Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society.

BACKGROUND: There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS: Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS: This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS: In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Normality Analysis of Numeric Rating Scale Scores in Patients with Chronic Axial Spine Pain Before and After Medial Branch Blocks: a Multicenter Study.

OBJECTIVE: The statistical analysis typically employed to compare pain both before and after interventions assumes scores are normally distributed. The present study evaluates whether Numeric Rating Scale (NRS), specifically the NRS-11, scores are indeed normally distributed in a clinically-relevant cohort of adults with chronic axial spine pain pre- and post-analgesic intervention. METHODS: Retrospective review from four academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after undergoing medial branch blocks. The pain diary assessed NRS-11 scores immediately pre-injection and at 12 different time points post-injection up to 48 hours. D'Agostino-Pearson tests were used to test normality at all time points. RESULTS: One hundred fifty pain diaries were reviewed and despite normally distributed pre-injection NRS-11 scores (K2 = 0.655, p = 0.72), all post-injection NRS-11 data was not normally distributed (K2 = 9.70- 17.62, p = 0.0001-0.008). CONCLUSIONS: Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics may not accurately describe the data and should expect manuscripts to utilize measures of normality to justify the selected statistical methods.

A 10-year analysis of application and match rates for pain medicine training in the United States.

OBJECTIVE: We analyzed application and match rates for pain medicine training in the United States and hypothesized that there would be (1) greater growth in the number of training positions than applicants, (2) higher match rates among US allopathic graduates relative to non-US allopathic graduates, and (3) greater number of unfilled training positions over time. DESIGN: Retrospective, cross-sectional study of all applicants for pain medicine training in the United States. METHOD: National Resident Matching Program data were obtained over a ten-year period (2014-2023). Match rates and applicant-to-position ratios were calculated and compared over time with linear regression. Comparisons were made with chi-square tests. RESULTS: Growth in the number of annual training positions (261-377, 44% increase) exceeded growth in the number of interested applicants (398-415, 4% increase) (P < .001). Annual applicant-to-training position ratios decreased (1.5-1.1, P < .001). The representation of US allopathic graduates among incoming pain medicine fellows decreased over the study period (73%-58%, P < .001) while US osteopathic graduates increased (9%-28%, P < .001).Match rates increased for both US allopathic graduates (71%-91%, P < .001) and non-US allopathic graduates (51%-81%, P < .001). From 2018 to 2023, US allopathic graduates (79%) had higher match rates than US osteopathic graduates (60%, P < .001) and international medical graduates (57%, P < .001). More available annual training positions went unfilled over the study period (2%-5%, P = .006). CONCLUSIONS: Stagnant annual applicant volume and increasing number of available training positions have led to increasing match rates for pain medicine fellowship training. Fewer US allopathic graduates are pursuing pain medicine training. The increasing percentage of unfilled training positions warrants ongoing surveillance.

Shoulder terminal sensory articular nerve radiofrequency ablation for non-surgical refractory shoulder pain due to rotator cuff pathology and osteoarthritis: A technical note.

BACKGROUND: Given the high prevalence of chronic shoulder pain and encouraging early results of terminal sensory articular branch (TSAB) radiofrequency ablation to treat shoulder pain, research is warranted to refine the procedural technique based on updated neuroanatomical knowledge with the goal of further improving patient outcomes. OBJECTIVE: We describe an updated radiofrequency ablation protocol that accounts for varied locations of the TSABs of suprascapular, axillary, subscapular and lateral pectoral nerves within individual patients. DESIGN: Technical note. METHODS: Cadaveric studies delineating the sensory innervation of the shoulder joint were reviewed, and a more comprehensive radiofrequency ablation (RFA) protocol is proposed relative to historical descriptions. CONCLUSIONS: Based on neuroanatomical dissections of the shoulder joint, the proposed RFA protocol will provide a safe means of more complete sensory denervation and potentially improve clinical outcomes compared to historical descriptions, which must be confirmed in prospective studies.

Capsaicin 8% Patch for Spinal Cord Injury Focal Neuropathic Pain, a Randomized Controlled Trial.

BACKGROUND: Neuropathic pain (NP) after spinal cord injury (SCI) exacerbates disability, decreases quality of life (QOL), and is often refractory to available therapies. Patients report willingness to trade potential recovery of strength, bowel, bladder, or sexual function for pain relief. One proposed mechanism causing NP is up-regulation of transient receptor potential vanilloid 1 (TRPV 1) proteins in uninjured C fibers and dorsal root ganglia causing neuronal excitability. Recent studies have found up-regulation of TRPV 1 proteins after SCI. OBJECTIVE: We hypothesize the application of capsaicin 8% patch (C8P), FDA approved for NP in diabetic peripheral neuropathy and post-herpetic neuralgia, will improve pain, function and QOL in persons with SCI. METHODS: Randomized single-blind crossover design in which 11 persons with SCI and NP refractory to two oral pain medications received C8P or a control low dose Capsaicin 0.025% patch (CON) over two 12-week periods. Pain (VAS, MPI-SCI), quality of life (WHO-QOL), and functional status (SCIM) were measured at 2-4-week intervals. RESULTS: There was a main treatment effect of C8P over CON on VAS and MPI-SCI outcomes with pain reduction of 35% and 29% at weeks 2 and 4, respectively. C8P also demonstrated a main treatment effect over CON on the SCIM mobility subscale. WHO-QOL scores did not improve with C8P. CONCLUSIONS: C8P improves pain and mobility for patients with SCI and refractory NP. Larger studies should be performed to evaluate impact of repeat applications and QOL outcomes.

Virtual Access to Subspecialty Care.

Telehealth programs existed in many subspecialities before the COVID-19 pandemic, and the public health event motivated many subspecialties to reflect on how current technologies could be leveraged to benefit patient outcomes and increase health-care access. This article reviews the history and current state of telehealth access in many areas of subspecialty care. Primary care physicians (PCPs) may be unaware of the telehealth services and options local subspecialists offer. To best serve patients, PCPs could partner with subspecialists to develop processes to link patients to the right subspecialist at the right time and in the right visit type.

Emerging Evidence for Intrathecal Management of Neuropathic Pain Following Spinal Cord Injury.

A high prevalence of patients with spinal cord injury (SCI) suffer from chronic neuropathic pain. Unfortunately, the precise pathophysiological mechanisms underlying this phenomenon have yet to be clearly elucidated and targeted treatments are largely lacking. As an unfortunate consequence, neuropathic pain in the population with SCI is refractory to standard of care treatments and represents a significant contributor to morbidity and suffering. In recent years, advances from SCI-specific animal studies and translational models have furthered our understanding of the neuronal excitability, glial dysregulation, and chronic inflammation processes that facilitate neuropathic pain. These developments have served advantageously to facilitate exploration into the use of neuromodulation as a treatment modality. The use of intrathecal drug delivery (IDD), with novel pharmacotherapies, to treat chronic neuropathic pain has gained particular attention in both pre-clinical and clinical contexts. In this evidence-based narrative review, we provide a comprehensive exploration into the emerging evidence for the pathogenesis of neuropathic pain following SCI, the evidence basis for IDD as a therapeutic strategy, and novel pharmacologics across impactful animal and clinical studies.

Dorsal Root Ganglion Stimulation.

The recent development and Food and Drug Administration approval in 2016 of dorsal root ganglion stimulation is a relatively new and novel form of target neuromodulation that promises improved outcomes compared with the current standard of care. Current literature is limited and dependent on industry evaluation. Future independent investigation will help clarify existing data and refine techniques to improve safety, effectiveness, and expand application.

To teach or not to teach? Assessing medical school faculty motivation to teach in the era of curriculum reform.

BACKGROUND: Medical schools have undergone a period of continual curricular change in recent years, particularly with regard to pre-clinical education. While these changes have many benefits for students, the impact on faculty is less clear. METHODS: In this study, faculty motivation to teach in the pre-clinical medical curriculum was examined using self-determination theory (SDT) as a framework. Basic science and clinical faculty were surveyed on factors impacting their motivation to teach using validated scales of motivation as well as open-ended questions which were coded using self-determination theory (SDT) as a guiding framework. RESULTS: Faculty reported that teaching activities often meet their basic psychological needs of competence, autonomy, and relatedness. Professors were more likely than associate professors to report that teaching met their need for autonomy. Faculty were more motivated by intrinsic as compared to external factors, although basic science faculty were more likely than clinical faculty to be motivated by external factors. Motivating and de-motivating factors fell into the themes Resources, Recognition and Rewards, Student Factors, Self-Efficacy, Curriculum, Contribution, and Enjoyment. The majority of factors tied to the faculty's need for relatedness. Based on these findings, a conceptual model for understanding medical school faculty motivation to teach was developed. CONCLUSIONS: Assessing faculty motivation to teach provided valuable insights into how faculty relate to their teaching roles and what factors influence them to continue in those roles. This information may be useful in guiding future faculty development and research efforts.

Analgesic Effects of Oxycodone in Combination With Risperidone or Ziprasidone: Results From a Pilot Randomized Controlled Trial in Healthy Volunteers.

Background and Objectives: Patients taking opioids are at risk of developing dependence and possibly abuse. Given the role of the mesolimbic dopamine system in opioid reward, blocking dopamine D2 receptors should limit the abuse liability of opioid analgesics. This pilot study evaluates the analgesic efficacy of oxycodone combined with an atypical antipsychotic (dopamine D2 receptor antagonist). Methods: A randomized, double-blind, within-subjects, controlled trial in healthy volunteers was conducted at UT Health SA Pain Clinic. Fifteen volunteers with previous medical exposure to opioids were enrolled. Risperidone (2 mg) or ziprasidone (80 mg) in combination with oxycodone (5, 10, 15 mg) was administered. Pain intensity using the cold pressor test, Current Opioid Misuse Measure (COMM), Addiction Research Center Inventory (ARCI, opioid subscale), Drug likability with drug effects questionnaire (DEQ) were assessed. Results: Oxycodone produced dose dependent increases in thermal analgesia on the cold pressor test that was significant at 10 and 15 mg (t = 3.087, P = 0.017). The combination did not significantly alter thermal analgesia. There was no significant effect of the combination on the ARCI or the POMS. Discussion and Conclusion: The combination of an atypical antipsychotic with oxycodone does not alter analgesic response or increase the incidence of adverse effects when compared to oxycodone alone. Such information is critical for the development of drug combinations for the treatment of pain and provide the foundation for future studies of abuse potential in drug users. Scientific Significance: This intervention in chronic pain patients is unique because it utilizes FDA approved drugs in combination to reduce abuse liability. The first step, and aim of this study, is to confirm the drug combination does not interfere with analgesic efficacy. The next step is to examine the combination in recreational drug users to assess the potential to block the euphoric effects of oxycodone. Ultimately, if this combination is effective, this approach could be beneficial in management of chronic pain.

Virtual Reality in the Management of Chronic Low Back Pain: A Scoping Review.

Virtual reality (VR) is a burgeoning treatment option for chronic pain. Its use has been heterogenous in the literature. This scoping review assesses the current literature for the use of VR in the treatment of chronic low back pain (CLBP). The following themes were identified by the analysis: safety and feasibility of VR, quality of life associated with VR treatment for CLBP, efficacy of VR to treat CLBP, and efficacy of VR to treat functional changes associated with CLBP. Gaps were identified after analysis of the extant literature. Although the nascent research uncovered in this scoping review found good evidence for safety and tolerability of VR, more studies of safety, acceptance, and satisfaction are recommended including focused studies of spinal pain risks specific to use of VR. Overall, the methodological quality of studies reviewed in this scoping review was poor and outcomes were limited to short-term posttreatment outcomes.

The role of identity in chronic pain cognitions and pain-related disability within a clinical chronic pain population.

OBJECTIVE: Chronic pain has a significant impact on functioning and results in the disruption of one's assumed life trajectory, potentially altering their self-perceived identity. The present research is designed to determine whether identity-related issues are associated with common chronic pain cognitions and pain-related disability, which may help inform understanding of clinical chronic pain populations. METHOD: Ninety-eight adult chronic pain patients were assessed at a local pain clinic during a regularly scheduled appointment focusing on pain management. Multivariate hierarchal regression was used to determine whether issues related to identity and death anxiety were associated with pain catastrophizing, pain acceptance, and pain-related disability, above and beyond pain severity, fear-avoidance, and age. RESULTS: Self-concept clarity was significantly related to pain catastrophizing and pain acceptance, above and beyond death anxiety, pain severity, fear-avoidance, and age. Death anxiety was associated with pain catastrophizing, pain acceptance, and pain-related disability above and beyond pain severity, fear-avoidance, and age. CONCLUSIONS: To the best of our knowledge, the present study is the first examination of self-concept clarity and death anxiety as they relate to pain catastrophizing, pain acceptance, and pain-related disability. These descriptive results support the inclusion of identity and death anxiety within the pain experience and could serve as a foundation for future directions relevant to clinical applications.

The Use of Radiofrequency in the Treatment of Pelvic Pain.

Radiofrequency ablation (RFA) is a procedure in which radio waves are used to destroy abnormal or dysfunctional tissue. It has been an increasingly utilized treatment option for a variety of medical conditions, such as chronic pain, wherein sensory nerves are targeted and ablated, eliminating their ability to transmit pain signals to the brain. There is a lack of clarity regarding the indications, technique, and efficacy of RFA for chronic pelvic pain. This article reviews recent literature and discusses these topics, including adverse events for different pelvic ablation and pulsed radiofrequency treatment of chronic pelvic pain.

Radiofrequency Ablation for Chronic Hip Pain: A Comprehensive, Narrative Review.

Chronic hip pain can be treated with physical therapy, oral medications, injections, and, definitively, total hip arthroplasty. Enough patients have contraindications to and refractory pain even after total hip arthroplasty, that there is a need to develop alternative managements for this disabling condition. This article examines the state of hip radiofrequency ablation literature including relevant anatomy, patient selection, and treatment outcomes.

Putting Our Shoulder to the Wheel: Current Understanding and Gaps in Nerve Ablation for Chronic Shoulder Pain.

Shoulder pain is prevalent, burdensome, and functionally limiting, with diverse pathology and associated treatments. This narrative review provides a summary of relevant neuroanatomy, proposed ablation targets, safety and efficacy concerns for ablation targets, and current research gaps. Radiofrequency ablation (RFA) of peripheral sensory nerves is a well-established treatment for chronic joint and spine pain, but it is relatively nascent for shoulder pain. Cadaveric studies demonstrate the shoulder joint is innervated by articular branches of the suprascapular nerve, axillary nerve, lateral pectoral nerve, and upper and lower subscapular nerves. Shoulder articular branch RFA appears to be a safe and effective treatment for chronic shoulder pain, but there are currently no widely accepted protocols for ablation targets. There are also no randomized controlled trials (RCT) assessing safety and efficacy of proposed targets or the prognostic value of articular blocks. Future research studies should prioritize categorical data, use appropriate functional measures as primary endpoints, and would ideally include a large-scale RCT.