Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Outcome Domains and Measures in Acute and Chronic Pain Clinical Trials

~ An important feature in the planning of any clinical trial regards the decisions made as to the outcome criteria that will be used to evaluate treatment efficacy. Traditionally, the outcomes used in both acute and chronic pain research have been a reduction in pain intensity and presence of adverse effects (AEs). However, more recently, other important factors have been identified that should be included as…

Clinical Trial Design Methodology and Data Analytic Strategies for Pain Outcome Studies

~ It is traditionally held that the first comparative clinical trial was performed in 1747 by Dr. James Lind of the British Royal Navy to identify a treatment for scurvy. Lind evenly assigned 12 scurvy-afflicted sailors to receive cider, vitriol (a weak acid), vinegar, sea water, oranges, lemons, or nutmeg paste. After six days, only the two sailors who had received oranges and ­lemons (and thus…

Pain Management at the End of Life and Home Care for the Terminally Ill Patient

Introduction The end stages of life bring a host of challenging symptoms and causes of suffering that may have accumulated with chronic, progressive, life-limiting diseases. The symptoms of pain, dyspnea, fatigue, and loss of mobility accompany emotional states, such as depression, anxiety, and a sense of uselessness. Of the many symptoms experienced by those at the end of life, pain is one of the most common…

Pain Management in the Critically Ill Patient

Introduction Pain in the critically ill has been historically poorly understood. Only recently has attention and investigation turned toward the issues of pain assessment and treatment in this patient population. The prevalence of poorly treated pain in the critically ill is considerable and greater than commonly believed among health care physicians. This chapter examines some salient issues as well as the modern, pertinent literature detailing barriers…

Disparities in Pain Care: Descriptive Epidemiology-Potential for Primary Prevention

Background to this Chapter This chapter is being written at an unprecedented time in the history of the United States. The coronavirus (SARS-CoV2) pandemic has swept across the country. COVID-19 case numbers, hospitalizations, and deaths show non-Hispanic Blacks, American Indians, and Hispanics to have been disproportionately affected. , The Centers for Disease Control (CDC) has reported age adjusted mortality rates for non-Hispanic Blacks and American Indians…

Pain Evaluation and Management in Patients With Limited Ability to Communicate Because of Dementia

Key Points Pain is challenging to assess in older adults with moderate to severe dementia because of limitations in ability to communicate pain because of cognitive and linguistic impairments. While older adults with mild to moderate dementia may be able to report on their pain using unidimensional scales, validated systematic observational approaches such as the PACSLAC-II or the PAINAD are needed to monitor pain levels in…

Burn Pain

Introduction The management of pain related to burns presents a clinical challenge for providers given the complex physiology of injury, chronicity of pain, and the related psychological effects. Despite the variability in etiology, pathophysiology, and severity of burn injuries, treatment options for pain remain largely uniform despite the type of injury. So called traditional analgesic agents, including opioids, have been and remain a mainstay for the…

Management of Pain in Sickle Cell Disease

~ Sickle hemoglobin results from a replacement of glutamine with valine at the sixth amino acid position in the b-globin subunit. Molecules of this abnormal hemoglobin polymerize upon deoxygenation into long polymers that physically deform the erythrocyte into the characteristic sickle shape and ultimately obstruct blood flow. This polymerization largely ceases when adult hemoglobin is present with sickle hemoglobin, the so-called sickle trait, or with high…

Pain Management in the Emergency Department

~ The management and treatment of the pain in the emergency department (ED) is unique from that experienced in other medical settings. Not only is pain often acute as opposed to chronic, but it is often unexpected and sudden. In addition, the type of painful conditions seen in the ED may respond differently to different types of treatments, such as the pain from a migraine versus…

Pain Management in Primary Care

Background and Introduction Of the myriad problems that present to the primary care clinician, pain is the most common and arguably the most concerning. Since pain can herald something as serious as a heart attack or as routine as an inflamed carbuncle, primary care providers (PCPs) must answer the complaint of pain with alacrity and focused attention. Misdiagnosis can cause an unfavorable outcome for the patient;…

Infection and Anticoagulation Considerations in Pain Procedures

Risk of infection in interventional pain procedures David A. Provenzano, Michael C. Hanes Introduction Infections related to interventional pain procedures and implantable devices vary considerably based on the target location, causative pathogens, anatomic structures involved, collateral damage, and severity. Surgical site infections (SSIs) have been shown to significantly increase mortality, prolong hospital length of stay, and reduce health-related quality of life. In addition, SSIs cost the…

Radiation Safety and Radiographic Contrast Agents

Key Points The biologic effects of ionizing radiation are proportional to the time of exposure, whereas radiation exposure is inversely proportional to the square of the distance from the radiation source. Modern fluoroscopy units typically employ ABC, which automatically adjusts kVp and mA to yield optimal brightness and contrast. The ICRP has produced estimates of the MPD of annual radiation to various organs. Exposure below these…

Intrathecal Drug Delivery

## Intrathecal drug delivery for the treatment of pain is an outgrowth of pioneering research into spinal cord mechanisms and receptors that modulate nociceptive signal transmission to and within the central nervous system. Since the 1970s, researchers have identified the peptide substance P in small dorsal root ganglion cells and observed that opioids would produce analgesia. These findings, as well as the observation that substance P…

Spinal Cord Stimulation, Peripheral Nerve Stimulation, Restorative Neurostimulation, Deep Brain Stimulation, and Motor Cortex Stimulation

Introduction Neuromodulation for chronic pain control has been used for several decades but recently has received much clinical interest mainly based on published improved therapy outcomes. Spinal cord (SCS), dorsal root ganglion (DRG), and peripheral nerve stimulation (PNS) for chronic pain are the mainstay of neuromodulation therapies and will be the focus of this brief review. Over the last 30 years, traditional, low frequency, paresthesia-based (40–90…

Biopsychosocial Pre-screening for Spinal Cord and Peripheral Nerve Stimulation Devices

Overview Pain is a complex and serious medical condition, with estimates from the Centers for Disease Control and Prevention in 2016 showing 50 million (20.4%) United States adults experiencing chronic pain, among whom 19.6 million experience high impact pain that limits life or work activities. Beyond the element of human suffering, there are enormous economic costs associated with chronic pain in terms of lost productivity and…

Minimally Invasive Procedures for Vertebral Compression Fractures

One in two women and one in five men aged >50 years will experience an osteoporotic fracture. These can result in substantial patient pain, morbidity, and healthcare utilization. A new osteoporotic vertebral fracture occurs every 22 s; 1.4 million occur worldwide every year. The majority are asymptomatic or result in tolerable symptoms, with only a third of patients with new fractures seeking medical attention. For the…

Myofascial Injections and Fascial Plane Blocks for Perioperative and Chronic Pain Management

Overview and Pathophysiology of Myofascial Pain Syndromes Myofascial pain is a common source of pain in the neck, low back, and other areas of the body. The term “myofascial pain” encompasses many different painful conditions, including muscle strain, myofascial trigger points (TrPs). It also includes specific myofascial pain syndromes, including piriformis syndrome, iliopsoas-related pain, and pain related to compression of the brachial plexus by the scalene…

Pain Interventions for the Knee, Hip, and Shoulder

Introduction Targeted treatment of peripheral joint pain because of musculoskeletal disorders involves the utilization of intraarticular (IA) injections as well as ablative procedures. IA joint and bursa injections are used to treat pain in the joint and surrounding soft tissue structures. Radiofrequency ablation (RFA) creates a controlled lesion targeting sensory nerves associated with the large peripheral joints, including the hip, knee, and shoulder. Musculoskeletal system disorders,…

Radiofrequency Treatment

The use of electric current for pain management has a long history. As early as the second half of the 19th century, brain lesions were made in animals with the application of direct current, and empirical rules for quantifying lesion size based on current and time were developed. , One of the first uses in humans was for the management of trigeminal neuralgia in 1931 when…

Interlaminar and Transforaminal Therapeutic Epidural Injections

The International Association for the Study of Pain (IASP) continues to deliberate the classification of chronic pain as a disease symptom or etiology. Semantics aside, pain is undoubtedly a public health crisis as the Institute of Medicine’s report estimates that over 100 million American citizens are living with chronic pain. Of this group, chronic low back pain is the most prevalent, and this diagnosis more than…