Research priorities in the field of posttraumatic pain and disability: Results of a transdisciplinary consensus-generating workshop

© Copyright 2016 David M.Walton et al. Background. Chronic or persistent pain and disability following noncatastrophic \u27musculoskeletal\u27 (MSK) trauma is a pervasive public health problem. Recent intervention trials have provided little evidence of benefit from several specific treatments for preventing chronic problems. Such findings may appear to argue against formal targeted intervention for MSK traumas. However, these negative findings may reflect a lack of understanding of the causal mechanisms underlying the transition from acute to chronic pain, rendering informed and objective treatment decisions difficult. The Canadian Institutes of Health Research (CIHR) Institute ofMusculoskeletalHealth and Arthritis (IMHA) has recently identified better understanding of causalmechanisms as one of three priority foci of their most recent strategic plan. Objectives. A 2-day invitation-only active participation workshop was held inMarch 2015 that included 30 academics, clinicians, and consumers with the purpose of identifying consensus research priorities in the field of trauma-relatedMSK pain and disability, prediction, and prevention. Methods. Conversations were recorded, explored thematically, and member-checked for accuracy. Results. From the discussions, 13 themes were generated that ranged from a focus on identifying causal mechanisms and models to challenges with funding and patient engagement. Discussion. Novel priorities included the inclusion of consumer groups in research from the early conceptualization and design stages and interdisciplinary longitudinal studies that include evaluation of integrated phenotypes and mechanisms

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

Background: The EMPA KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. Methods: EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. Findings: Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5–2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62–0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16–1·59), representing a 50% (42–58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). Interpretation: In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. Funding: Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council

The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol.

IntroductionSleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction.MethodsThis cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI.DiscussionTo our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI.Trial registrationThe research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097

Experiences of Individuals Living with Spinal Cord Injuries (SCI) and Acquired Brain Injuries (ABI) during the COVID-19 Pandemic

The COVID-19 pandemic presents unique challenges for people living with acquired neurological conditions. Due to pandemic-related societal restrictions, changes in accessibility to medical care, equipment, and activities of daily living may affect the mental health of individuals with a SCI or ABI. This study aimed to understand the impact of the pandemic on psychological wellbeing, physical health, quality of life, and delivery of care in persons living with SCI and ABI. A secondary objective included exploring the use of virtual services designed to meet these challenges. In a companion study, participants were surveyed using validated scales of psychosocial health, physical health and healthcare access. In this study, 11 individuals gathered from the survey participated in virtual individual semi-structured interviews to provide accounts of lived experiences regarding critical health challenges and eHealth. Two researchers independently coded interviews for themes using a hermeneutic phenomenological approach. Through analysis of interviews, 5 themes were identified regarding COVID-19 and recovery, access to care, virtual healthcare, systemic barriers, and coping. Overall, limited opportunities due to the pandemic led to a need for adaptation and multifaceted outcomes on one’s wellbeing, which provides guidance for future clinical practice

A Retrospective Cohort Study of Healthcare Utilization Associated with Paravertebral Blocks for Chronic Pain Management in Ontario

Background: Injections, particularly paravertebral blocks (PVBs), are frequently performed procedures in Ontario, Canada, for the management of chronic pain, despite limited evidence and risk of complications. Aim: This study examines usage patterns of PVBs to evaluate their effects on healthcare utilization and opioid prescribing. Methods: A retrospective cohort study in Ontario using administrative data. Ontario residents receiving their initial PVBs between July 1, 2013 and March 31, 2018 were included. Changes in use of other interventions, physician visits, and opioids were compared to the 12-month periods before and after index PVBs. Data use was authorized under section 45 of Ontario’s Personal Health Information Protection Act. Results: 47,723 patients received their initial PVBs in the study period. The rate of index PVBs increased from 1.61 per 10,000 population (2013) to 2.26 per 10,000 (2018). Initial PVBs were performed most commonly by family physicians (N = 25,042), followed by anesthesiologists (N = 14,195). 23,386 patients (49%) received 1 to 9 repeat PVBs in the 12 months after index PVB; 12,474 patients (26.15%) received 10 or more. Use of other nonimage guided interventional pain procedures per patient (mean±SD) increased from 2.19 ± 9.35 to 31.68 ± 52.26 in the year before and after index PVB. Relevant physician visits per patient (mean±SD) also increased from 2.92 ± 3.61 to 9.64 ± 11.77. Mean opioid dosing did not change significantly between the year before and the year after index PVB. Conclusion: PVBs are associated with increases in healthcare utilization and no change in opioid use patterns

Sacro-Iliac Joint Sensory Block and Radiofrequency Ablation: Assessment of Bony Landmarks Relevant for Image-Guided Procedures

Image-guided sensory block and radiofrequency ablation of the nerves innervating the sacro-iliac joint require readily identifiable bony landmarks for accurate needle/electrode placement. Understanding the relative locations of the transverse sacral tubercles along the lateral sacral crest is important for ultrasound guidance, as they demarcate the position of the posterior sacral network (S1–S3 ± L5/S4) innervating the posterior sacro-iliac joint. No studies were found that investigated the spatial relationships of these bony landmarks. The purpose of this study was to visualize and quantify the interrelationships of the transverse sacral tubercles and posterior sacral foramina to inform image-guided block and radiofrequency ablation of the sacro-iliac joint. The posterior and lateral surfaces of 30 dry sacra (15 M/15 F) were digitized and modeled in 3D and the distances between bony landmarks quantified. The relationships of bony landmarks (S1–S4) were not uniform. The mean intertubercular and interforaminal distances decreased from S1 to S4, whereas the distance from the lateral margin of the posterior sacral foramina to the transverse sacral tubercles increased from S1 to S3. The mean intertubercular distance from S1 to S3 was significantly () larger in males. The interrelationships of the sacral bony landmarks should be taken into consideration when estimating the site and length of an image-guided strip lesion targeting the posterior sacral network.Peer Reviewe

Sacro-Iliac Joint Sensory Block and Radiofrequency Ablation: Assessment of Bony Landmarks Relevant for Image-Guided Procedures

Image-guided sensory block and radiofrequency ablation of the nerves innervating the sacro-iliac joint require readily identifiable bony landmarks for accurate needle/electrode placement. Understanding the relative locations of the transverse sacral tubercles along the lateral sacral crest is important for ultrasound guidance, as they demarcate the position of the posterior sacral network (S1–S3 ± L5/S4) innervating the posterior sacro-iliac joint. No studies were found that investigated the spatial relationships of these bony landmarks. The purpose of this study was to visualize and quantify the interrelationships of the transverse sacral tubercles and posterior sacral foramina to inform image-guided block and radiofrequency ablation of the sacro-iliac joint. The posterior and lateral surfaces of 30 dry sacra (15 M/15 F) were digitized and modeled in 3D and the distances between bony landmarks quantified. The relationships of bony landmarks (S1–S4) were not uniform. The mean intertubercular and interforaminal distances decreased from S1 to S4, whereas the distance from the lateral margin of the posterior sacral foramina to the transverse sacral tubercles increased from S1 to S3. The mean intertubercular distance from S1 to S3 was significantly (p<0.05) larger in males. The interrelationships of the sacral bony landmarks should be taken into consideration when estimating the site and length of an image-guided strip lesion targeting the posterior sacral network