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Clark JD. A Spicy New Treatment for Postoperative Pain. Anesthesiology 2024; 141:201-203. [PMID: 38980161 PMCID: PMC11239119 DOI: 10.1097/aln.0000000000004999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- J. David Clark
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford CA, 94305
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2
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Cook JA, Steigman PJ, Burke-Miller JK, Pashka N, Ruiz A, Egli D, Cortez C, Prestipino J, Brown A, Furlong M, Razzano LA. Impact of Individual Budgets on Work and Financial Well-Being of Supported Employment Recipients With Serious Mental Illness. Psychiatr Serv 2024:appips20230597. [PMID: 38957051 DOI: 10.1176/appi.ps.20230597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
OBJECTIVE The authors sought to determine whether providing recipients of supported employment with individual budgets from which they could purchase employment-related goods and services would improve employment and financial outcomes. METHODS Sixty study participants were recruited from an individual placement and support (IPS) program and randomly assigned (1:1) to receive IPS services only (N=32) or IPS services with a 12-month $950 flexible fund called a career account (N=28). Participants receiving IPS and a career account met with staff who helped them identify employment goals and create a budget for purchases directly tied to these goals. The primary outcome was competitive employment; secondary outcomes included job tenure, days worked, total earnings, and financial well-being. Outcomes were analyzed by using adjusted generalized linear models (GLMs) with binary logistic, negative binomial, and linear distributions. RESULTS The proportion of participants who achieved competitive employment was largely similar for those in the career account+IPS group (54%) and in the IPS-only group (47%). However, the GLM analysis revealed that career account+IPS participants had significantly longer job tenure, more total days of employment, and higher total earnings than IPS-only participants. Feelings of financial well-being increased significantly among career account participants, whereas financial well-being declined among control participants. The amount of career account dollars participants spent was positively and significantly associated with longer job tenure, more days employed, and higher total earnings. CONCLUSIONS Combining flexible funds with IPS-supported employment achieved some superior outcomes compared with IPS only. Further research is needed to assess the longer-term effects of this practice and its cost-effectiveness.
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Affiliation(s)
- Judith A Cook
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Pamela J Steigman
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Jane K Burke-Miller
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Nicole Pashka
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Anabel Ruiz
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Drew Egli
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Claudia Cortez
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - John Prestipino
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Adrienne Brown
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Mark Furlong
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
| | - Lisa A Razzano
- Department of Psychiatry, College of Medicine, University of Illinois, Chicago (Cook, Steigman, Burke-Miller, Egli, Cortez, Razzano); Thresholds, Chicago (Pashka, Ruiz, Prestipino, Brown, Furlong, Razzano)
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3
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Kapural L, Melton J, Kim B, Mehta P, Sigdel A, Bautista A, Petersen EA, Slavin KV, Eidt J, Wu J, Elshihabi S, Schwalb JM, Garrett Jr HE, Veizi E, Barolat G, Rajani RR, Rhee PC, Guirguis M, Mekhail N. Primary 3-Month Outcomes of a Double-Blind Randomized Prospective Study (The QUEST Study) Assessing Effectiveness and Safety of Novel High-Frequency Electric Nerve Block System for Treatment of Post-Amputation Pain. J Pain Res 2024; 17:2001-2014. [PMID: 38860215 PMCID: PMC11164212 DOI: 10.2147/jpr.s463727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 05/10/2024] [Indexed: 06/12/2024] Open
Abstract
Purpose This multicenter, randomized, double-blinded, active sham-controlled pivotal study was designed to assess the efficacy and safety of high-frequency nerve block treatment for chronic post-amputation and phantom limb pain. Patients and Methods QUEST enrolled 180 unilateral lower-limb amputees with severe post-amputation pain, 170 of whom were implanted with the Altius device, were randomized 1:1 to active-sham or treatment groups and reached the primary endpoint. Responders were those subjects who received ≥50% pain relief 30 min after treatment in ≥50% of their self-initiated treatment sessions within the 3-month randomized period. Differences between the active treatment and sham control groups as well as numerous secondary outcomes were determined. Results At 30-min, (primary outcome), 24.7% of the treatment group were responders compared to 7.1% of the control group (p=0.002). At 120-minutes following treatment, responder rates were 46.8% in the Treatment group and 22.2% in the Control group (p=0.001). Improvement in Brief Pain Inventory interference score of 2.3 ± 0.29 was significantly greater in treatment group than the 1.3 ± 0.26-point change in the Control group (p = 0.01). Opioid usage, although not significantly different, trended towards a greater reduction in the treatment group than in the control group. The incidence of adverse events did not differ significantly between the treatment and control groups. Conclusion The primary outcomes of the study were met, and the majority of Treatment patients experienced a substantial improvement in PAP (regardless of meeting the study definition of a responder). The significant in PAP was associated with significantly improved QOL metrics, and a trend towards reduced opioid utilization compared to Control. These data indicate that Altius treatment represents a significant therapeutic advancement for lower-limb amputees suffering from chronic PAP.
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Affiliation(s)
- Leonardo Kapural
- Carolinas Pain Institute and Center for Clinical Research, Winston-Salem, NC, USA
| | - Jim Melton
- Department of Vascular Surgery, Cardiovascular Health Clinic, Oklahoma City, OK, USA
| | - Billy Kim
- Department of Vascular Surgery, The Surgical Clinic, Nashville, TN, USA
| | - Priyesh Mehta
- Department of Pain Medicine, Meta Medical Research Institute, Dayton, OH, USA
| | - Abindra Sigdel
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Alexander Bautista
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas, Little Rock, AR, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
- Department of Neurology, Jesse Brown VA Medical Center, Chicago, IL, USA
| | - John Eidt
- Department of Vascular Surgery, Baylor Scott and White Heart and Vascular Hospital Dallas, Dallas, TX, USA
| | - Jiang Wu
- Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Said Elshihabi
- Department of Neurosurgery, Legacy Brain & Spine Surgical Center, Atlanta, GA, USA
| | | | - H Edward Garrett Jr
- Department of Vascular Surgery, University of Tennessee-Memphis, Memphis, TN, USA
| | - Elias Veizi
- Department of Pain Medicine, VA Northeast OH Healthcare System, Cleveland, OH, USA
| | - Giancarlo Barolat
- Department of Neurosurgery, Barolat Neuroscience, Presbyterian/St Luke’s Medical Center, Denver, CO, USA
| | - Ravi R Rajani
- Department of Vascular Surgery, Emory University and Grady Memorial Hospital, Atlanta, GA, USA
| | - Peter C Rhee
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Maged Guirguis
- Department of Interventional Pain Management, Ochsner Health System, New Orleans, LA, USA
| | - Nagy Mekhail
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
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4
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Schnitzer TJ, Conaghan PG, Berenbaum F, Abraham L, Cappelleri JC, Bushmakin AG, Viktrup L, Yang R, Brown MT. Effect size varies based on calculation method and may affect interpretation of treatment effect: an illustration using randomised clinical trials in osteoarthritis. Adv Rheumatol 2024; 64:31. [PMID: 38650049 DOI: 10.1186/s42358-024-00358-y] [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: 03/27/2023] [Accepted: 02/14/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND To illustrate how (standardised) effect sizes (ES) vary based on calculation method and to provide considerations for improved reporting. METHODS Data from three trials of tanezumab in subjects with osteoarthritis were analyzed. ES of tanezumab versus comparator for WOMAC Pain (outcome) was defined as least squares difference between means (mixed model for repeated measures analysis) divided by a pooled standard deviation (SD) of outcome scores. Three approaches to computing the SD were evaluated: Baseline (the pooled SD of WOMAC Pain values at baseline [pooled across treatments]); Endpoint (the pooled SD of these values at the time primary endpoints were assessed); and Median (the median pooled SD of these values based on the pooled SDs across available timepoints). Bootstrap analyses were used to compute 95% confidence intervals (CI). RESULTS ES (95% CI) of tanezumab 2.5 mg based on Baseline, Endpoint, and Median SDs in one study were - 0.416 (- 0.796, - 0.060), - 0.195 (- 0.371, - 0.028), and - 0.196 (- 0.373, - 0.028), respectively; negative values indicate pain improvement. This pattern of ES differences (largest with Baseline SD, smallest with Endpoint SD, Median SD similar to Endpoint SD) was consistent across all studies and doses of tanezumab. CONCLUSION Differences in ES affect interpretation of treatment effect. Therefore, we advocate clearly reporting individual elements of ES in addition to its overall calculation. This is particularly important when ES estimates are used to determine sample sizes for clinical trials, as larger ES will lead to smaller sample sizes and potentially underpowered studies. TRIAL REGISTRATION Clinicaltrials.gov NCT02697773, NCT02709486, and NCT02528188.
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Affiliation(s)
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, National Institute for Health Research, Leeds Biomedical Research Centre-University of Leeds, Leeds, UK
| | - Francis Berenbaum
- Sorbonne University, INSERM CRSA, AP-HP Saint-Antoine hospital, Paris, France
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Medrea I, Tepper SJ, Wang D, Mathew PG, Burish M. Commentary on 2022 guidelines on clinical trial design in cluster headache and further suggestions. J Headache Pain 2024; 25:32. [PMID: 38454380 PMCID: PMC10921584 DOI: 10.1186/s10194-024-01732-3] [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: 12/15/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND New guidelines for cluster headache clinical trials were recently published. We welcome these new guidelines and raise additional considerations in trial methodologies. MAIN BODY We present non-inferiority trials to overcome ethical issues with placebo use, and additionally discuss issues with trial recruitment. CONCLUSIONS We highlight some possible issues and solutions to be considered with the recently published cluster headache trial guidelines.
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Affiliation(s)
- Ioana Medrea
- SUNY Upstate Medical University, Syracuse, New York, USA.
| | - Stewart J Tepper
- The New England Institute for Neurology and Headache, 30 Buxton Farms Rd, Stamford, CT, USA
| | - Donliang Wang
- SUNY Upstate Medical University, Syracuse, New York, USA
| | - Paul G Mathew
- Harvard Medical School, Boston, MA, USA
- Mass General Brigham Health, Department of Neurology, Foxboro, MA, USA
- Atrius Health, Department of Neurology, Quincy, MA, USA
| | - Mark Burish
- UTHealth Houston, Department of Neurosurgery, Houston, TX, USA
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Wu CL, Landau R, Perlas A. Hamlet and regional anesthesia: a clinical trial dilemma - "to be or not to be…". Reg Anesth Pain Med 2024; 49:153-154. [PMID: 38242641 DOI: 10.1136/rapm-2023-105252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/06/2024] [Indexed: 01/21/2024]
Affiliation(s)
- Christopher L Wu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Ruth Landau
- Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
- Columbia Obstetric Anesthesia Family, Columbia University, New York, New York, USA
| | - Anahi Perlas
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Toronto, Canada
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Saueressig T, Pedder H, Owen PJ, Belavy DL. Contextual effects: how to, and how not to, quantify them. BMC Med Res Methodol 2024; 24:35. [PMID: 38350852 PMCID: PMC10863156 DOI: 10.1186/s12874-024-02152-2] [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: 01/24/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
The importance of contextual effects and their roles in clinical care controversial. A Cochrane review published in 2010 concluded that placebo interventions lack important clinical effects overall, but that placebo interventions can influence patient-reported outcomes such as pain and nausea. However, systematic reviews published after 2010 estimated greater contextual effects than the Cochrane review, which stems from the inappropriate methods employed to quantify contextual effects. The effects of medical interventions (i.e., the total treatment effect) can be divided into three components: specific, contextual, and non-specific. We propose that the most effective method for quantifying the magnitude of contextual effects is to calculate the difference in outcome measures between a group treated with placebo and a non-treated control group. Here, we show that other methods, such as solely using the placebo control arm or calculation of a 'proportional contextual effect,' are limited and should not be applied. The aim of this study is to provide clear guidance on best practices for estimating contextual effects in clinical research.
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Affiliation(s)
- Tobias Saueressig
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801, Bochum, Germany.
- Physio Meets Science GmbH, Johannes Reidel Str. 19, 69181, Leimen, Germany.
| | - Hugo Pedder
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall 39, Whatley Road, Bristol, BS8 2PN, UK
| | - Patrick J Owen
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Daniel L Belavy
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Gesundheitscampus 6-8, 44801, Bochum, Germany
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Liu G, Ying J. Regional analgesia techniques for lumbar spine surgery: a frequentist network meta-analysis. Int J Surg 2024; 110:598-599. [PMID: 37737903 PMCID: PMC10793805 DOI: 10.1097/js9.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Affiliation(s)
| | - Jichong Ying
- Department of Orthopaedics, Ningbo No.6 Hospital, Ningbo, Zhejiang, People’s Republic of China
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9
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Beaton AC, Solanki D, Salazar H, Folkerth S, Singla N, Minkowitz HS, Leiman D, Vaughn B, Skuban N, Niebler G. A randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of a bupivacaine hydrochloride implant in patients undergoing abdominoplasty. Reg Anesth Pain Med 2023; 48:601-607. [PMID: 37076252 PMCID: PMC10646917 DOI: 10.1136/rapm-2022-104110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Surgical site infiltration with bupivacaine hydrochloride (HCl) is a standard element of postoperative analgesia for soft tissue surgeries, but results in short-lived analgesia. A novel bupivacaine implant, XARACOLL (bupivacaine HCl), is Food and Drug Administration approved for treatment of acute postsurgical pain following adult inguinal herniorrhaphy. This study examined the efficacy and safety of the bupivacaine implant (300 mg) compared with placebo for postsurgical pain after abdominoplasty. METHODS In this double-blind, placebo-controlled study, patients undergoing abdominoplasty were randomized to three 100 mg bupivacaine implants or three placebo collagen implants, in a 1:1 ratio, implanted intraoperatively. No other analgesics were administered into the surgical site. Patients were allowed opioids and acetaminophen for postoperative pain. Patients were followed for up to 30 days after treatment. PRIMARY OUTCOME the analgesic effect of the bupivacaine implants through 24 hours postsurgery, measured by the sum of time-weighted pain intensity (SPI24). Prespecified key secondary outcomes included SPI48 and SPI72, percentage of opioid-free patients through 24, 48, and 72 hours, and adverse events, which were tested sequentially to control for multiplicity (ie, if the first variable failed to reach significance, no subsequent variables were declared statistically significant). RESULTS The bupivacaine implant patients (n=181) reported statistically significant lower SPI24 (mean (SD) SPI24=102 (43), 95% CI 95 to 109) compared with placebo patients (n=184; SPI24=117 (45), 95% CI 111 to 123, p=0.002). SPI48 was 190 (88, 95% CI 177 to 204) for INL-001 and 206 (96, 95% CI 192 to 219) for placebo, and not significantly different between groups. The subsequent secondary variables were therefore declared not statistically significant. SPI72 was 265 (131, 95% CI 244 to 285) for INL-001 and 281 (146, 95% CI 261 to 301) for placebo. The opioid-free percentage of patients at 24, 48, and 72 hours was 19%, 17%, and 17% for INL-001 and 6.5% for placebo patients (at all timepoints). The only adverse event occurring in ≥5% of patients and for which proportion INL-001 >placebo was back pain (7.7% vs 7.6%). CONCLUSION The study design was limited by not containing an active comparator. Compared with placebo, INL-001 provides postoperative analgesia that is temporally aligned with the period of maximal postsurgical pain in abdominoplasty and offers a favorable safety profile. TRIAL REGISTRATION NUMBER NCT04785625.
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Affiliation(s)
| | | | | | | | - Neil Singla
- Lotus Clinical Research, LLC, Pasadena, California, USA
| | | | - David Leiman
- HD Research/First Surgical Hospital, Bellaire, Texas, USA
| | | | - Nina Skuban
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
| | - Gwendolyn Niebler
- Innocoll Pharmaceuticals Limited, Innocoll Biotherapeutics, Princeton, New Jersey, USA
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10
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Hassan S, Nesovic K, Babineau J, Furlan AD, Kumbhare D, Carlesso LC. Identifying chronic low back pain phenotypic domains and characteristics accounting for individual variation: a systematic review. Pain 2023; 164:2148-2190. [PMID: 37027149 DOI: 10.1097/j.pain.0000000000002911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
ABSTRACT Interpatient variability is frequently observed among individuals with chronic low back pain (cLBP). This review aimed at identifying phenotypic domains and characteristics that account for interpatient variability in cLBP. We searched MEDLINE ALL (through Ovid), Embase Classic and EMBASE (through Ovid), Scopus, and CINAHL Complete (through EBSCOhost) databases. Studies that aimed to identify or predict cLBP different phenotypes were included. We excluded studies that focused on specific treatments. The methodological quality was assessed using an adaptation of the Downs and Black tool. Forty-three studies were included. Although the patient and pain-related characteristics used to identify phenotypes varied considerably across studies, the following were among the most identified phenotypic domains and characteristics that account for interpatient variability in cLBP: pain-related characteristics (including location, severity, qualities, and duration) and pain impact (including disability, sleep, and fatigue), psychological domains (including anxiety and depression), behavioral domains (including coping, somatization, fear avoidance, and catastrophizing), social domains (including employment and social support), and sensory profiling (including pain sensitivity and sensitization). Despite these findings, our review showed that the evidence on pain phenotyping still requires further investigation. The assessment of the methodological quality revealed several limitations. We recommend adopting a standard methodology to enhance the generalizability of the results and the implementation of a comprehensive and feasible assessment framework to facilitate personalized treatments in clinical settings.
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Affiliation(s)
- Samah Hassan
- Institute of Education Research (TIER), University Health Network, Toronto, ON, Canada
| | - Karlo Nesovic
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Jessica Babineau
- Institute of Education Research (TIER), University Health Network, Toronto, ON, Canada
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Andrea D Furlan
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dinesh Kumbhare
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa C Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
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11
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Aurucci GV, Preatoni G, Damiani A, Raspopovic S. Brain-Computer Interface to Deliver Individualized Multisensory Intervention for Neuropathic Pain. Neurotherapeutics 2023; 20:1316-1329. [PMID: 37407726 PMCID: PMC10480109 DOI: 10.1007/s13311-023-01396-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 07/07/2023] Open
Abstract
To unravel the complexity of the neuropathic pain experience, researchers have tried to identify reliable pain signatures (biomarkers) using electroencephalography (EEG) and skin conductance (SC). Nevertheless, their use as a clinical aid to design personalized therapies remains scarce and patients are prescribed with common and inefficient painkillers. To address this need, novel non-pharmacological interventions, such as transcutaneous electrical nerve stimulation (TENS) to activate peripheral pain relief via neuromodulation and virtual reality (VR) to modulate patients' attention, have emerged. However, all present treatments suffer from the inherent bias of the patient's self-reported pain intensity, depending on their predisposition and tolerance, together with unspecific, pre-defined scheduling of sessions which does not consider the timing of pain episodes onset. Here, we show a Brain-Computer Interface (BCI) detecting in real-time neurophysiological signatures of neuropathic pain from EEG combined with SC and accordingly triggering a multisensory intervention combining TENS and VR. After validating that the multisensory intervention effectively decreased experimentally induced pain, the BCI was tested with thirteen healthy subjects by electrically inducing pain and showed 82% recall in decoding pain in real time. Such constructed BCI was then validated with eight neuropathic patients reaching 75% online pain precision, and consequently releasing the intervention inducing a significant decrease (50% NPSI score) in neuropathic patients' pain perception. Our results demonstrate the feasibility of real-time pain detection from objective neurophysiological signals, and the effectiveness of a triggered combination of VR and TENS to decrease neuropathic pain. This paves the way towards personalized, data-driven pain therapies using fully portable technologies.
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Affiliation(s)
- Giuseppe Valerio Aurucci
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Greta Preatoni
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Arianna Damiani
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland
| | - Stanisa Raspopovic
- Laboratory for Neuroengineering, Department of Health Science and Technology, Institute for Robotics and Intelligent Systems, ETH Zürich, 8092, Zurich, Switzerland.
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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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13
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Faber CG, Attal N, Lauria G, Dworkin RH, Freeman R, Dawson KT, Finnigan H, Hajihosseini A, Naik H, Serenko M, Morris CJ, Kotecha M. Efficacy and safety of vixotrigine in idiopathic or diabetes-associated painful small fibre neuropathy (CONVEY): a phase 2 placebo-controlled enriched-enrolment randomised withdrawal study. EClinicalMedicine 2023; 59:101971. [PMID: 37152360 PMCID: PMC10154969 DOI: 10.1016/j.eclinm.2023.101971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Background No pharmacological treatments are specifically indicated for painful small fibre neuropathy (SFN). CONVEY, a phase 2 enriched-enrolment study, evaluated the efficacy and safety of vixotrigine, a voltage- and use-dependent sodium channel blocker, in participants with idiopathic or diabetes-associated painful SFN. Methods CONVEY was a phase 2, multicentre, placebo-controlled, double-blind (DB), enriched-enrolment, randomised withdrawal study. The study was conducted at 68 sites in 13 countries (Europe and Canada) between May 17, 2018, and April 12, 2021. Following a 4-week open-label period in which 265 adults with painful SFN (a mixture of large and small fibre neuropathy was not exclusionary) received oral vixotrigine 350 mg twice daily (BID), 123 participants (with a ≥30% reduction from baseline in average daily pain [ADP] score during the open-label period) were randomised 1:1:1 to receive 200 mg BID, 350 mg BID or placebo for a 12-week double-blind (DB) period. Primary endpoint was change from baseline in ADP at DB Week 12. Secondary endpoints included the proportion of participants with a ≥30% reduction from baseline in ADP and the proportion of Patient Global Impression of Pain (PGIC) responders at DB Week 12. Treatment-emergent adverse events (AEs) were monitored. Statistical significance was set at 0.10 (2-sided). The trial was registered on ClinicalTrials.gov (NCT03339336) and on ClinicalTrialsregister.eu (2017-000991-27). Findings A statistically significant difference from placebo in least squares mean reduction in ADP score from baseline to DB Week 12 was observed with vixotrigine 200 mg BID (-0.85; SE, 0.43; 95% CI, -1.71 to 0.00; p = 0.050) but not 350 mg BID (-0.17; SE, 0.43; 95% CI, -1.01 to 0.68; p = 0.70). Numerically, but not statistically significantly, more participants who received vixotrigine vs placebo experienced a ≥30% ADP reduction from baseline (68.3-72.5% vs 52.5%), and only the 350 mg BID group had significantly more PGIC responders vs placebo (48.8% vs 30.0%; odds ratio = 2.60; 95% CI, 0.97-6.99; p = 0.058) at DB Week 12. AEs were mostly mild to moderate in the vixotrigine groups. The most common AEs (≥5% of vixotrigine-treated participants) in the DB 200 mg BID and 350 mg BID vixotrigine groups were falls, nasopharyngitis, muscle spasm, and urinary tract infection. Interpretation In our study, vixotrigine 200 mg BID, but not 350 mg BID, met the primary endpoint; more vixotrigine-treated participants experienced a ≥30% reduction from baseline in ADP at DB Week 12. Vixotrigine (at both dosages) was well tolerated in participants with SFN. Funding Biogen, Inc.
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Affiliation(s)
- Catharina G. Faber
- Department of Neurology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, P. Debeyelaan 25, Maastricht 6229 HX, the Netherlands
| | - Nadine Attal
- INSERM U987, Ambroise Paré Hospital, APHP, Boulogne-Billancourt F-92100, France
- Université UVSQ Paris-Saclay, Versailles 78000, France
| | - Giuseppe Lauria
- Third Neurology Unit, Fondazione IRCCS Istituto Neurologico “Carlo Besta”, Via Celoria 11, Milan 20133, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Via Festa del Perdono 7, Milan 20122, Italy
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | | | | | | - Mona Kotecha
- Biogen, Cambridge, MA 02142, USA
- Corresponding author.
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14
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Pratscher SD, Sibille KT, Fillingim RB. Conscious connected breathing with breath retention intervention in adults with chronic low back pain: protocol for a randomized controlled pilot study. Pilot Feasibility Stud 2023; 9:15. [PMID: 36694217 PMCID: PMC9872326 DOI: 10.1186/s40814-023-01247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 01/16/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Chronic pain is a major source of human suffering, and chronic low back pain (cLBP) is among the most prevalent, costly, and disabling of pain conditions. Due to the significant personal and societal burden and the complex and recurring nature of cLBP, self-management approaches that can be practiced at home are highly relevant to develop and test. The respiratory system is one of the most integrated systems of the body, and breathing is bidirectionally related with stress, emotion, and pain. Thus, the widespread physiological and psychological impact of breathing practices and breathwork interventions hold substantial promise as possible self-management strategies for chronic pain. The primary aim of the current randomized pilot study is to test the feasibility and acceptability of a conscious connected breathing with breath retention intervention compared to a sham control condition. METHODS The rationale and procedures for testing a 5-day conscious connected breathing with breath retention intervention, compared to a deep breathing sham control intervention, in 24 adults (18-65 years) with cLBP is described. Both interventions will be delivered using standardized audio recordings and practiced over 5 days (two times in-person and three times at-home), and both are described as Breathing and Attention Training to reduce possible expectancy and placebo effects common in pain research. The primary outcomes for this study are feasibility and acceptability. Feasibility will be evaluated by determining rates of participant recruitment, adherence, retention, and study assessment completion, and acceptability will be evaluated by assessing participants' satisfaction and helpfulness of the intervention. We will also measure other clinical pain, psychological, behavioral, and physiological variables that are planned to be included in a follow-up randomized controlled trial. DISCUSSION This will be the first study to examine the effects of a conscious connected breathing with breath retention intervention for individuals with chronic pain. The successful completion of this smaller-scale pilot study will provide data regarding the feasibility and acceptability to conduct a subsequent trial testing the efficacy of this breathing self-management practice for adults with cLBP. TRIAL REGISTRATION Clinicaltrials.gov, identifier NCT04740710 . Registered on 5 February 2021.
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Affiliation(s)
- Steven D Pratscher
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA.
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA.
| | - Kimberly T Sibille
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
- Department of Physical Medicine & Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Roger B Fillingim
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA
- Pain Research and Intervention Center of Excellence, University of Florida, Gainesville, FL, USA
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15
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Bascour-Sandoval C, Gajardo-Burgos R, Muñoz-Poblete C, Riedemann-González P, Erices-Salas S, Martínez-Molina A, Gálvez-García G. Transcutaneous Vagal Stimulation in Knee Osteoarthritis (TRAVKO): Protocol of a Superiority, Outcome Assessor- and Participant-Blind, Randomised Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:311. [PMID: 36612632 PMCID: PMC9819338 DOI: 10.3390/ijerph20010311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
Current treatments for knee osteoarthritis (KOA) are partially effective. It is, therefore, necessary to find new strategies that can complement the existing ones. In this scenario, transcutaneous vagal stimulation (TVS) neurophysiological effects could be a helpful solution. However, there is no evidence of the efficacy of TVS in KOA. This trial aims to assess the efficacy of TVS in decreasing pain in participants aged 55 years or older with KOA. A randomised controlled, two-arm, double-blind (participants and outcome assessors) and clinical superiority trial will be conducted for 70 patients with KOA. All the participants will carry out an exercise program. It consists of 12 sessions over four weeks. In addition, they will be randomly assigned to (1) active TVS plus physical exercise or (2) sham TVS plus physical exercise. The application of active TVS consists of electronic stimulation of the auricular concha using a portable device. Sham TVS condition consists of the stimulation of the earlobe that does not cause neurophysiological effects. The primary outcome is the reduction in pain intensity. Additionally, functional capacity, physical performance, pain-related interference, pain-related distress, quality of life in older adults and global change will be measured. Assessments will be conducted at the beginning of the study (baseline), at the end of the intervention and after 1 and 3 months of follow-up. This trial will generate evidence regarding the efficacy of TVS in pain perception in individuals with KOA. This information will serve as an input in the clinical decision-making on the use or non-use of TVS in individuals with KOA. Thus, if the efficacy of TVS is confirmed, a new therapeutic tool may be included in the rehabilitation of individuals with KOA.
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Affiliation(s)
- Claudio Bascour-Sandoval
- Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco 4780000, Chile
- Programa de Magister en Terapía Física Mención Musculoesquelética, Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco 4780000, Chile
| | - Rubén Gajardo-Burgos
- Programa de Magister en Terapía Física Mención Musculoesquelética, Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco 4780000, Chile
- Instituto de Aparato Locomotor y Rehabilitación, Facultad de Medicina, Universidad Austral de Chile, Valdivia 5090000, Chile
| | - Claudio Muñoz-Poblete
- Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco 4780000, Chile
- Programa de Magister en Terapía Física Mención Musculoesquelética, Departamento de Ciencias de la Rehabilitación, Universidad de La Frontera, Temuco 4780000, Chile
| | | | | | - Agustín Martínez-Molina
- Departamento de Psicología Social y Metodología, Facultad de Psicología, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Germán Gálvez-García
- Departamento de Psicología, Universidad de La Frontera, Temuco 4780000, Chile
- Departamento de Psicología Básica, Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Salamanca, 37008 Salamanca, Spain
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16
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Hasvik E, Gran JM, Haugen AJ, Grøvle L. Strategies to manage auxiliary pain medications in chronic pain trials: a topical review. Eur J Clin Pharmacol 2022; 78:1377-1384. [PMID: 35842457 PMCID: PMC9365733 DOI: 10.1007/s00228-022-03355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022]
Abstract
Chronic pain trials commonly allow auxiliary pain medications such as rescue and concomitant analgesics in addition to the randomized treatment. Changes in auxiliary pain medications after randomization represent intercurrent events that may affect either the interpretation or the existence of the measurements associated with the clinical question of interest, complicating the assessment of treatment efficacy. In chronic pain trials, pain intensity typically varies and patients may take the auxiliary medications 1 day but not the next or increase and decrease the dosages temporarily while continuing their randomized study medication. This distinctive feature of auxiliary pain medications as an intercurrent event has received little attention in the literature. Further clarifications on how to manage these issues are therefore pressing. Here we provide perspectives on issues related to auxiliary pain medication-related intercurrent events in randomized controlled chronic pain trials considering the strategies suggested in the E9(R1) addendum to the ICH guideline on statistical principles for clinical trials.
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Affiliation(s)
- Eivind Hasvik
- Department of Physical Medicine and Rehabilitation, Østfold Hospital Trust, 1714, Grålum, Norway.
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | | | - Lars Grøvle
- Department of Rheumatology, Østfold Hospital Trust, Grålum, Norway
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17
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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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18
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Kleykamp BA, Dworkin RH, Turk DC, Bhagwagar Z, Cowan P, Eccleston C, Ellenberg SS, Evans SR, Farrar JT, Freeman RL, Garrison LP, Gewandter JS, Goli V, Iyengar S, Jadad AR, Jensen MP, Junor R, Katz NP, Kesslak JP, Kopecky EA, Lissin D, Markman JD, McDermott MP, Mease PJ, O'Connor AB, Patel KV, Raja SN, Rowbotham MC, Sampaio C, Singh JA, Steigerwald I, Strand V, Tive LA, Tobias J, Wasan AD, Wilson HD. Benefit-risk assessment and reporting in clinical trials of chronic pain treatments: IMMPACT recommendations. Pain 2022; 163:1006-1018. [PMID: 34510135 PMCID: PMC8904641 DOI: 10.1097/j.pain.0000000000002475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic pain clinical trials have historically assessed benefit and risk outcomes separately. However, a growing body of research suggests that a composite metric that accounts for benefit and risk in relation to each other can provide valuable insights into the effects of different treatments. Researchers and regulators have developed a variety of benefit-risk composite metrics, although the extent to which these methods apply to randomized clinical trials (RCTs) of chronic pain has not been evaluated in the published literature. This article was motivated by an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials consensus meeting and is based on the expert opinion of those who attended. In addition, a review of the benefit-risk assessment tools used in published chronic pain RCTs or highlighted by key professional organizations (ie, Cochrane, European Medicines Agency, Outcome Measures in Rheumatology, and U.S. Food and Drug Administration) was completed. Overall, the review found that benefit-risk metrics are not commonly used in RCTs of chronic pain despite the availability of published methods. A primary recommendation is that composite metrics of benefit-risk should be combined at the level of the individual patient, when possible, in addition to the benefit-risk assessment at the treatment group level. Both levels of analysis (individual and group) can provide valuable insights into the relationship between benefits and risks associated with specific treatments across different patient subpopulations. The systematic assessment of benefit-risk in clinical trials has the potential to enhance the clinical meaningfulness of RCT results.
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Affiliation(s)
- Bethea A Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
- Center for Health and Technology, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Zubin Bhagwagar
- Department of Psychiatry, Yale School of Medicine, CT, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | | | - Susan S Ellenberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Scott R Evans
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, United States
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Roy L Freeman
- Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders, Boston, MA, United States
| | - Louis P Garrison
- School of Pharmacy, University of Washington, Seattle, WA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Veeraindar Goli
- Pfizer, Inc, New York, NY, United States. Dr. Goli is now with the Emeritus Professor, Duke University School of Medicine, Durham, NC, United States
| | - Smriti Iyengar
- Division of Translational Research, NINDS, NIH, Rockville, MD, United States
| | - Alejandro R Jadad
- Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Beati, Inc, Toronto, ON, Canada
| | - Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, United States
| | | | - Nathaniel P Katz
- Tufts University School of Medicine, Boston, MA, United States
- Analgesic Solutions, Wayland, MA, United States
| | | | | | - Dmitri Lissin
- DURECT Corporation, Cupertino, CA, United States. Dr. Lissin is now woth the Scilex Pharmaceuticals, Inc., San Diego, CA, United States
| | - John D Markman
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Philip J Mease
- Division of Rheumatology Research, Swedish Medical Center/Providence St. Joseph Health and University of Washington, Seattle, WA, United States
| | - Alec B O'Connor
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Kushang V Patel
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C Rowbotham
- Department of Anesthesia, UCSF School of Medicine, Research Institute, CPMC Sutter Health, San Francisco, CA, United States
| | - Cristina Sampaio
- Clinical Pharmacology Lab, Faculdade de Medicina de Lisboa, University Lisbon, Lisbon, Portugal
| | - Jasvinder A Singh
- Medicine Service, VA Medical Center, Birmingham, AL, United States
- Department of Medicine at the School of Medicine, University of Alabama (UAB) at Birmingham, Birmingham, AL, United States
- Department of Epidemiology at the UAB School of Public Health, Birmingham, AL, United States
| | - Ilona Steigerwald
- Chief Medical Officer SVP Neumentum, Inc, Morristown NJ, United States
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University, Palo Alto CA, United States
| | - Leslie A Tive
- Department of Biopharmaceuticals, Pfizer, Inc, New York, NY, United States
| | | | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, United States
| | - Hilary D Wilson
- Patient Affairs and Engagement, Boehringer Ingelheim, Ridgefield, CT, United States
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19
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Dworkin RH, Anderson BT, Andrews N, Edwards RR, Grob CS, Ross S, Satterthwaite TD, Strain EC. If the doors of perception were cleansed, would chronic pain be relieved? Evaluating the benefits and risks of psychedelics. THE JOURNAL OF PAIN 2022; 23:1666-1679. [PMID: 35643270 DOI: 10.1016/j.jpain.2022.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/01/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022]
Abstract
Psychedelic substances have played important roles in diverse cultures, and ingesting various plant preparations to evoke altered states of consciousness has been described throughout recorded history. Accounts of the subjective effects of psychedelics typically focus on spiritual and mystical-type experiences, including feelings of unity, sacredness, and transcendence. Over the past two decades, there has been increasing interest in psychedelics as treatments for various medical disorders, including chronic pain. Although concerns about adverse medical and psychological effects contributed to their controlled status, contemporary knowledge of psychedelics suggests that risks are relatively rare when patients are carefully screened, prepared, and supervised. Clinical trial results have provided support for the effectiveness of psychedelics in different psychiatric conditions. However, there are only a small number of generally uncontrolled studies of psychedelics in patients with chronic pain (e.g., cancer pain, phantom limb pain, migraine, and cluster headache). Challenges in evaluating psychedelics as treatments for chronic pain include identifying neurobiologic and psychosocial mechanisms of action and determining which pain conditions to investigate. Truly informative proof-of-concept and confirmatory randomized clinical trials will require careful selection of control groups, efforts to minimize bias from unblinding, and attention to the roles of patient mental set and treatment setting. Perspective: There is considerable promise for the use of psychedelic therapy for pain, but evidence-based recommendations for the design of future studies are needed to ensure that the results of this research are truly informative.
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Affiliation(s)
- Robert H Dworkin
- Departments of Anesthesiology and Perioperative Medicine, Neurology, and Psychiatry, and Center for Health + Technology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States.
| | - Brian T Anderson
- Department of Psychiatry and Behavioral Sciences, UCSF Weill Institute for the Neurosciences and Zuckerberg San Francisco General Hospital, San Francisco, CA, United States, and UC Berkeley Center for the Science of Psychedelics, Berkeley, CA, United States
| | - Nick Andrews
- Behavior Testing Core, Salk Institute of Biological Studies, La Jolla, CA, United States
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Charles S Grob
- Departments of Psychiatry and Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, United States, and UCLA School of Medicine, Los Angeles, CA, United States
| | - Stephen Ross
- Departments of Psychiatry and Child and Adolescent Psychiatry, and New York University Langone Center for Psychedelic Medicine, New York, NY, United States
| | - Theodore D Satterthwaite
- Department of Psychiatry, and Lifespan Informatics and Neuroimaging Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Eric C Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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20
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Lazuardi M, Hestianah EP, Restiadi TI. Designing prototype rapid test device at qualitative performance to detect residue of tetracycline in chicken carcass. Vet World 2022; 15:1058-1065. [PMID: 35698527 PMCID: PMC9178584 DOI: 10.14202/vetworld.2022.1058-1065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Aim: Human health problems due as a microbial resistance or tumors and cancers because consumption of the carcasses containing residues of tetracycline are main global problems in the context of fight against antimicrobial resistance phenomena. Explanation of the sustainable development goals, particularly point 3, is well recognized that all animal products for human consumption must be safe to live a healthy life. This study aimed to design a prototype of rapid test devices (RTD) based on principles of precipitate to obtain a specific color change after the process of reactions as an indicator to determine tetracycline residues in the carcass. Materials and Methods: Five samples of tetracycline-containing poultry carcasses using artificial add the tetracycline at pharmaceutics grade were examined using a prototype of a strong reaction solution for tetracycline fixation based on the concept bonded by ion Fe(III) at atom O in position atom C-1 at the ring of tetracycline and ion N+ as the functional branch of tetracycline. RTD detection was evaluated using a yellow color presentation and an absorbance spectrometric technique at a wavelength of 273 nm. Results: The following chemicals were used to create the best-fixed tetracycline residue: HCl and H2SO4 dissolved in H2O, chromatographic grade of 0.1 N and 0.5 N of HNO3, and 1% Fe (III) Cl. The RTD had a higher limit of detection (LOD) than the ultraviolet-visible spectrophotometer. Conclusion: The results of this study revealed that RTD, as constructed in this study, can be used to detect residue at LOD 44.764 mg/mL during 120 min of exposure through a light-emitting diode at 980 nm wavelength (p<0.05). The necessity for using RTD was because of the apparent limitations of conventional devices.
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Affiliation(s)
- Mochamad Lazuardi
- Veterinary-Pharmacy Science Subdivision, Faculty of Veterinary Medicine, Universitas Airlangga, Mulyorejo rd. "C" Campus Universitas Airlangga, Surabaya, 60115, Indonesia
| | - Eka Pramyrtha Hestianah
- Veterinary Histology Subdivision, Faculty of Veterinary Medicine, Universitas Airlangga, Mulyorejo rd. "C" campus Universitas Airlangga, Surabaya, 60115, Indonesia
| | - Tjuk Imam Restiadi
- Veterinary Reproduction Division, Faculty of Veterinary Medicine, Universitas Airlangga, Mulyorejo rd. "C" Campus Universitas Airlangga, Surabaya, 60115, Indonesia
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21
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Sjöberg V, Tseli E, Monnier A, Westergren J, LoMartire R, Äng BO, Hagströmer M, Björk M, Vixner L. Effectiveness of the eVISualisation of physical activity and pain intervention (eVIS) in Swedish Interdisciplinary Pain Rehabilitation Programmes: study protocol for a registry-based randomised controlled clinical trial. BMJ Open 2022; 12:e055071. [PMID: 35428627 PMCID: PMC9014054 DOI: 10.1136/bmjopen-2021-055071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Living with chronic pain often involves negative consequences. Interdisciplinary Pain Rehabilitation Programmes (IPRP) is considered superior to single-treatment measures in patients with chronic pain. Despite this, effects emerge suboptimal and more than 20% of patients deteriorate in patient-reported physical health outcomes after IPRP. A novel e-Health intervention, eVISualisation (eVIS) of physical activity and pain, was systematically developed to facilitate individualisation of physical activity levels. By adding elements of data collection, visualisation and communication of objectively measured physical activity and patient-reported outcomes (pain intensity, interference of pain, pharmaceutical consumption) to existing treatment modalities in IPRP, the IPRP team acquires prerequisites to adapt advice and physical activity prescriptions and to evaluate set activity goals. The overall aim is twofold. First, the aim is to evaluate the feasibility of the subsequent registry-based randomised controlled clinical trial (R-RCT). Second, the aim is to prospectively evaluate the effectiveness of the eVIS-intervention as a supplement to IPRP on our defined primary (physical health) and secondary outcomes. METHODS AND ANALYSIS In the R-RCT, recruitment of 400 patients with chronic pain will be performed at 15 IPRP units. A random allocation to either IPRP + eVIS or to control group that will receive IPRP only will be performed. Data from the initial 30 participants completing the study period (6 months) will be included in a pilot study, where key feasibility outcomes (recruitment, randomisation, implementation, treatment integrity, data collection procedure, preliminary outcome measures) will be evaluated. Outcome variables will be extracted from the web application Pain And TRaining ON-line (PATRON) and from six national registries. Multivariate statistics and repeated measure analyses will be performed. Quality-adjusted life years and incremental cost-effectiveness ratio will be calculated for cost-effectiveness evaluation. ETHICS/DISSEMINATION The Swedish Ethics Review Board granted approval (Dnr 2021/02109). Results will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05009459. Protocol V.1.
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Affiliation(s)
- Veronica Sjöberg
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Elena Tseli
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
| | - Andreas Monnier
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
- Military Academy Karlberg, Swedish Armed Forces, Solna, Sweden
| | - Jens Westergren
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
| | - Riccardo LoMartire
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna, Falun, Sweden
| | - Björn O Äng
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna, Falun, Sweden
| | - Maria Hagströmer
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Huddinge, Sweden
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden
| | - Mathilda Björk
- Department for Prevention, Rehabilitation, and Community Medicine, Division of Occupational Therapy, Institution of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Linda Vixner
- Department of Sport and Medicin, School of Health and Welfare, Dalarna University, Falun, Sweden
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22
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Dworkin RH, Kerns RD, McDermott MP, Turk DC, Veasley C. The ACTTION Guide to Clinical Trials of Pain Treatments, part II: mitigating bias, maximizing value. Pain Rep 2021; 6:e886. [PMID: 33521484 PMCID: PMC7838005 DOI: 10.1097/pr9.0000000000000886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/14/2020] [Indexed: 12/28/2022] Open
Abstract
Summaries of the articles included in part II of the ACTTION Guide to Clinical Trials of Pain Treatments are followed by brief overviews of methodologic considerations involving precision pain medicine, pragmatic clinical trials, real world evidence, and patient engagement in clinical trials.
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Affiliation(s)
- Robert H. Dworkin
- Departments of Anesthesiology and Perioperative Medicine, Neurology, and Psychiatry, Center for Health + Technology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, USA
| | - Michael P. McDermott
- Departments of Biostatistics and Computational Biology and Neurology, Center for Health + Technology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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