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McGregor RH, Warner FM, Linde LD, Cragg JJ, Osborn JA, Varshney VP, Schwarz SKW, Kramer JLK. Quality of meta-analyses of non-opioid, pharmacological, perioperative interventions for chronic postsurgical pain: a systematic review. Reg Anesth Pain Med 2022; 47:263-269. [DOI: 10.1136/rapm-2021-102981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
BackgroundIn an attempt to aggregate observations from clinical trials, several meta-analyses have been published examining the effectiveness of systemic, non-opioid, pharmacological interventions to reduce the incidence of chronic postsurgical pain.ObjectiveTo inform the design and reporting of future studies, the purpose of our study was to examine the quality of these meta-analyses.Evidence reviewWe conducted an electronic literature search in Embase, MEDLINE, and the Cochrane Database of Systematic Reviews. Published meta-analyses, from the years 2010 to 2020, examining the effect of perioperative, systemic, non-opioid pharmacological treatments on the incidence of chronic postsurgical pain in adult patients were identified. Data extraction focused on methodological details. Meta-analysis quality was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) critical appraisal tool.FindingsOur search yielded 17 published studies conducting 58 meta-analyses for gabapentinoids (gabapentin and pregabalin), ketamine, lidocaine, non-steroidal anti-inflammatory drugs, and mexiletine. According to AMSTAR 2, 88.2% of studies (or 15/17) were low or critically low in quality. The most common critical element missing was an analysis of publication bias. Trends indicated an improvement in quality over time and association with journal impact factor.ConclusionsWith few individual trials adequately powered to detect treatment effects, meta-analyses play a crucial role in informing the perioperative management of chronic postsurgical pain. In light of this inherent value and despite a number of attempts, high-quality meta-analyses are still needed.PROSPERO registration numberCRD42021230941.
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The neglect of sex: A call to action for including sex as a biological variable in placebo and nocebo research. Contemp Clin Trials 2022; 116:106734. [PMID: 35306216 PMCID: PMC9332926 DOI: 10.1016/j.cct.2022.106734] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
Abstract
Sex differences exist in the prevalence, progression and treatment efficacy of a wide array of medical conditions. While the placebo and nocebo effects have become increasingly relevant in the clinical arena, little is known about the influence of biological sex on placebo and nocebo effects. This paper discusses the existing, relatively limited and sometimes conflicting evidence about how sex impacts the occurrence and magnitude of the placebo and nocebo effects, mainly focusing on pain studies. We present recent evidence that when compared to men, women suffering from chronic orofacial pain may derive greater benefit from the placebo effect for analgesia. Nonetheless, we broadly argue that the field is not currently positioned to draw definitive conclusions and propose several important factors that may explain the inconsistency in the literature and that should be taken into account in future research. These include the specific target symptom of the placebo or nocebo manipulation and whether or not the target is related to the medical condition, the placebo or nocebo induction method, the sex of the experimenter or physician, and so forth. Future research should intentionally include sex a biological variable to favor translation of placebo and nocebo mechanisms into clinical applications.
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Austin PD, Craig A, Middleton JW, Tran Y, Costa DSJ, Wrigley PJ, Siddall PJ. The short-term effects of head-mounted virtual-reality on neuropathic pain intensity in people with spinal cord injury pain: a randomised cross-over pilot study. Spinal Cord 2020; 59:738-746. [PMID: 33077900 DOI: 10.1038/s41393-020-00569-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022]
Abstract
STUDY DESIGN Within-subject, randomised cross-over trial. OBJECTIVES To determine whether a commercially available 3D head-mounted (HMD) virtual reality (VR) device results in significant reductions in neuropathic pain compared to using a 2D screen device in people with spinal cord injury (SCI). SETTING Greenwich Hospital, Sydney, Australia. METHODS Sixteen men with established SCI and chronic neuropathic pain participated in a single-session randomised cross-over trial. We compared the effects of 3D HMD VR and a 2D screen application on SCI neuropathic pain intensity and levels of perceived presence. RESULTS Participants reported significantly lower pain intensity after 3D HMD VR compared to 2D screen application (1.9 ± SD 1.8 versus 3.4 ± SD 1.6, mean 95% CI: 1.5, P < 0.0001). Participants reported significantly higher perceived levels of presence with the 3D HMD VR compared to 2D screen of (49.6 ± SD 8.9 versus 32.8 ± SD 11.1, mean 95% CI: 16.6, P < 0.0001). Increased perceived presence was associated with significantly lower pain intensity regardless of randomised sequencing of the two conditions (mean 95% CI: 0.06, P = 0.005). Effect size for pain reduction using 3D HMD VR was 0.80. CONCLUSIONS We suggest that 3D HMD VR may provide neuropathic pain relief for people with SCI. Given the lack of cybersickness and ease of access, we propose that immersive VR could be a helpful adjunct to current pharmacotherapy. Further research is required to show that VR can be effective for more long-term reductions in SCI pain.
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Affiliation(s)
- Philip D Austin
- Department of Pain Management, HammondCare, Greenwich Hospital, Greenwich, Sydney, NSW, Australia.
| | - Ashley Craig
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - James W Middleton
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Yvonne Tran
- Centre of Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Daniel S J Costa
- Faculty of Medicine and Health, Pain Management Research Institute, The University of Sydney, Sydney, NSW, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,School of Psychology, University of Sydney, Sydney, NSW, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - Paul J Wrigley
- Faculty of Medicine and Health, Pain Management Research Institute, The University of Sydney, Sydney, NSW, Australia.,Kolling Institute, Northern Sydney Local Health District, Sydney, NSW, Australia.,The University of Sydney, Sydney, NSW, Australia.,Michael J Cousins Pain Management and Research Centre, NSW Health, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Philip J Siddall
- Department of Pain Management, HammondCare, Greenwich Hospital, Greenwich, Sydney, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Neuropathic pain in spinal cord injury: topical analgesics as a possible treatment. Spinal Cord Ser Cases 2020; 6:73. [PMID: 32792476 DOI: 10.1038/s41394-020-00321-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023] Open
Abstract
STUDY DESIGN Review of the literature and semi-structured interviews. OBJECTIVE To explore the possible use of topical analgesics for the treatment of neuropathic pain (NP) in spinal cord injury (SCI). SETTING Institute for Neuropathic Pain, Soest, The Netherlands. METHODS A review was performed of studies on topical analgesics for SCI-related NP published up to May 2019. In addition, eight persons with SCI-related NP who were treated with topical analgesics were interviewed in a semi-structured interview on their experience with topical analgesics. RESULTS Seven studies (five case reports and two case series) were found that evaluated the use of topical analgesics for SCI-related NP. None of the studies used a control treatment. Topical analgesics included baclofen, ketamine, lidocaine, capsaicin, and isosorbide dinitrate. All studies reported a decrease in NP over time. Persons interviewed were 49-72 years of age and all but one had an incomplete SCI. They used topical agents containing phenytoin, amitriptyline, baclofen, ketamine or loperamide. All showed a decrease in pain of at least 3 points on the 11-point numeric rating scale during this treatment. DISCUSSION/CONCLUSIONS Evidence on the use of topical analgesics in SCI is scarce. Case reports, case series and interviews suggest that the use of topical analgesics can be beneficial in treating SCI-related NP. Placebo-controlled studies are required to investigate the effect of topical analgesics on SCI-related NP.
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Nagai K, Matsubayashi K, Ide K, Seto K, Kawasaki Y, Kawakami K. Factors Influencing Placebo Responses in Rheumatoid Arthritis Clinical Trials: A Meta-Analysis of Randomized, Double-Blind, Placebo-Controlled Studies. Clin Drug Investig 2020; 40:197-209. [PMID: 31953723 DOI: 10.1007/s40261-020-00887-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVE A better understanding of placebo responses and the specific factors influencing these outcomes is important for clinical trial design. We investigated the magnitude of placebo responses at 3 months and the potential factors influencing these outcomes in rheumatoid arthritis (RA) clinical trials. METHODS We conducted a systematic review of randomized placebo-controlled trials of pharmacological agents for RA identified from PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. The primary placebo outcome was American College of Rheumatology 20% response rate (ACR20). Data were pooled with a random-effects model. Factors influencing placebo response were assessed by meta-regression analyses. Subgroup analyses were performed for studies conducted in non-Western countries only versus in Western countries (North America and/or Europe) only or both. RESULTS The meta-analysis included 88 studies comprising 8406 patients receiving a placebo. The pooled estimate of placebo ACR20 was 29.0% (range 10.0-46.2; 95% confidence interval 27.2-30.9). Placebo ACR20 was negatively associated with trials in non-Western (Asian) countries and patient populations showing an inadequate response to biological disease-modifying antirheumatic drugs (DMARDs) in the multivariable analysis, whereas it was positively associated with the year of publication. No background DMARD treatment was also a negative predictor (albeit statistically non-significant). In subgroup analyses of Western and multiregional studies, study population and publication year were significant factors. CONCLUSIONS Our meta-analysis suggests that study location, patient population, and a background DMARD treatment influence placebo ACR20. These along with placebo response temporal profiles have important implications for designing and interpreting RA clinical trials.
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Affiliation(s)
- Kota Nagai
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
- Eisai Co., Ltd., 4-6-10 Koishikawa, Bunkyo-ku, Tokyo, 112-8088, Japan
| | - Keisuke Matsubayashi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kazuki Ide
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
- Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, 606-8501, Japan
| | - Kahori Seto
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
- Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, 606-8501, Japan.
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