Landmark Studies in Pain Management

[No_Pain_No_Gain]

What would you consider to be some of the most important studies in pain management?

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[bedrock]

Resident report due ?

 

[gaspasser127]

the SENZA PDN study

 

[Agast]

The article published in the New England Journal that said epidural steroid injections were worthless and a scam

I think PCPs went along with it until they realized not referring out meant having to continue prescribing narcotics themselves

 

[Status Sciaticus]

this is actually worth discussing since a lot of denials can be combatted with evidence. Some crap insurances here frequently quote that MBBs/RFAs are not supported by evidence, and is therefore experimental.

 

[gaseous_clay]

Find me a study showing something works, and I’ll find you one that shows it doesn’t.

 

[bubaghanush]

SCS doesn't work for radic

Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT03546738.

pubmed.ncbi.nlm.nih.gov

Scs doesn't work for back pain

Spinal cord stimulation for low back pain - PubMed

Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.

pubmed.ncbi.nlm.nih.gov

Epidurals don't work

Diagnosis and Management of Lumbar Spinal Stenosis: A Review - PubMed

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with...

pubmed.ncbi.nlm.nih.gov

Non-opioids don't work

Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews - PubMed

We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a...

pubmed.ncbi.nlm.nih.gov

Opioids don't work

SPACE - A randomized study of SBRT vs conventional fractionated radiotherapy in medically inoperable stage I NSCLC - PubMed

There was no difference in PFS and OS between SBRT and conventionally treated patients despite an imbalance of prognostic factors. We observed a tendency of an improved disease control rate in the SBRT group and they experienced better HRQL and less toxicity. SBRT is convenient for patients and...

pubmed.ncbi.nlm.nih.gov

Vertebroplasty doesn't work

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture - PubMed

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and...

pubmed.ncbi.nlm.nih.gov

CBT works a little

Psychological therapies for the management of chronic pain (excluding headache) in adults - PubMed

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly...

pubmed.ncbi.nlm.nih.gov

 

[Status Sciaticus]

SCS doesn't work for radic

Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT03546738.

pubmed.ncbi.nlm.nih.gov

Scs doesn't work for back pain

Spinal cord stimulation for low back pain - PubMed

Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.

pubmed.ncbi.nlm.nih.gov

Epidurals don't work

Diagnosis and Management of Lumbar Spinal Stenosis: A Review - PubMed

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with...

pubmed.ncbi.nlm.nih.gov

Non-opioids don't work

Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews - PubMed

We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a...

pubmed.ncbi.nlm.nih.gov

Opioids don't work

SPACE - A randomized study of SBRT vs conventional fractionated radiotherapy in medically inoperable stage I NSCLC - PubMed

There was no difference in PFS and OS between SBRT and conventionally treated patients despite an imbalance of prognostic factors. We observed a tendency of an improved disease control rate in the SBRT group and they experienced better HRQL and less toxicity. SBRT is convenient for patients and...

pubmed.ncbi.nlm.nih.gov

Vertebroplasty doesn't work

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture - PubMed

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and...

pubmed.ncbi.nlm.nih.gov

CBT works a little

Psychological therapies for the management of chronic pain (excluding headache) in adults - PubMed

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly...

pubmed.ncbi.nlm.nih.gov

Nice try, insurance guy.

 

[gaseous_clay]

SCS doesn't work for radic

Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT03546738.

pubmed.ncbi.nlm.nih.gov

Scs doesn't work for back pain

Spinal cord stimulation for low back pain - PubMed

Data in this review do not support the use of SCS to manage low back pain outside a clinical trial. Current evidence suggests SCS probably does not have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention.

pubmed.ncbi.nlm.nih.gov

Epidurals don't work

Diagnosis and Management of Lumbar Spinal Stenosis: A Review - PubMed

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with...

pubmed.ncbi.nlm.nih.gov

Non-opioids don't work

Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews - PubMed

We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a...

pubmed.ncbi.nlm.nih.gov

Opioids don't work

SPACE - A randomized study of SBRT vs conventional fractionated radiotherapy in medically inoperable stage I NSCLC - PubMed

There was no difference in PFS and OS between SBRT and conventionally treated patients despite an imbalance of prognostic factors. We observed a tendency of an improved disease control rate in the SBRT group and they experienced better HRQL and less toxicity. SBRT is convenient for patients and...

pubmed.ncbi.nlm.nih.gov

Vertebroplasty doesn't work

Percutaneous vertebroplasty for osteoporotic vertebral compression fracture - PubMed

Based upon high- to moderate-quality evidence, our updated review does not support a role for vertebroplasty for treating acute or subacute osteoporotic vertebral fractures in routine practice. We found no demonstrable clinically important benefits compared with placebo (sham procedure) and...

pubmed.ncbi.nlm.nih.gov

CBT works a little

Psychological therapies for the management of chronic pain (excluding headache) in adults - PubMed

We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly...

pubmed.ncbi.nlm.nih.gov

Or he will

 

[Ducttape]

SCS doesn't work for radic

not exactly what that study says.

it actually states that burst is no different than placebo stim.

of note, both burst and placebo groups did get 9.3-10 point reduction compared to baseline in oswestry score. likewise, for NRS, baseline was 7.3, and burst was 5.9 and placebo 6.1. what was noteworthy is that burst wasnt statistically significant from placebo, which begets the next point...

i did not find anywhere in the article what were the exact measurements/parameters of "placebo stimulation". not once in the article did it say it was zero stim, interestingly.

Scs doesn't work for back pain

while i agree with this premise and conclusion, the article was basically a meta-analysis.

and one of the authors has a significant preconceived bias.

Amazon product

Epidurals don't work

not a meta-analysis. a review article.

the article does not say "epidurals dont work." it specifically states "Long-term benefits from epidural steroid injections have not been established."

which we are well aware of.

Non-opioids don't work

Vertebroplasty doesn't work

2 Cochrane reviews, that seem fairly well done.

Opioids don't work

would agree, but the study is about the SPACE trial, which is pertaining to radiotherapy for stage 1 cancer....

SPACE (Stereotactic Precision And Conventional radiotherapy Evaluation) is the first randomized phase II trial comparing SBRT and conventional fractionated radiotherapy (3DCRT).

 

[kstarm]

Forest and trees Ductape, forest and trees!!

 

[lobelsteve]

A 2 point NRS or a 20 point VAS reduction is considered a clinically significant pain reduction.
Failure to meet those numbers means treatment did not work for that outcome measure.

 

[Status Sciaticus]

A 2 point NRS or a 20 point VAS reduction is considered a clinically significant pain reduction.
Failure to meet those numbers means treatment did not work for that outcome measure.

So I had a peer-to-peer today. I marked a decrease in pain from a 10 to a 6 on the NRS. Reviewer said that only correlates to a 400% reduction in pain and therefore doesnt meet the 80% or more criteria. Are they expecting a drop to 1/10 or 2/10 for all patients? seems wild

 

[Ferrismonk]

80% relief for 3 months is standard minimum relief. Don't all your patients meet this criteria?

 

[BobBarker]

Yes, you have to say 80% decrease in the index pain we attempting to treat or something like that.

 

[RoloTomassi]

Just play along, it's the only way to survive

 

[lobelsteve]

Former CEO Of Medical Device Company Convicted Of Creating And Selling A Fake Component That Was Implanted Into Patients

Damian Williams, the United States Attorney for the Southern District of New York, announced that a jury returned a guilty verdict today against LAURA PERRYMAN on two counts of an Indictment charging her with conspiracy to commit health care fraud and wire fraud and substantive health care fraud...

www.justice.gov

Great read

 

[Ducttape]

80% for MBB.

for duration of agent used, so dont use steroids.

50% for ESI or RFA.

for 6 months.

or improved functioning of at least 50% of improved painful activity or ADLs. which a couple of my insurers have used as reason for denial (Medicaid)