Predicting the Collapse of Pain Medicine Using the Economic Recession of 2008 as a Comparator: Lessons Remain Unlearned

Sayed E Wahezi,1 Corey W Hunter,2 Farshad M Ahadian,3 Charles E Argoff,4 Michael E Schatman5,6 1Department of Physical Medicine & Rehabilitation, Montefiore Medical Center, Bronx, NY, USA; 2Ainsworth Institute of Pain Management, New York, NY, USA; 3Department of Anesthesiology, Center for Pain and Palliative Medicine, University of California, San Diego Medical Center, San Diego, CA, USA; 4Department of Neurology, Albany Medical Center, Albany, NY, USA; 5Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA; 6Department of Population Health – Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY, USACorrespondence: Sayed E Wahezi, Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, 1250 Waters Place, Tower #2 8th Floor, Bronx, NY, 10461, USA, Tel +1 718-920-7246, Fax +1 929-263-3950, Email [email protected]: The last decade has seen a boom in pain medicine, basic science and interventional pain management. Concomitantly, there is a need to educate trainees, young attendings, and seasoned attendings on these innovations. There has been a growth in the number of societies that represent pain medicine physicians, each with its own philosophy and guiding principles. The variety of thought within pain management, within the various groups that practice this field, and amongst the societies which protect those missions inherently creates divergence and isolation within these different communities. There is the enormous opportunity for our field to grow, but we need the voices of all different specialties and sub-specialties which practice pain medicine to collectively design the future of our emerging field. The explosion of revolutionary percutaneous surgeries, medications, psychotherapy, and research and development in our field has outpaced the ability of payers to fully embrace them. There is an increased number of pain practitioners using novel therapies, postgraduate training programs do not adequately train users in these techniques thereby creating a potential for sub-optimal outcomes. In part, this is a reason why payers for many of our more novel treatments have decreased patient access or eliminated remuneration for some of them. We believe that society-based collaborative regulation of education, research, and treatment guidelines is needed to improve visibility for payers and end users who provide these treatments. Furthermore, postgraduate chronic pain fellowship education has been deemed by many to be insufficient to educate on all of the necessary requirements needed for the independent practice of pain medicine, especially the consummation of newer technologies. Here, we draw comparison with this tenuous stage in pain management history with the last United States recession to remind us of how poor institutional regulation and neglect for long-term growth hampers a community.Keywords: fellowship, training, futur

Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications—a review

Item does not contain fulltextBACKGROUND: The objective of this review is to evaluate the efficacy of Pulsed Radiofrequency (PRF) treatment in chronic pain management in randomized clinical trials (RCTs) and well-designed observational studies. The physics, mechanisms of action, and biological effects are discussed to provide the scientific basis for this promising modality. METHODS: We systematically searched for clinical studies on PRF. We searched the MEDLINE (PubMed) and EMBASE database, using the free text terms: pulsed radiofrequency, radio frequency, radiation, isothermal radiofrequency, and combination of these. We classified the information in two tables, one focusing only on RCTs, and another, containing prospective studies. Date of last electronic search was 30 May 2010. The methodological quality of the presented reports was scored using the original criteria proposed by Jadad et al. FINDINGS: We found six RCTs that evaluated the efficacy of PRF, one against corticosteroid injection, one against sham intervention, and the rest against conventional RF thermocoagulation. Two trials were conducted in patients with lower back pain due to lumbar zygapophyseal joint pain, one in cervical radicular pain, one in lumbosacral radicular pain, one in trigeminal neuralgia, and another in chronic shoulder pain. CONCLUSION: From the available evidence, the use of PRF to the dorsal root ganglion in cervical radicular pain is compelling. With regards to its lumbosacral counterpart, the use of PRF cannot be similarly advocated in view of the methodological quality of the included study. PRF application to the supracapular nerve was found to be as efficacious as intra-articular corticosteroid in patients with chronic shoulder pain. The use of PRF in lumbar facet arthropathy and trigeminal neuralgia was found to be less effective than conventional RF thermocoagulation techniques

Assessing the effectiveness of ‘pulse radiofrequency treatment of dorsal root ganglion’ in patients with chronic lumbar radicular pain: study protocol for a randomized control trial

<p>Abstract</p> <p>Background</p> <p>Chronic lumbar radicular pain can be described as neuropathic pain along the distribution of a particular nerve root. The dorsal root ganglion has been implicated in its pathogenesis by giving rise to abnormal impulse generation as a result of irritation, direct compression and sensitization. Chronic lumbar radicular pain is commonly treated with medications, physiotherapy and epidural steroid injections. Epidural steroid injections are associated with several common and rarer side effects such as spinal cord infarction and death. It is essential and advantageous to look for alternate interventions which could be effective with fewer side effects.</p> <p>Pulse radio frequency is a relatively new technique and is less destructive then conventional radiofrequency. Safety and effectiveness of pulse radio frequency in neuropathic pain has been demonstrated in animal and humans studies. Although its effects on dorsal root ganglion have been studied in animals there is only one randomized control trial in literature demonstrating its effectiveness in cervical radicular pain and none in lumbar radicular pain. Our primary objective is to study the feasibility of a larger trial in terms of recruitment and methodology. Secondary objectives are to compare the treatment effects and side effects.</p> <p>Methods/designs</p> <p>This is a single-center, parallel, placebo-controlled, triple-blinded (patients, care-givers, and outcome assessors), randomized control trial. Participants will have a history of chronic lumbar radicular pain for at least 4 months in duration. Once randomized, all patients will have an intervention involving fluoroscopy guided needle placement to appropriate dorsal root ganglion. After test stimulation in both groups; the study group will have a pulse radio frequency treatment at 42°C for 120 s to the dorsal root ganglion, with the control group having only low intensity test stimulation for the same duration. Primary outcome is to recruit at least four patients every month with 80% of eligible patients being recruited. Secondary outcomes would be to assess success of intervention through change in the visual analogue scale measured at 4 weeks post intervention and side effects. Allocation to each group will be a 1:1 ratio with allocation block sizes of 2, 4, and 6.</p> <p>Trial registration</p> <p>ClinicalTrials.gov NCT01117870</p