Chen Y, Vu T, Chinchilli V, Farrag M, Roybal A, Huh A, Cohen ZO, Becker A, Arvanaghi B, Agrawal M, Ogden J, Cohen S

There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome. They retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions.

Chen, Y., Vu, T. N., Chinchilli, V., Farrag, M., Roybal, A., Huh, A., Cohen, Z., Becker, A., Arvanaghi, B., Agrawal, M., Ogden, J., & Cohen, S. (2021). Clinical and technical factors associated with knee radiofrequency ablation outcomes: A multicenter analysis. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-102017

Kohan L, Durbhakula S, Zaidi M, Phillips C, Rowan C, Brenner G, Cohen S

The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis of unprecedented proportions that has altered the practice of medicine. The pandemic has required pain clinics to transition from in-person visits to telemedicine, postpone procedures, and cancel face-to-face educational sessions. There are no data on how fellowship programs have adapted. A 17-question survey was developed covering topics including changes in education, clinical care, and psychological stress due to the COVID pandemic. Results showed a shift to online alternatives for clinical care and education, with correlations between per capita infection rates, and clinical care demands and redeployment, but not with overall trainee anxiety levels. It is likely that medicine in general, and pain medicine in particular, will change after COVID-19, with greater emphasis on telemedicine, virtual education, and greater national and international cooperation. Physicians should be prepared for these changes.

Kohan, L., Durbhakula, S., Zaidi, M., Phillips, C., Rowan, C., Brenner, G., & Cohen, S. (2021). Changes in Pain Medicine Training Programs Associated With COVID-19: Survey Results. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005314

Cohen S, Doshi T, Kurihara C, Dolomisiewicz E, Liu R, Dawson T, Hager N, Durbhakula S, Verdun A, Hodgson J, Pasquina P

The rising use of injections to treat low back pain (LBP) has led to efforts to improve selection. Nonorganic (Waddell) signs have been shown to portend treatment failure for surgery and other therapies but have not been studied for minimally invasive interventions. This study prospectively evaluated the association between Waddell signs and treatment outcome in 3 cohorts: epidural steroid injections (ESI) for leg pain and sacroiliac joint (SIJ) injections and facet interventions for LBP. Categories of Waddell signs included nonanatomic tenderness, pain during sham stimulation, discrepancy in physical examination, overreaction, and regional disturbances divulging from neuroanatomy. The primary outcome was change in patient-reported “average” numerical rating scale for pain intensity (average NRS-PI), modeled as a function of the number of Waddell signs using simple linear regression. Secondary outcomes included a binary indicator of treatment response. Secondary and sensitivity analyses were conducted to account for potential confounders. Whereas this study found no consistent relationship between Waddell signs and decreased mean pain scores, a significant relationship between the number of Waddell signs and treatment failure was observed.

Cohen, S., Doshi, T., Kurihara, C., Dolomisiewicz, E., Liu, R., Dawson, T., Hager, N., Durbhakula, S., Verdun, A., Hodgson, J., & Pasquina, P. (2021). Waddell (Nonorganic) Signs and Their Association with Interventional Treatment Outcomes for Low Back Pain. Anesthesia & Analgesia. https://doi.org/10.1213/ANE.0000000000005054

Cohen S, Provenzano D, Narouze S

Cohen SP, Provenzano DA, Narouze S. (2021). Facet guidelines, serial medial branch blocks and issues surrounding recommending procedures with no mechanistic foundation. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2020-101634.

Crowell M, Brindle R, Mason J, Pitt W, Miller E, Posner M, Cameron K, Goss D

There is a large incidence of shoulder instability among active young athletes and military personnel. Shoulder stabilization surgery is the commonly employed intervention for treating individuals with instability. Following surgery, a substantial proportion of individuals experience acute post-operative pain, which is usually managed with opioid pain medications. Unfortunately, the extended use of opioid medications can have adverse effects that impair function and reduce military operational readiness, but there are currently few alternatives. However, Battlefield Acupuncture (BFA) is a minimally invasive therapy demonstrating promise as a non-pharmaceutical intervention for managing acute post-operative pain.

Crowell, M., Brindle, R., Mason, J., Pitt, W., Miller, E., Posner, M., Cameron, K., & Goss, D. (2020). The effectiveness of battlefield acupuncture in addition to standard physical therapy treatment after shoulder surgery: a protocol for a randomized clinical trial. Trials. https://doi.org/10.1186/s13063-020-04909-8

Symsack A, Gaunaurd I, Thaper A, Springer B, Bennett C, Clemens S, Lucarevic J, Kristal A, Sumner M, Isaacson B, Pasquina P, Gailey R

Telehealth is an increasingly common approach to improve healthcare delivery, especially within the Veterans Health Administration and Department of Defense (DoD). Telehealth has diminished many challenges to direct access for clinical follow-up; however, the use of mobile telehealth for specialty rehabilitative care is emerging and is referred to as telerehabilitation. As early adopters of telehealth, the Veterans Affairs and DoD have supported collaborated efforts for programs designed to increase the access and quality of rehabilitative care while improving the functional ability of our service members (SMs) and veterans with lower limb amputation (LLA). The DoD and Veterans Health Administration collaborated on a Mobile Device Outcomes-based Rehabilitation Program (MDORP) to help injured SMs and veterans with LLA. The MDORP project utilized a mobile health system called the Rehabilitative Lower Limb Orthopedic Accommodating Device (ReLOAD) to assess walking quality. The ReLOAD system includes real-time auditory biofeedback to notify the user of their most prominent gait deviation and then recommends exercises that address specific balance and strength impairments. The purpose of this study was to describe the responses to a postintervention survey evaluating the feasibility and usability of ReLOAD completed by SMs and veterans with LLA who used the system for 5 months.

Symsack, A., Gaunaurd, I., Thaper, A., Springer, B., Bennett, C., Clemens, S., Lucarevic, J., Kristal, A., Sumner, M., Isaacson, B., Pasquina, P., & Gailey, R. (2020). Usability Assessment of the Rehabilitation Lower-limb Orthopedic Assistive Device by Service Members and Veterans with Lower Limb Loss. Military Medicine. https://doi.org/10.1093/milmed/usaa428

Isaacson B, Miranda M, Hager N, Wagner L, West S, Lucio W, Heller J, Dalgarno R, Dickens J, Schoomaker E, Pasquina P

The cost of health care in the United States has increased exponentially over the past 60 years, soaring from $27.2 billion in 1960 (5% of gross domestic product) and $147 per resident to $3.5 trillion (17.9% of gross domestic product) and $11 000 per resident in 2017. Health care expenditures continue to rise significantly faster than the median household income, and this poses a financial strain for patients, providers, and the health care system alike. Removing unnecessary variation through evidence-based medicine is critical to improving outcomes and making care more affordable. This may be accomplished through standardized protocols, order sets, and check lists, with positive results previously demonstrated for obstetrics/gynecology, critical care, pediatrics, gastrointestinal surgery, orthopedics, and rehabilitation. Effective communication with a multidisciplinary team has also shown to enhance quality of treatment, reduce complications, and decrease postoperative issues. Although treatment normalization is a pragmatic solution for removing health care waste, evidence supports that even when guidelines are available, only two-thirds of patients receive the recommended care, and another quarter get treatment that may be unnecessary and/or harmful.

Isaacson B., Miranda M., Hager N., Wagner L., West S., Lucio W., Heller J., Dalgarno R., Dickens J., Schoomaker E., Pasquina P. (2020). Standardizing Postoperative Rehabilitation Protocols for the Tri-Service: A Consensus Meeting Hosted by the Musculoskeletal Injury Rehabilitation Research for Operational Readiness Organization. Military Medicine. https://doi.org/10.1093/milmed/usaa207

Velasco T, Leggit J

Chronic exertional compartment syndrome is a debilitating condition primarily associated in highly active individuals with an estimated incidence of approximately 1 in 2000 persons/year. The etiology remains unclear to date. The differential diagnosis includes, but is not limited to stress fractures, medial tibial stress syndrome, and popliteal artery entrapment syndrome. Clinical signs and symptoms include pain in the involved compartment with exertion dissipating quickly after activity. Diagnostic tests include intramuscular compartment pressure testing, magnetic resonance imaging, near-infrared spectrometry as well as shear wave electrography. Treatments consist of nonsurgical, surgical, or the combination of the two. Gait retraining and the use of botulinum toxin appear most promising. Diagnostic lidocaine injections are emerging as a prognostic and mapping tool. Minimal invasive surgical options are being utilized allowing quicker return to activity and decreased morbidity. This article reviews the anatomy, clinical signs and symptoms, diagnostics, nonsurgical, and surgical treatments for chronic exertional compartment syndrome.

Velasco, Teonette O. PT, DPT, OCS; Leggit, Jeffrey C. MD, CAQSM. Chronic Exertional Compartment Syndrome: A Clinical Update. Current Sports Medicine Reports 19(9):p 347-352, September 2020. https://doi.org/10.1249/JSR.0000000000000747

Cohen S, Baber Z, Buvanedran A, Mclean b, chen y, hooten wm, laker s, wasan a, kennedy d, sandbrink f

It is nearly impossible to overestimate the burden of chronic pain, which is associated with enormous personal and socioeconomic costs. Chronic pain is the leading cause of disability in the world, is associated with multiple psychiatric comorbidities, and has been causally linked to the opioid crisis. Access to pain treatment has been called a fundamental human right by numerous organizations. The current COVID-19 pandemic has strained medical resources, creating a dilemma for physicians charged with the responsibility to limit spread of the contagion and to treat the patients they are entrusted to care for.

In these guidelines, we provide a framework for pain practitioners and institutions to balance the often-conflicting goals of risk mitigation for health care providers, risk mitigation for patients, conservation of resources, and access to pain management services. Specific issues discussed include general and intervention-specific risk mitigation, patient flow issues and staffing plans, telemedicine options, triaging recommendations, strategies to reduce psychological sequelae in health care providers, and resource utilization.

Pain Medicine, Volume 21, Issue 7, July 2020, Pages 1331–1346, https://doi.org/10.1093/pm/pnaa127

Shanthanna H, Strand N, Provenzano D, Lobo C, Eldabe S, Bhatia A, Wegener J, Curtis K, Cohen S, Narouze S

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgeries, procedures, and patient visits, including pain management services, have been postponed or cancelled. This has impacted the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognized during this pandemic for chronic pain patients include ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritizing necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Shanthanna H., Strand N.H., Provenzano D.A., Lobo C.A., Eldabe S., Bhatia A., Wegener J., Curtis K., Cohen S.P., Narouze S. (2020). Caring for patients with pain during the COVID‐19 pandemic: consensus recommendations from an international expert panel. Anesthesia. https://doi.org/10.1111/anae.15076

Cohen S, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten M, Hurley R, Kennedy D, McLean B, Moon J, Narouze S, Pangarkar S, Provenzano D, Rauck R, Sitzman B, Smuck M, Zundert J, Vorenkamp K, Wallace M, Zhao Z

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Cohen SP, Bhaskar A, Bhatia A, et al. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia & Pain Medicine. https://doi.org/10.1136/rapm-2019-101243

Lacey S, Cohen S, Jacobs M

Discogenic Low Back Pain (DLBP) is a common condition with an unfavourable prognosis and limited treatment options. After experiencing insufficient response to standard conservative care of physical therapy, non-steroidal anti-inflammatory medications and activity modification, three patients with chronic DLBP were treated with intradiscal injection of dehydrated Human Amnion Chorion Membrane (dHACM). Diagnosis was established by Magnetic Resonance Imaging (MRI) revealing disc disease with anatomically concordant pain. Results indicated a trend toward reduced pain as measured by the Numerical Rating Scale for pain (NRS-Pain) and increased function as measured by the Oswestry Disability Index (ODI).

Lacey, S., Cohen, S., & Jacobs, M. (2020). Intradiscal Injection of Dehydrated Human AmnionChorion Membrane for Treatment of Chronic Discogenic Low Back Pain: A Case Series. Journal of Regenerative Medicine. https://doi.org/10.37532/jrgm.2020.9(1).155

Bhatia A, Engle A, Cohen S

Choosing appropriate pharmacotherapy for acute and chronic LBP continues to pose a major challenge to health-care providers and sufferers. Identifying distinct phenotypes that respond to targeted treatments, improving diagnosis to enable mechanism-based rather than symptom-based treatment of pain (e.g. muscle relaxants for muscle spasms, antidepressants for LBP with a neuropathic character), treating concomitant conditions that may undermine effectiveness (e.g. sleep and psychological disorders) and exploring stepped care and interdisciplinary models, while monitoring for adverse effects are promising approaches that need to be studied for comparative-effectiveness against standard of care. The paucity of pharmacologic treatments for LBP has spurred a search for more efficacious and safer medications. Although they have not been extensively studied for back pain per se, intravenous infusion tests designed to identify pain mechanisms and predict response to oral analgesic therapy represents an area ripe for investigation [30]. Nerve growth factor inhibitors, cannabinoids, newer opioids, ketamine, and botulinum toxin have been evaluated in a variety of clinical studies for LBP. The evidence regarding the role of these therapies is mixed and of low quality. Table 2 provides a summary of some of the important studies on these agents in the last decade. Increasing evidence on newer options will help to optimize the treatment of this challenging and growing problem. It is also important to consider non-pharmacological options for LBP such as physical therapy and psychological treatments. Health-care providers should advise their patients with low back pain about non-pharmacological analgesic options that are supported by evidence of efficacy and safety, while informing them that many of them may not respond to currently available treatments, in which case functional restoration in the context of persistent pain may improve their quality of life.

Bhatia, A., Engle, A., & Cohen, S. P. (2020). Current and future pharmacological agents for the treatment of back pain. Expert Opinion on Pharmacotherapy, 21(8), 857–861. https://doi.org/10.1080/14656566.2020.1735353

Zhao Z, Larkin T, Cohen S

The shoulder is one of the most complex joints in the body, with potential pain generators such as the glenohumeral and acromioclavicular joints, multiple bursae, and numerous soft tissue structures to include multiple tendons and muscles. The lifetime prevalence of shoulder pain is estimated at 7% to 67%, with the prevalence variation stemming from differences in study populations and diagnostic criteria. According to some sources, pain arising from subacromial impingement syndrome is the most common source of chronic shoulder pain, though many patients have pain from multiple pathologies and some have pain despite minimal or no radiologic pathology. In the United States, the estimated cost of chronic shoulder pain is largely unknown, though ∼$3 billion dollars are spent each year on the evaluation and management of rotator cuff tears alone. In Australia, the average annual cost per patient with chronic shoulder pain has been estimated at AU$22,378. Yet, despite the high prevalence and economic expenditures on shoulder pain, surgical and nonsurgical treatments are characterized by high failure rates. According to one systematic review, there is no difference in pain or functional outcomes between surgical and nonsurgical management for shoulder impingement syndrome. In this issue of Pain Medicine, Eckmann et al. report their results with radiofrequency (RF) ablation of the terminal sensory articular nerves of the shoulder joint for chronic, refractory shoulder pain.

Zhao, Z., Larkin, T., & Cohen, S. (2020). Reflections on Innovative Interventional Pain-Relieving Procedures: Lessons Learned from Previous Mistakes. Pain Medicine. https://doi.org/10.1093/pm/pnz380