A Systematic Evaluation of Burst Spinal Cord Stimulation for Chronic Back and Limb Pain.

BACKGROUND: Traditional tonic spinal cord stimulation (SCS) has been approved by FDA for chronic pain of intractable back and limb pain. However, it induces paresthesia and relieves pain poorly to some extent. Recently, burst SCS has been developed for pain reduction without the mandatory paresthesia. STUDY DESIGN: A systematic review of burst SCS for chronic back and limb pain. OBJECTIVE: The objective of this systematic review is to determine the effects of burst SCS on pain relief without paresthesia for various conditions including failed back surgery syndrome, painful diabetic neuropathy, and radiculopathy. METHODS: The available literature on burst SCS in managing chronic pain without paresthesia was reviewed. The 2011 American Academy of Neurology (AAN) Classification of Evidence Guidelines Process Manual was used to grade the evidence and risk of bias. Data sources included relevant literature identified through searches of PubMed, MEDLINE/OVID, SCOPUS, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES: The primary outcome measure was pain relief and paresthesia status. Secondary outcome measures were improvement in pain quality, functional status, and complications. RESULTS: For this review, five studies including a total of 117 patients met the eligibility criteria. All studies were graded a Class IV study. LIMITATIONS: The limitations of this systematic review include an overall paucity of high quality studies. CONCLUSION: Burst SCS is a new approach that possibly causes more pain reduction for short-term duration than tonic SCS without eliciting paresthesia. The evidence based on this systematic review for burst SCS in treating chronic intractable pain is considered fair and limited. This is an AAN recommendation level U. Further research is needed with a larger sample size and a standardized study design.

Current Regulations Related to Opioid Prescribing.

It is the responsibility of medical professionals to do all that is possible to safely alleviate pain. Opioids are frequently prescribed for pain but are associated with the potential for misuse, addiction, diversion, and overdose mortality, and thus they are strictly regulated. To adhere to legitimate practice standards, physicians and other health care providers who prescribe opioids for pain, particularly on a long-term basis, need current information on federal and state laws, treatment guidelines, and regulatory actions aimed at reducing opioid-related harm. The number of opioid-prescribing policies is increasing as federal and state governments increase scrutiny to alleviate opioid-related problems in society. Failure to adequately comply with opioid-prescribing laws and policies may put a prescriber at risk for legal or regulatory sanctions. Necessary actions include thorough documentation of prescribing decisions and assessment and follow-up of patient risk for opioid misuse or addiction. Tools to check for patient adherence to the prescribed regimen include prescription monitoring databases and urine drug screening. This article presents an overview of the legal and regulatory framework surrounding controlled substances law. It further discusses recent actions at the federal and state level to prevent opioid-related harm.

Recommendations for a new curriculum in pain medicine for medical students: toward a career distinguished by competence and compassion.

OBJECTIVE: The education of physicians is a fundamental obligation within medicine that must remain closely aligned with clinical care. And although medical education in pain care is essential, the current state of medical education does not meet the needs of physicians, patients, or society. To address this, we convened a committee of pain specialist medical student educators. METHODS: Tasked with creating systematically developed and valid recommendations for clinical education, we conducted a survey of pain medicine leadership within the American Academy of Pain Medicine (AAPM). The survey was conducted in two waves. We asked AAPM board members to rate 194 previously published pain medicine learning objectives for medical students; 79% of those eligible for participation responded. RESULTS: The "Top 5" list included the awareness of acute and chronic pain, skillfulness in clinical appraisal, promotion of compassionate practices, displaying empathy toward the patient, and knowledge of terms and definitions for substance abuse. The "Top 10" list included the major pharmacological classes as well as skills in examination, communication, prescribing, and interviewing. The "Top 20" list included the pain care of cognitively impaired populations, those with comorbid illness, and older adults. With the survey results in consideration, the committee produced a new recommended topic list for curricula in pain medicine. We strongly recommend that adequate resources are devoted to fully integrated medical curricula in pain so that students will learn not only the necessary clinical knowledge but also be prepared to address the professional, personal, and ethical challenges that arise in caring for those with pain. CONCLUSIONS: We conclude that improved medical education in pain is essential to prepare providers who manifest both competence and compassion toward their patients.

Neuropathic pain.

Neuropathic pain is a clinical entity that presents unique diagnostic and therapeutic challenges. This chapter addresses the classification, epidemiology, pathophysiology, diagnosis, and treatment of neuropathic pain syndrome. Neuropathic pain can be distinguished from nociceptive pain based on clinical signs and symptoms. Although neuropathic pain presents a significant burden to individuals and society, a more accurate assessment of resource utilization, costs, and impairments associated with neuropathic pain would facilitate appropriate planning of healthcare policies. The underlying pathophysiology of neuropathic pain is not well defined. Several theories regarding the mechanism of neuropathic pain have been proposed, including central and peripheral nervous system sensitization, deafferentation, neurogenic inflammation, and the wind up theory. Neuropathic pain is a clinical diagnosis and requires a systematic approach to assessment, including a detailed history, physical examination, and appropriate diagnostic testing. The mainstay of treatment for neuropathic pain is pharmacological, including the use of antidepressants, antiepileptics, topical anesthetics, and opioids. Nonpharmacological treatments include psychological approaches, physical therapy, interventional therapy, spinal cord stimulation, and surgical procedures. Neuropathic pain is difficult to treat, but a combination of therapies may be more effective than monotherapy. Clinical practice guidelines provide an evidence-based approach to the treatment of neuropathic pain.

Pediatric analgesic clinical trial designs, measures, and extrapolation: report of an FDA scientific workshop.

Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.

The story of the Texas Pain Society: formation and function of a regional pain society.

The idea of forming a Texas Pain Society came to the Founders in 1987 due to disparity and deficiencies in the practice of pain management in the United States and, in particular, the State of Texas. The Founders considered very carefully the implication of forming such a society. They diligently mapped out the mission and goals of the Texas Pain Society in those early formative years. This report is the history of Texas Pain Society as the activities unfolded from 1989 to 2011. The reader may question why there is a need to tell such a story. We believe strongly that, with disparities of standards of practice in pain medicine and poor recognition of advances in pain management, this scenario is quite common in many states and countries. The practitioners of pain management in these regions certainly must have considered getting together and forming a consensus on the standards of practice in their communities. This historical report of the Texas Pain Society provides the relevant information necessary and the efforts to be made for a society's mission to achieve its goals and have an ongoing impact in its own region. We hope that we have shed some light on a process for the formation of a regional pain society such as ours.

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

STUDY DESIGN: Clinical practice guideline. OBJECTIVE: To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain. SUMMARY OF BACKGROUND DATA: Management of patients with persistent and disabling low back pain remains a clinical challenge. A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial. Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain. METHODS: A multidisciplinary panel was convened by the American Pain Society. Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials. Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group. RESULTS: Investigators reviewed 3348 abstracts. A total of 161 randomized trials were deemed relevant to the recommendations in this guideline. The panel developed a total of 8 recommendations. CONCLUSION: Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented. Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations.

Through the looking glass: a personal view of the field of rehabilitation medicine. The 56th John Stanley Coulter Memorial Lecture.

This lectureship reviews the past, present, and future of the field of physical medicine and rehabilitation (PM&R) from the clinical, educational, and research points of view. I make recommendations for the field on how members of the various PM&R associations can make a difference in mapping the future.

Management of chronic low back pain.

Chronic low back pain is common. It presents a clinical challenge with widespread implications for resource utilization on a national scale. The causes of chronic low back pain may be mechanical or nonmechanical, nociceptive or neuropathic. Diagnosis is problematic because available tools lack both specificity and sensitivity. In rare instances, the cause of chronic low back pain can be attributed to an identified cause. Comprehensive pain management relies on the use of pharmacotherapy, physical therapy, and a multidisciplinary approach to treatment. Recent studies have shown a benefit for traditional adjunctive therapies and interdisciplinary treatment. Antidepressants and opioids have been and remain key elements for medical management, and some recently developed therapies have shown promising results in clinical trials. The following article presents an overview of evidence-based management for chronic low back pain, with an emphasis on pharmaceutical therapies.

The American Congress of Rehabilitation Medicine: where do we go from here?

This presidential address reflects on my last 2 years as president of American Congress of Rehabilitation Medicine (ACRM). It recognizes those individuals who have been of significant help and support. The address discusses choices I have made in my professional life including selecting physical medicine and rehabilitation as a subspecialty; committing to an academic career; and choosing to get involved in local, state, national, and international physical medicine and rehabilitation societies. I review my presidential speech of 2001 when I spoke about the path we choose-to succeed or not to succeed. ACRM has come a long way in trying to succeed but continued opportunities remain in obtaining financial security, increased membership, and cost-effective and efficient management. This address includes 11 suggestions designed not only to keep the organization viable but also to allow ACRM to succeed. These suggestions include a new commitment to our strategic plan and the implementation of prioritized goals, reorganization of ACRM's national office, and adherence to a realistic budget. Finally, we must continue to move the agenda of research in rehabilitation forward much more aggressively.