentially important resource to expand high-quality evidence beyond clinical trials, but rigorous quality standards need to be set to maximize the validity of RWE studies.
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14
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Short S, Tuttle M, Youngman D. A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy. Int J Sports Phys Ther 2023; 18:262-271. [PMID: 36793565 PMCID: PMC9897024 DOI: 10.26603/001c.67936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/03/2022] [Indexed: 02/05/2023] Open
Abstract
Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while "passive" therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white "sides," a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active. Level of Evidence 5.
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15
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Groessl EJ, Hafey C, McCarthy A, Hernandez RM, Prado-Nava M, Casteel D, McKinnon S, Chang DG, Ayers CR, Rutledge TR, Lang AJ, Bormann JE. Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231220623. [PMID: 38152342 PMCID: PMC10752061 DOI: 10.1177/27536130231220623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
Background Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD. Methods In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions. Results The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue. Conclusions Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.
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Affiliation(s)
- Erik J. Groessl
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Carol Hafey
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Adhana McCarthy
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- US Army, San Antonio, TX, USA
| | - Rahil M. Hernandez
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Miguel Prado-Nava
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Danielle Casteel
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Symone McKinnon
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Douglas G. Chang
- Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Catherine R. Ayers
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Thomas R. Rutledge
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Ariel J. Lang
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Jill E. Bormann
- VA San Diego Healthcare System, San Diego, CA, USA
- Hahn School of Nursing and Health Sciences, Beyster Institute of Nursing Research, University of San Diego, San Diego, CA, USA
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16
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Kennedy N, Nelson S, Jerome RN, Edwards TL, Stroud M, Wilkins CH, Harris PA. Recruitment and retention for chronic pain clinical trials: a narrative review. Pain Rep 2022; 7:e1007. [PMID: 38304397 PMCID: PMC10833632 DOI: 10.1097/pr9.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/22/2022] [Accepted: 04/02/2022] [Indexed: 11/25/2022] Open
Abstract
Opioid misuse is at a crisis level. In response to this epidemic, the National Institutes of Health has funded $945 million in research through the Helping to End Addiction Long-term (HEAL) Pain Management Initiative, including funding to the Vanderbilt Recruitment Innovation Center (RIC) to strategize methods to catalyze participant recruitment. The RIC, recognizing the challenges presented to clinical researchers in recruiting individuals experiencing pain, conducted a review of evidence in the literature on successful participant recruitment methods for chronic pain trials, in preparation for supporting the HEAL Pain trials. Study design as it affects recruitment was reviewed, with issues such as sufficient sample size, impact of placebo, pain symptom instability, and cohort characterization being identified as problems. Potential solutions found in the literature include targeted electronic health record phenotyping, use of alternative study designs, and greater clinician education and involvement. For retention, the literature reports successful strategies that include maintaining a supportive staff, allowing virtual study visits, and providing treatment flexibility within the trial. Community input on study design to identify potential obstacles to recruitment and retention was found to help investigators avoid pitfalls and enhance trust, especially when recruiting underrepresented minority populations. Our report concludes with a description of generalizable resources the RIC has developed or adapted to enhance recruitment and retention in the HEAL Pain studies. These resources include, among others, a Recruitment and Retention Plan Template, a Competing Trials Tool, and MyCap, a mobile research application that interfaces with Research Electronic Data Capture (REDCap).
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Affiliation(s)
- Nan Kennedy
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Sarah Nelson
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Rebecca N. Jerome
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Terri L. Edwards
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Mary Stroud
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
- Office of Health Equity, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul A. Harris
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Keefe FJ, Jensen MP, de C Williams AC, George SZ. The yin and yang of pragmatic clinical trials of behavioral interventions for chronic pain: balancing design features to maximize impact. Pain 2022; 163:1215-1219. [PMID: 35027519 PMCID: PMC9148368 DOI: 10.1097/j.pain.0000000000002546] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Francis J. Keefe
- Duke Pain Prevention and Treatment Research Program, Duke University Medical Center, Durham, North Carolina, USA
| | - Mark P. Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Amanda C de C Williams
- Department of Clinical, Educational and Health Psychology, University College London, UK
| | - Steven Z. George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
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Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs. In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design. Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments. Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice. In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden. Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials. Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level. Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.
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Lim J, Lee H, Kim YS. Applying the PRECIS-2 tool for self-declared 'pragmatic' acupuncture trials: protocol for a systematic review. BMJ Open 2022; 12:e052861. [PMID: 35414545 PMCID: PMC9006803 DOI: 10.1136/bmjopen-2021-052861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The pragmatic design has received much attention in the field of acupuncture clinical trials because of insufficient information about the specific effects of acupuncture. However, pragmatism in pragmatic acupuncture trials has not been comprehensively investigated. The PRECIS-2 tool was developed and has been gradually used to design pragmatic trials; therefore, we will apply the PRECIS-2 tool to investigate the pragmatism of pragmatic acupuncture trials in this study. METHODS AND ANALYSIS In this systematic review, self-declared 'pragmatic' randomised clinical trials (RCTs) or protocols of self-declared 'pragmatic' RCTs investigating acupuncture will be searched and included to be reviewed. MEDLINE, EMBASE, the Cochrane Central Register for Controlled Trials, CINAHL, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure, VIP, WANFANG, Taiwan Periodical Literature Database, KoreaMed, KMbase, Research Information Service System, Oriental Medicine Advanced Searching Integrated System, CiNii and ClinicalTrials.gov for registered trials will be electronically searched from inception to March 2022. Protocols of published RCTs or secondary analysis of RCTs will be excluded. Additionally, no language restriction will be applied. Two authors will independently extract descriptive information and assess the pragmatism of pragmatic acupuncture trials using nine domains of the PRECIS-2 tool and one additional domain-control. Descriptive statistics will be reported for each domain and the overall score, and a one-sample t-test will be used to statistically analyse whether the score is greater than 3 (equally pragmatic and explanatory). The wheel diagrams of the nine domains of the PRECIS-2 tool will be used to demonstrate the pragmatism of the included studies. ETHICS AND DISSEMINATION Ethical approval is not warranted as this study will obtain data from previously reported articles. The results will be disseminated through peer-reviewed journals and conferences. PROSPERO REGISTRATION NUMBER CRD42021236975.
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Affiliation(s)
- Jinwoong Lim
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea (the Republic of)
| | - Hyeonhoon Lee
- Department of Clinical Korean Medicine, Graduate School, Kyung Hee University, Seoul, Korea (the Republic of)
| | - Yong-Suk Kim
- Department of Acupuncture and Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Korea (the Republic of)
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Courvoisier DS, Lauper K, Kedra J, de Wit M, Fautrel B, Frisell T, Hyrich KL, Iannone F, Machado PM, Ørnbjerg LM, Rotar Z, Santos MJ, Stamm TA, Stones SR, Strangfeld A, Bergstra SA, Landewé RBM, Finckh A. EULAR points to consider when analysing and reporting comparative effectiveness research using observational data in rheumatology. Ann Rheum Dis 2022; 81:780-785. [DOI: 10.1136/annrheumdis-2021-221307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/06/2022] [Indexed: 12/23/2022]
Abstract
BackgroundComparing treatment effectiveness over time in observational settings is hampered by several major threats, among them confounding and attrition bias.ObjectivesTo develop European Alliance of Associations for Rheumatology (EULAR) points to consider (PtC) when analysing and reporting comparative effectiveness research using observational data in rheumatology.MethodsThe PtC were developed using a three-step process according to the EULAR Standard Operating Procedures. Based on a systematic review of methods currently used in comparative effectiveness studies, the PtC were formulated through two in-person meetings of a multidisciplinary task force and a two-round online Delphi, using expert opinion and a simulation study. Finally, feedback from a larger audience was used to refine the PtC. Mean levels of agreement among the task force were calculated.ResultsThree overarching principles and 10 PtC were formulated, addressing, in particular, potential biases relating to attrition or confounding by indication. Building on Strengthening the Reporting of Observational Studies in Epidemiology guidelines, these PtC insist on the definition of the baseline for analysis and treatment effectiveness. They also focus on the reasons for stopping treatment as an important consideration when assessing effectiveness. Finally, the PtC recommend providing key information on missingness patterns.ConclusionTo improve the reliability of an increasing number of real-world comparative effectiveness studies in rheumatology, special attention is required to reduce potential biases. Adherence to clear recommendations for the analysis and reporting of observational comparative effectiveness studies will improve the trustworthiness of their results.
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Pacheco-Barrios K, de Melo PS, Vasquez-Avila K, Cardenas-Rojas A, Gonzalez-Mego P, Marduy A, Parente J, Sanchez IR, Cortez P, Whalen M, Castelo-Branco L, Fregni F. Accelerating the translation of research findings to clinical practice: insights from phantom limb pain clinical trials. PRINCIPLES AND PRACTICE OF CLINICAL RESEARCH (2015) 2021; 7:1-7. [PMID: 35434310 PMCID: PMC9009529 DOI: 10.21801/ppcrj.2021.74.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Paulo Sampaio de Melo
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Karen Vasquez-Avila
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alejandra Cardenas-Rojas
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Paola Gonzalez-Mego
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anna Marduy
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joao Parente
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ingrid Rebello Sanchez
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Pablo Cortez
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Meghan Whalen
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Luis Castelo-Branco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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