chronic pain health needs assessment report version 0 3
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Chronic pain health needs assessment 1
Health Needs Assessment for Chronic
Pain Jammi Rao, Editor
with support and contribution of Sadia Janjua, Janine Dretzke, Daniel Eayres, Chris
Chiswell,
Version History
Document Title
Version 0.3
Author West Midlands Commissioning Support Unit
Publication Date 12 November 2012
Review Date
Supersedes/New Version 0.2
Comments
This version incorporates changes agreed at meetings between EA, DE, AFS, CC
and SJ. Major review and rewrite of the evidence review section; evidence
tables recast and moved to the appendix with a commentary on each SR in the
main text; DE’s sestion on epidemiology and prevalence of the major subtypes
of chronic pain, CC’s new section on cli nical pathway for chronic pain and
specialised services definitions for chronic pain treatments delivered as part of
the specialised services commissioning process
Previous versions
Version Date Changes
0.1 21.08.2012 First draft sent to EA for comments re style , layout and outline content
0.2 14.09.2012 Planned changes including a) exec summary; b) Corporate needs
assessment chapter out in, c) some editorial and technical tidying up of
content including Table and chart references, bibliographic references, and
spellings and typographic errors. This version was sent to the Black Country
Clinical Senate in time for 36.09 meeting agenda.
There was not the time before his deadline to address the comments made
by EA to version 0.1
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Chronic pain health needs assessment 3
Contents
Executive summary................................................................................................5
1 Introduction ........................................................................................................ 8
2 Background ......................................................................................................... 9
Health needs assessment ............................................................................................ 9
The national context .................................................................................................. 10
The Nature of Chronic Pain ........................................................................................ 12
3 Epidemiology of chronic pain ............................................................................. 14
Definitions .................................................................................................................. 14
Sub-classification of chronic pain .............................................................................. 15
Most common sites of chronic pain .......................................................................... 19
Incidence and prevalence of chronic pain conditions ............................................... 19
The natural history of chronic pain ........................................................................... 37
4 The economic costs of chronic pain ................................................................... 38
NHS Expenditure on chronic pain .............................................................................. 38
NHS chronic pain expenditure in the West Midlands ............................................... 43
Notes on Programme Budget data quality and limitations ....................................... 47
5 Health service utilisation - outpatient activity .................................................... 52
Commissioner perspective ........................................................................................ 52
out-patient activity – provider perspective ............................................................... 58
6 Health service utilisation – inpatient and day case procedures ........................... 61
Data sources and methods ........................................................................................ 61
Results ........................................................................................................................ 62
Trends in Specific Procedures in pain management ................................................. 69
Analysis by provider Trusts ........................................................................................ 72
7 Stakeholder and Corporate needs Assessment ................................................... 74
Chronic Pain – Stakeholders ...................................................................................... 74
Chronic Pain – Service Delivery ................................................................................. 79
Commissioning chronic pain services ........................................................................ 82
Measuring Outcomes ................................................................................................ 84
Recommended Core Outcome Measures in Research .............................................. 85
4 Chronic Pain Health Needs Assessment
Taxonomy of Chronic Pain Services ........................................................................... 86
Pathways for Chronic Pain Patients ........................................................................... 90
8 Rapid evidence review of the effectiveness of interventions for chronic pain. .... 96
Objective .................................................................................................................... 96
Methods ..................................................................................................................... 96
Search methods for identification of studies ............................................................ 96
Data collection and analysis ...................................................................................... 97
Results ........................................................................................................................ 98
Manual therapy ......................................................................................................... 98
Pharmacological procedures ..................................................................................... 98
Patient education. ................................................................................................... 100
Physical treatments ................................................................................................. 100
Behavioural (BT) and cognitive behavioural therapy (CBT) .................................... 102
Invasive procedures ................................................................................................. 103
Multi-disciplinary interventions (MDI) .................................................................... 108
Appendix I – Admitted Patient Commissioning Data Set (CDS) data request
specifications ........................................................................................................... 111
Appendix II – Pain management procedure codes .................................................. 114
Appendix nn ............................................................................................................. 118
Appendix nn ............................................................................................................. 120
Chronic Pain Health Needs Assessment 5
EXECUTIVE SUMMARY
Chronic pain is widely prevalent, affecting an estimated 7.8 million people in England. It is
not one specific disease entity, rather it is a syndrome that usually involves more than self
reported pain in a particular anatomic location.
Estimates of the prevalence of chronic pain vary between surveys, depending on the
definition used, whether disability and interference with normal function is taken into
account, the country location of the study and the method of epidemiological enquiry. In
the UK the prevalence is probably between 11 and 13% of the adult population.
Referrals to pain management clinics are growing across the West Midlands. Total out-
patient attendances rose from 44,700 5 years ago to 51,587 in 2011/12. Just under a third of
these attendances are first appointments. The crude rate of pain clinic attendances as 11.7
per 1000 population, suggesting that a substantial proportion of the estimated cases that
are prevalent in the population are either self-managed or managed in the primary care
setting. There is wide variation between PCTs and between PCT clusters.
In keeping with the rise in out-patient attendances, clinical interventions and procedures in
hospital for the management of chronic pain also show a rise in recent years – from 27,694 5
years ago to 32,444 in 2011/12. Joint injections (43%), spinal operations (19%) and epidural
injections (17%) make up almost 80% of all procedures. The majority of interventions (86%)
are carried out as day cases.
There is a paucity of high quality research evidence to support the use of the many
treatments and interventions that are commonly deployed in the management of chronic
pain. Many of the published clinical trials suffer from methodological problems such as
small sample size, inadequate description of the intervention, short duration of follow up,
failure to achieve blinded assessment of outcomes, high rates of losses to follow-up and
failure to use validated measures of outcome. Systematic reviews of the available clinical
trials are available but they are necessarily limited by the lack of quality in the underlying
clinical trials.
In the case of chronic low back pain,
the evidence does not support the routine use of MRI as a diagnostic aid.
Surgical treatment based exclusively on MRI findings is not supported by the evidence.
Facet joint injections are of little proven value in chronic low back pain.
Spinal cord stimulation in cases of failed back surgery syndrome may confer pain relief more
effectively than either conventional medical management or re-operation, but the risk of
complications needs carefully to be considered.
Surgical operations on the spine when performed in carefully selected patients with lumbar
intervertebral disc prolapse may provide faster pain relief than conservative management
but the effect on longer term outcomes is uncertain. The risk of complications needs
6 Chronic Pain Health Needs Assessment
carefully to be considered and set against the risk of progression when neurological
symptoms are present.
There are several interventional procedure guidance documents produced by NICEThese
include laser decompression, mechanical decompression, coblation, endoscopic laser
discectomy and endoscopic laser foraminoplasty. In all these instances the data on safety
and efficacy are not robust enough to allow them to be done without special arrangements
for consent for audit and research.
Cognitive behavioural therapy and other psychological therapies may offer short term
benefit but the quality of research evidence on longer term outcomes is much weaker.
Multi-disciplinary pain management programmes show promise of effectiveness with
moderately strong evidence from systematic reviews; but the underlying clinical trials are of
variable quality, with weak evidence for long term outcomes. There is support for such
programmes in the various guidelines that are available.
In the case of chronic pain other than chronic low back pain:
The available evidence does not support the use of electrotherapy, auriculotherapy and
acupuncture, low level laser therapy for neck pain and for carpal tunnel syndrome. The
generally poor quality of the trials makes it difficult reliably to draw conclusions without the
risk of bias.
Injections of Botulinum toxin-A may show some short term benefits in some cases, but the
quality of the trials lead to a conclusion of insufficient evidence for long term benefit in neck
pain, shoulder pain, myofascial pain, chronic musculoskeletal pain, or the pain of lateral
epicondylitis (tennis elbow)
Interlaminar epidural injections may confer some short term benefit in chronic neck and
upper limb pain but the trials were small and the quality of evidence was poor.
Intra-articular steroid injection in osteoarthritis was shown to confer significant clinical
benefit in but the effect disappears in 3-4 weeks.
Repeated injections of hyaluronic acid in knee osteo-arthritis was shown to confer short
term symptom relief but the evidence of disease modification in the long term is at best
speculative.
Manipulation or mobilisation in subacute or chronic neck pain produces short term benefit
but long term data are lacking.
Mechanical tyraction for chronic neck pain with or without radiculopathy is not statistically
significantly different from placebo.
Manual therapy and exercise in neck pain significanlt reduces pain and improves quality of
life, though the effect on radiculopathy is uncertain.
Gabapentin and pregabalin are effective in reducing pain in neuropathic pain and
fibromyalgia. Some studies suggest that the effect may extend to other outcomes such as a
return to work. Carbamazepine is also effective in reducing pain in chronic neuropathic pain
but side effects may limit its use.
Lamotrigine is not effective in treating chronic pain. Valproic acid is probably not effective in
neuropathic pain and fibromyalgia.
Chronic Pain Health Needs Assessment 7
The evidence base for opioids is mixed. Patients able to continue long term opioids
experience significant clinical benefit, even though the evidence for quality of life and
functional improvement is inconclusive.
Cannabinoids are safe and effective in neuropathioc pain and probably also in fibrimyalgia
and rheumatoid arthritis.
Antidepressants are effective in improving pain scores in the treatment of neuropathic pain.
Surgical interventions such as sympathectomy (whether done surgically, chemically or by
radiofrequency ablation) may achieve significant reduction in pain score but the trials were
small and did not include a placebo arm.
Intrathecal delivery of drugs using implantable devices is supported only by low quality
evidence; they are associated with high rates on reversal and infrequent but serious
complications.
Multi-disciplinary interventions in chronic pain offer a safe and effective option for many
chronic pain syndromes. It remains unclear which of the components are critical for patient
benefit. Patient education programmes have not been shown to be effective. Behavioural
and psychological therapies in isolation have weak effects in improving pain.
8 Chronic Pain Health Needs Assessment
1 INTRODUCTION
1.1 Chronic pain is a common and universal condition that has a major impact on the lives
of the many millions of people affected by it. Widely quoted estimates of its prevalence
suggest that as many as 7.8 million people in the UK may be affected by chronic pain of
at least moderate severity.
1.2 Chronic pain may be both a symptom of an underlying disease and, more commonly, an
illness or syndrome in its own right. In the latter situation, it can have a substantial
adverse effect on quality of life and well-being due to unemployment, sleeplessness and
depression. However it is relatively recently that chronic pain has come to be
recognised as a public health problem that calls for a different approach to the
traditional one based on regarding pain as a symptom for which there must be a
pathological cause that is amenable to diagnosis and treatment. Concepts are evolving
for the assessment of chronic pain in people without an underlying cause based on an
understanding of chronic pain as a distinct condition that merits a different approach to
management.
1.3 While the majority of cases of chronic pain in population based epidemiologic studies
are accounted for by three categories – pain following trauma, low back pain, and
arthritis and osteoarthritis – there are some disease entities that present major
diagnostic and management challenges. Fibromyalgia or chronic widespread pain is an
example of such a condition where the experience of pain and the consequent effects on
daily life itself leads to further pain and disability. Because of their chronicity and the
lack of effective curative treatments such cases tend to take up a disproportionate
amount of time from both primary care and specialist services.
1.4 There is a close inter-relationship between work, the experience of pain and the
availability of welfare payments for those deemed unfit for work. The initial experience
of pain leads to a prescription of rest and abstention from work and activity; this in turn
leads to deterioration of the original problem which, coupled with welfare payments,
acts as a disincentive to an early return to work. Acute pain is often the trigger for a
prescription of time off work, leading to chronicity, welfare dependency and continuing
chronic pain.
1.5 It is timely therefore to carry out a health needs assessment for chronic pain. In the
following pages this report will consider
The nature and patho-physiology of chronic pain Estimates of the prevalence of chronic pain The use of specialist hospital services for the treatment and management of patients with chronic pain; and the trends in the use of selected surgical procedures Trends in the use of pharmacological agents The effectiveness of treatment and management options available for the management of chronic pain.
Chronic Pain Health Needs Assessment 9
2 BACKGROUND
HEALTH NEEDS ASSESSMENT
2.1 Health needs assessment (HNA) is a formal and structured method to understand the
need for health care and related services and support in a defined population, usually in
respect of a specified health or disease based topic. While individuals can also go
through a process of assessment as to their health and/or healthcare needs, HNA is
usually applied to whole populations or large subgroups thereof. HNA makes clear the
distinctions between need, demand and supply.
2.2 Need is defined as the capacity to benefit. It therefore follows that need can exist only
when there is an effective intervention to ameliorate the condition and resources are
available with which to procure the intervention.
2.3 Demand is what patients ask for, based on their lived experiences, what they know and
understand of their condition, and their knowledge and experience of the services and
treatments they expect to be available. It can be more or less than normative need, and
is often influenced by many factors including the media, advertising by suppliers and
anecdotal accounts of their peers. In health care, supply of services often generates its
own demand.
2.4 Supply refers to the health care that is provided; it is determined by the interests and
priorities of professionals, the political process and the resources that are made
available. Newer treatments are often supplied with the expectation that it will generate
its own demand and before the need for them has been fully and unarguably established
by high quality research.
2.5 HNA has the potential to tease out these conflicting and overlapping concepts and make
explicit the choices available to commissioners together with a clearer understanding of
likely impacts of their decisions. Seen in this light, HNA is not an isolated activity but an
integral part of the process of commissioning health care.
2.6 The traditional model of HNA is a composite of 3 separate but interlinked exercises:
Epidemiological needs assessment consists of the use of available data and information from whatever sources may be available to draw a picture of the scale of the condition or disease in question; its distribution among segments of the population defined by age, gender, ethnicity, social class, deprivation, and geographic location. Comparative needs assessment sets the local findings in the context of the region and the country. Comparisons are also possible with other areas of the country that share the same or similar socio-demographic, economic and cultural characteristics. Corporate needs assessment takes account of the views of key stakeholders involved in the provision of current services.
2.7 A distinction is also often drawn between healthcare needs and health needs
assessment. In practice the term HNA is often loosely used to include both; it is helpful
however to be clear of the distinction. Healthcare needs assessment confines itself to
the clinical and other curative and/or professionally delivered support and services that
10 Chronic Pain Health Needs Assessment
can be delivered. Health needs assessment takes a broader, more holistic approach and
considers also the wider determinants of health that can often make a big difference to
the outcomes that people and communities experience and value. This report will
confine itself to healthcare needs of people with chronic pain.
THE NATIONAL CONTEXT
2.8 Chronic pain is not formally identified in any national service framework or policy
document as a priority for the health service. It is implicitly included in policy statements
and guidance documents that relate to the underlying diseases that give rise to chronic
pain.
2.9 In March 2000 the Clinical Standards Advisory Group (CSAG) produced a report (1),
‘Services for Patients with Pain’, at the request of Ministers ‘to advise on standards of
clinical care for patients with acute and chronic pain and on access to and availability of
services.’ A part of their report was based on a study carried out by a team from
Manchester and Leicester Universities in 1997 in 12 acute hospital trusts. The report
found that there was wide variation in the provision of services, with acute pain better
catered for than chronic pain. Some hospital services were poorly organised with lack of
dedicated time from consultants and an agreed role for specialist nurses. Among other
findings:
An estimated 7% of the population suffers chronic pain at any one time. A quarter of the population suffers from bouts of musculoskeletal pain, especially in the back. Most people treat themselves or seek help from their general practice. In most areas, pain services were ‘part of the package’. There were few explicit contracts for pain relief and not much by way of needs assessment. Local guidelines where they existed were of poor quality. Chronic pain services were poorly resourced and were unable to cope with the demands placed on them. Shortages of staff trained in psychology, occupational therapy, physiotherapy and of dedicated pharmacist support prevented a multi-disciplinary approach to management. Routine data and information systems did not record activity and outcomes in a systematic and meaningful way to allow evaluation of the services that were offered. Professionals thought that chronic pain as an issue had less of a profile than palliative care and it was difficult to attract investment in services. There was little by way of integration between different parts of the service either between general practice and specialist pain clinics or between pain specialists and other medical specialties. Specialist pain services often discharged fewer patients than they took on, building up a backlog of referrals and leaving patents feeling that their condition was not taken seriously.
2.10 In 2008 the Chief Medical Officer, Sir Liam Donaldson highlighted the problem of chronic
pain in his Annual Report (2). He stated that ‘...millions of people experience chronic
pain... imposing a heavy burden on them, their families and the economy at large.
Although we now have effective means of tackling both pain and the consequences of
pain, services have not kept up with demand and too many people struggle to cope with
their symptoms.’ The report concluded:
Chronic Pain Health Needs Assessment 11
Pain is the most common symptoms and affects 7.8 million people in England. Chronic pain is more prevalent now than it was 40 years ago. All age groups are affected: a quarter of school age children reported pain lasting on average more than 3 years; most elderly residents of nursing homes experienced frequent moderate to severe pain. Pain and its effects are costly. Back pain alone is estimated to cost the economy £12.3 billion each year. Not enough is being done to implement programmes to treat pain early and effectively and thus stop pain becoming persistent. Specialist services are inadequate and unable to cope with the demand. Only 14% of people with pain have seen a pain specialist.
2.11 In Nov 2004 a research project by Dr Foster(3) reported on a survey of adult chronic pain
management in primary care. This survey was carried out in association with the Long
Term Medical Conditions Alliance, a charity representing the voice of patients, carers
and service users, and was funded by an educational grant from NAPP Pharmaceuticals,
a company that makes and sells drugs used in pain management. Among the important
conclusions of this survey are:
Chronic pain management is not a healthcare priority in the UK. 64% of primary care organisations (PCOs) failed to allocate specific funding for services in a primary care setting. Only 20% reported having a formal or structured chronic pain management service delivered in primary care. Only 4% of PCOs reported having a practice based register of people with chronic pain. 69% of PCOs reported that they did not have specific guidelines or recommendations for the management of non-cancer chronic pain. Only 8% of PCOs allocate part of their education and training budget to GP training for in the management of chronic pain. The provision and organisation of primary care chronic pain management services varies across the country. There is acknowledgement that there is insufficient money allocated to chronic pain services; that staff is poorly equipped to manage chronic pain; and that prescribing and management guidelines are needed.
2.12 In 2011 the Healthcare Quality Improvement Partnership, Dr Foster Intelligence and the
British Pain Society reported on the first phase of the National Pain Audit(4) – a three
year study set up in October 2009 that aims to establish a national data collection
system to monitor performance of pain services. The audit covers all specialist pain
services in England and Wales and reports organisational performance against a wide
range of standards set by the faculty of Pain medicine, British Pain Society and the
International Association for the Study of Pain. The results of this first phase of the audit
showed:
A total of 214 services were identified in England and Wales. Most PCTs reported between 1 and 3 specialist services for their populations. The poorest returns were for the Midlands and the South East. Most services reported meeting the NHS waiting time targets. The extent to which this also met the needs of patients is not known
12 Chronic Pain Health Needs Assessment
64% of Services in England assessed themselves as ‘multi-disciplinary’. But using stricter criteria to define the label in terms of the presence of key personnel, only 40% would meet this standard. Services claiming to offer specialist treatments and interventions often lacked the appropriate staff (as assessed by their own data returns). Training for staff was not available for the majority of services.
THE NATURE OF CHRONIC PAIN
2.13 Pain is the oldest affliction known to man. In traditional medical practice pain is
traditionally seen as an important and useful symptom of an underlying disease. Its
severity, nature, fluctuation and how it responds to or is exacerbated by physical stimuli
are all useful pointers to an underlying pathology or disease process and therefore to a
therapeutically useful clinical diagnosis. When successful and effective treatment of the
underlying condition relieves the pain it provides comfort to the patient and satisfaction
to the doctor that the diagnosis was correct.
2.14 While this concept is helpful in acute short lived pain, it is less so when the pain
continues for more than a few days or weeks, or when the presumed underlying
diagnosis and its treatment fail to relieve the pain. Should pain therefore be regarded as
a disease or syndrome in its own right, quite independent from any presumed causative
disease process?
2.15 Croft (5) presents a compelling argument that chronic pain fits the criteria for a
condition independent of any underlying disease and one that merits definition by
reference to the subjective experience of pain, its severity, and duration. Clinical
experience amply demonstrates individual variation in the experience of pain following
equivalent tissue injury. At population level, variations of the prevalence of chronic pain
with social class, income levels and gender suggest the existence of risk factors that
would allow a public health approach to chronic pain. Physiological evidence from
neuro-imaging studies (PET, functional MRI, EEG and magnetoencephalography) points
to distinct and identifiable structural and functional changes in the brains of patients
with chronic pain (6,7). There remains uncertainty whether these changes lead to or
result from the chronic pain.
2.16 These ideas have led to the emergence of the concept of chronic pain as a condition or
disease or syndrome in its own right. The trigger for the initial experience of pain may
be an external injury or disease but other factors such as an underlying propensity to
chronicity, the availability or lack of fast effective treatment, the presence or lack of a
supportive environment for recovery, and a range of social and economic factors that
determine the level of motivation of the individual come together to determine whether
the end-result is chronic pain.
2.17 The distinction between the traditional biomedical view of pain-as-symptom-of-disease
and the emerging view of pain as a biopsychosocial condition (i.e. with a biological basis
at origin but with psycholigical and sociological determinants that justify viewing chronic
pain as a distinct disease entity) has practical implications . By viewing pain as a
symptom it is tempting for the patient to seek, and for the doctor to provide, extensive
Chronic Pain Health Needs Assessment 13
diagnostic work-up and repeated trials of therapeutic interventions in the search for a
cure that may not in reality be possible. Indeed the pursuit of such diagnostic and
therapeutic interventions perpetuates in the mind of the patient the notion that the
pain is a symptom and acts as a barrier to consideration of the alternative model. In
contrast, the model of chronic pain as a specific disease allows alternative and
potentially more effective interventions to be considered and found acceptable.
14 Chronic Pain Health Needs Assessment
3 EPIDEMIOLOGY OF CHRONIC PAIN
DEFINITIONS
3.1 From a clinical perspective, chronic pain exists when the patient feels that the pain is not
improving with readily available routine treatments. Pain itself is a subjective symptom
that the patient relates and therefore any distinction between acute and chronic pain must
also be led by the patient. However, for the purpose of epidemiological study of the
prevalence of chronic pain in the population, we need a clear definition even if its use in
questionnaires is dependent upon the subjective experience of patients.
3.2 The International Association for the Study of Pain (IASP) has defined pain as:
"An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage" (8)
3.3 Pain is classified by its chronicity (acute / chronic) and by whether the original underlying
tissue damage occurred within the nervous system or elsewhere (neuropathic /
nociceptive).
3.4 Acute pain is pain that is caused by occurrences such as traumatic injury, surgical
procedures, or medical disorders and which is short-lived, resolving during an appropriate
healing period.
3.5 Chronic pain is used to describe pain that is continuous, long-term or enduring beyond the
expected healing time. Pain itself is a subjective symptom that the patient relates and
therefore any distinction between acute and chronic pain must also be led by the patient.
However, for the purpose of epidemiological study of the prevalence of chronic pain in the
population, we need a clear definition even if its use in questionnaires is dependent upon
the subjective experience of patients. The IASP defines chronic pain as:
“Pain without apparent biological value that has persisted beyond the normal
tissue healing time (usually taken to be 3 months)” [Citation needed]
3.6 With chronic pain the patient’s presentation becomes more complex. There may be
psychological features, including complaints of poor or non-refreshing sleep, tiredness,
depression and poor concentration. Please note that this definition does not exclude the
presence of an underlying pathology.
3.7 The stated duration of 3 months is somewhat arbitrary but has come to be regarded as the
standard by most pain experts. In clinical practice some patients may approach doctors for
help sooner or later than the 3-month cut off period; some clinicians too may be inclined
to refer patients for help at an earlier stage; however, the IASP definition serves as a
useful, simple and practical definition to use in studying the population prevalence of
chronic pain.
3.8 For many underlying diseases and for many patients, pain is not constantly present; and
when it is constant the intensity often fluctuates. This variability in the experience of pain
is captured by the World Health Organisation (WHO) definition of chronic pain as [Citation
needed]:
Chronic Pain Health Needs Assessment 15
“Current and persistent pain that has been present most of the time for 6 months or
more”
3.9 Other definitions that have been used in studies include: [IASR 2003]
“Recurrent or continuous pain for more than 3 months”
“Pain on most days for more than 3 months”
“Pain every day for more than 6 months”
“Pain or discomfort, continuous or intermittent, for more than 3 months”
3.10 There are other pain syndromes where there is enough known about the natural history of
the underlying disease process to allow a definition that is not so dependent on duration
alone. For example, post herpetic pain and the pain of trigeminal neuralgia follow very
different courses in the ‘average’ case. An exceptional situation is that of fibromyalgia, an
ill-defined condition that has become prominent in recent years and differs from other
pain syndromes in its lack of definition in terms of the site of the pain and in many cases by
its widespread nature. The term fibromyalgia is seen as unhelpfully suggesting the tissues
involved with little or no evidence in support. Pain experts prefer the term Chronic
Widespread Pain (CWP). The American College of Rheumatology (9) defined CWP as pain
that has lasted for more than 3 months in at least two contra-lateral quadrants of the
body together with pain in the axial skeleton. This leads to some loss of specificity for the
most severe cases and a group from Manchester proposed what is known as modification
that has come to be known as the Manchester definition (10): pain that has persisted for
more than 3 months in at least two sections of two contra-lateral limbs together with
pain in the axial skeleton.
3.11 Pain can be classified clinically as either nociceptive or neuropathic, although in practice
these can co-exist (mixed).
3.12 Nociceptive pain (tissue damage pain) arises from mechanical, chemical or thermal
stimulation of nociceptors (e.g. after surgery, trauma or associated with degenerative
processes such as osteoarthritis). It is important to realise that pain may persist long after
the nociceptive process has ended and that other factors, e.g. psychosocial features, may
need to be considered.
3.13 Neuropathic pain (nerve damage pain) is initiated or caused by a primary lesion,
dysfunction, disease or pathological change in the central or peripheral nervous system
(e.g. in conditions such as diabetic neuropathy or spinal cord injury). It has quite different
clinical features from nociceptive pain. It is less well localised and often is described as
burning or shooting. It can occur in areas that are numb and where there is no tissue
damage. It commonly presents in primary care and can be difficult to diagnose.
SUB-CLASSIFICATION OF CHRONIC PAIN
16 Chronic Pain Health Needs Assessment
3.14 For the purpose of health needs assessment pain needs to be described in terms of sub-
categories of need. McQuay et al describe such a categorisation based on an audit of
demand at a pain clinic over a one month period. (11) The categorisation does not use the
mechanism of pain, apart from the generic grouping of neuropathic pain, giving the
following categories:
Musculoskeletal
Cancer
MUPS (medically unexplainable painful syndromes)
Face/head
Neuropathic
Vascular
Chronic postoperative pain.
Examples of conditions under each of these categories is given in Table 1.
3.15 The rationale given for including cancer as a category was that pain clinics commonly
provide invasive options for cancer pain at the behest of the palliative care team. [Text
here on whether/why we are excluding/ including cancer in the remit of this report]
Table 1 :Sub-classification of chronic pain
Musculoskeletal Back degenerative disc disease osteoporotic collapse stenosis facet joint post-trauma/surgery ankylosing spondylitis no clear pathology
Neck degenerative disc disease whiplash
Fibromyalgia/myofascial polymyalgia rheumatica Arthritis osteoarthritis, rheumatoid
Cancer Breakthrough cancer pain neuropathic, movement related, poor control
with oral morphine
MUPS (medically unexplained painful syndromes)
non-cardiac chest pain abdominal pelvic chest pain
Face/head pain Migraine Headache Trigeminal neuralgia Dental atypical facial
Neuropathic diabetic neuropathy postherpetic neuralgia multiple sclerosis
Chronic Pain Health Needs Assessment 17
post stroke repetitive strain injury reflex sympathetic dystrophy (CRPS1) traumatic
Vascular Peripheral claudication/Raynaud’s Central angina
Chronic postoperative pain
pain after amputation (phantom and stump) chronic postoperative breast pain chronic postoperative thoracotomy pain chronic postoperative cholecystectomy pain
Source: McQuay et al, 2007(11)
Musculoskeletal pain
3.16 Musculoskeletal pain is pain that arises in or affects the muscles, bones, joints, ligaments
and/or tendons. It may be caused by degenerative diseases such as arthritis or
degenerative disc disease, by a specific trauma or injury, by overuse, underuse
(immobilisation), repetitive actions, poor body alignment, or may have no clear pathology.
3.17 Approximately half of this category is due to back pain. Back pain itself can be classified
into neck pain (cervical), upper back pain (thoracic) and lower back pain (lumbo-sacral).
Lower back pain is the commonest back problem.
Medically unexplained pain syndromes (MUPS)
3.18 These are conditions where the patient has symptoms for which no medical cause can be
found. That is not to say that there is no physical cause, only that such a cause is uncertain,
not determined or in dispute.
3.19 Conditions included in this category include chronic fatigue syndrome (CFS), myalgic
encephalomyelitis (ME), and unexplained chest, abdominal, and pelvic pain. Symptoms of
CFS and ME often include widespread muscle and joint pain and headaches. [Query
overlap between CFS/ME and fibromyalgia/CWP in musculo-skeletal pain]
Face/head pain
3.20 This category included any chronic pain conditions occurring in the face or head. Examples
are migraine, headache, trigeminal neuralgia, atypical facial pain and dental pain.
Neuropathic pain
3.21 As described above neuropathic pain is caused by a lesion, disease or pathological change
in the central or peripheral nervous system. It may be caused by several, often
overlapping, disease processes and represents a varying set of conditions rather than a
single diagnosis. There is no universally accepted sub-classification but four broad classes
of disease based on aetiology and anatomy are recognised: (12)
focal and multifocal lesions of the peripheral nervous system
generalised polyneuropathies of the peripheral nervous system
18 Chronic Pain Health Needs Assessment
lesions in the central nervous system
complex neuropathic disorders
Examples of conditions in each of these classes are given in Table 2.(13)
3.22 Neuropathic pain commonly presents in primary care, can be difficult to diagnose and is
often unrecognised. Diagnosis is based on characteristic symptoms, altered sensation, and
a clinical history that matches a neuroanatomical or dermatomal pattern.
Table 2: Neuropathic pain syndromes
Sub-category Conditions
Peripheral nervous system focal and multifocal lesions
Post-herpetic neuralgia Diabetic mononeuropathy Nerve entrapment syndromes Plexopathy from malignancy or radiation Phantom limb pain Post-traumatic neuralgia (such as nerve root compression, post-thoracotomy) Ischaemic neuropathy
Peripheral nervous system generalised polyneuropathies
Metabolic/nutritional conditions: diabetes mellitus amyloid pellagra, beriberi multiple nutritional deficiency, hypothyroidism
Toxic conditions: alcohol platinum or taxane based chemotherapy isoniazid antiretroviral drugs
Infective/autoimmune conditions: HIV acute inflammatory polyneuropathy (Guillain-Barré syndrome) neuroborreliosis (Bannwarth’s syndrome)
Heriditary conditions: Fabry’s disease
Malignant conditions: Carcinomatosis
Other: idiopathic small fibre neuropathy
Central nervous system lesions Spinal cord injury Prolapsed disc Stroke (brain infarction, spinal infarction) Multiple sclerosis Parkinson’s disease Surgical lesions (such as rhizotomy, cordotomy)
Complex neuropathic disorders Complex regional pain syndrome types I and II
Chronic Pain Health Needs Assessment 19
Sub-category Conditions
Source: Freynhagen et al, 2009. (13)
Vascular pain
3.23 Vascular pain is the pain resulting from central and /or peripheral vascular conditions such
as coronary artery disease and atherosclerosis. Constriction or blockages of blood vessels
restrict blood flow and starve the muscles of oxygen resulting in cramps and/or pain. This
usually occurs under exertion or stress and is relieved by rest. Examples include
claudication, ischaemic rest pain, Raynaud’s phenomenon and angina.
Chronic postoperative pain
3.24 Chronic postoperative pain is pain that persists after the expected healing time for surgery.
It is usually focussed around the wound but may also radiate out to other parts of the
body. Specific causes include damage to peripheral nerves or body tissue during surgery,
scarring, and infection or inflammation at the site of the wound. Examples include pain
following amputation (phantom limb pain, stump pain) , mastectomy, thoracotomy, and
cholecystectomy, other postoperative abdominal and spinal pain; and failed back surgery
syndrome.
MOST COMMON SITES OF CHRONIC PAIN
3.25 A WHO survey of chronic care in primary care across 15 centres in Europe, Asia, Africa and
the Americas reported a prevalence of 22% of patients reporting ‘persistent’ pain.(14) The
most common anatomical sites where the pain occurred are given in table C. Back pain
was the most frequent affecting just under half of all those reporting pain. More than two-
thirds of patients reported pain in two or more sites.
Table 3: Anatomical site of pain
Anatomical site Subjects reporting pain (%)
Backpain 47.8
Headache 45.2
Joint Pain 41.7
Arm or leg pain 34.3
Chest Pain 28.9
Abdominal Pain 24.9
Pain Elsewhere 11.7
Number of anatomical sites
1 32.1
2 27.5
3 22.8
4+ 17.5
Source: Gureje et al, 1998. (14)
INCIDENCE AND PREVALENCE OF CHRONIC PAIN CONDITIONS
20 Chronic Pain Health Needs Assessment
3.26 A large number of studies have been carried out in many countries over many years to
estimate the population prevalence of chronic pain conditions. The results are influenced
greatly by a variety of factors, of which the most important are the definition of chronic
pain used, the type of study undertaken (population survey or analysis of health records),
method of interview (whether by telephone or face to face), the non-response rate,
specific demographic characteristics of the population studied, the method by which the
sample was drawn, and the specification of the sampling frame.
3.27 Given the intermittent, recurrent, episodic nature of chronic pain, careful consideration
must also be given to the choice of measure of the disease frequency, particularly for the
purposes of health needs assessment. The most commonly reported measures of
incidence of new patients or the point prevalence of patients with chronic pain conditions
provide limited information of the need faced by services. Ideally what is required is a
measure of the frequency over a given period of time. A common measure reported by
population surveys is the lifetime prevalence of a condition, i.e. what proportion of the
population have ever experienced the condition at any point in their life thus far. This too
is difficult to use for needs assessment. In most cases the best measure is period
prevalence, i.e. the proportion of people who have experienced an episode of the
condition during a defined time period, usually one year.
3.28 It is not the purpose of this report to review this vast literature in detail, rather it is to
present reasonable estimates of the incidence and/or prevalence of the various chronic
pain conditions to help quantify the burden of disease.
Chronic pain overall
3.29 The Chief Medical Officer’s report 2008 estimated that 7.8 million people in the UK live
with chronic pain defined as ‘moderate to severe pain that has lasted over 6 months’,
approximately 13% of the population.(2)
3.30 A European-wide pain survey in 2004 reported a similar prevalence figure of 18% in
Scotland with only 3% of people accessing specialist pain clinics.(15) However in a 2007
health needs assessment for chronic pain McQuay et al reviewed a number of European
and Canadian studies which mostly reported much a higher prevalence of up to 50% of the
population.(11)These are summarised in
Chronic Pain Health Needs Assessment 21
3.31 Table 4.
3.32 These studies suggest that chronic pain increases in frequency with age and is more
prevalent amongst women than men. Chronic pain may be particularly common in older
people in nursing homes or long-term care institutions. (16) Musculoskeletal pain is the
predominant sub-category. Two of the studies reported that for approximately half of
those with chronic pain the pain was severe.
3.33 McQuay et al estimated a typical Primary Care Trust population to have a prevalence rate
of patients with severe chronic pain of 5-10%.(11)
22 Chronic Pain Health Needs Assessment
Table 4: Studies of chronic pain prevalence
Study Location Definition of chronic pain Age group
Prevalence findings
Andersson 1993 (17)
Sweden Duration > 3 months 25-74 Men: 50% Women: 50% Musculoskeletal pain most common. Prevalence increased with age.
Brattberg et al 1989 (18)
Sweden Obvious pain Duration > 6 months
18-84 Men: 38% Women: 42% Musculoskeletal pain most common. Peak prevalence in 45-64 years olds.
Birse & Lander 1998 (19)
Canada Recurrent or persistent pain Duration > 6 months
18+ Men: 35% Women: 66% Musculoskeletal pain most common. Peak prevalence in older age group and young women.
Bowsher et al 1991 (20)
GB Chronic pain lasting on or off Duration > 3months
15+ Persons: 11.5% Prevalence increased with age. Higher prevalence in women than men (1.5:1).
Chrubasik et al 1998
Germany Prolonged pain in the previous 6 months
18-80 Persons: 47% Of which: 87% > 1 year duration; 50% had severe pain; 29% severe and > 1year duration. Musculoskeletal pain most common.
Elliott et al 1999 (21)
Scotland Continuous or persistent pain Duration > 3 months
25+ Persons: 47% Of which half had severe pain or disability. Musculoskeletal pain most common. Prevalence increased with age.
Arnow 2006 USA Currently troubled by pain all the time or on an d off Duration > 6 months
21-75 Persons: 45% 33% reported non-disabling chronic pain. 13% reported disabling chronic pain. Persons with chronic pain were 5 times more likely to be suffering a major depressive disorder.
Chronic Pain Health Needs Assessment 23
Study Location Definition of chronic pain Age group
Prevalence findings
Croft 2010 Various Various Adults Crude estimates based on a review of studies: Persons: 40% 25% prevalence for chronic pain interfering with life 10% prevalence for chronic disabling pain.
SjØgren 2009 Denmark Chronic/long-lasting pain Duration > 6 months
Persons: 20% Higher in females and increasing age. Higher prevalence associated with divorce, separation or widowed, <10 years of education and high BMI. 66.6% of chronic pain due to musculoskeletal diseases.
Musculoskeletal pain
3.34 Musculoskeletal disorders are the most common cause of chronic pain. Parsons et al
undertook a review of the literature for the incidence and prevalence of musculoskeletal
conditions for the period 1999-2010.(22) They identified two studies providing population
prevalence estimates for musculoskeletal pain overall: The Tameside Musculoskeletal
Project reported a prevalence of self-reported musculoskeletal pain of 11% in adult men
and 14% in women (13% for persons); the General Household survey 2006 reported similar
figures for long-standing musculoskeletal conditions of 12.6% for adult men and 18.3% for
women (15.6% for persons).(23,24)
Back Pain
3.35 Back pain is one of the commonest causes of disability and absence from work, particularly
during the productive middle years of adult life.(25) Low back pain probably affects around
one-third of the UK adult population each year. Of these, around 20% will consult their GP
about their back pain.(26) From this we can estimate 2.9 million people in England (1 in 15
of the population) will seek advice about back pain from their GP each year.
3.36 The data for quantifying how much of this is chronic pain is less reliable. One of the reasons
for this is the lack of agreement about definitions of chronic back pain, the different time
periods used and its intermittent nature.
3.37 A 1997 low back pain health needs assessment by Croft et al identified two UK surveys
reporting low back pain prevalence.(27) For both studies the one- year period prevalence
for low back pain lasting more than one day was 38% of adults.(28,29) Rates did not vary
much with age or gender. The OPCS study provided a breakdown by the number of days
of pain experience during the year. It reported that 10% of adults had pain for more than
12 weeks and 6% for more than a year.
24 Chronic Pain Health Needs Assessment
3.38 A UK-based survey carried out by Webb et al in 1996, using a very broad case definition of
self-reported ‘back pain lasting more than one day in the past 12 months’, found an annual
period prevalence rate of 40% in adults. Using a more clinically relevant definition of pain
reported as ‘lasting for the whole year’, adult prevalence was estimated as 15%.(30)
3.39 Hillman et al, in a two-phase survey carried out in Bradford, reported a one-year
prevalence of low back pain of 39% in adults aged 25-64 years. A quarter of these were
classed as chronic, lasting over 3 months (10%). For 62% of those with chronic low back
pain, the condition was a long-standing problem with a history of five or more years.(31)
3.40 The COST European guidelines for the management of chronic nonspecific low back pain
identified a number of reviews and studies of back pain prevalence.(32) One systematic
review of 30 population prevalence studies of low back pain reported point prevalence of
low back pain ranging from 12-33%, 1-year prevalence from 22-65% and lifetime
prevalence from 11-84%.(33) A further study carried out in Sweden reported a prevalence
of chronic low back pain lasting longer than 3months of 23%.(17)
3.41 The one year period prevalence of low back pain which radiates to the legs below the
knees was 11% and is consistent with other studies reporting figures of 12 to 15% of all
adults.(34,35)
3.42 The prevalence of true sciatica has been estimated at 5%.(36)
3.43 The OPCs study reported 10% of adults reported at least one day of moderate or severe
disability, for 8% this was of more than 12 weeks duration. For 5% of adults disability was
both severe and longer than 12 weeks duration. Scandinavian and Canadian studies have
reported 10-12% of the adult population having low back problems that result in
impairment of daily activities or high disability.(36,37,38)
3.44 The 2007 General Household Survey found 3.7% of men and 3.4% of women reported
longstanding illness as a result of back pain.(24)
Table 5: One year period prevalence of low back pain by category and duration
Category By total days in pain in past year Total
<12 weeks 12 weeks – 1 year
All Year
Prevalence of low back pain (%) 28% 4% 6% 38%
Prevalence of low back pain with leg pain (%)
5% 2% 4% 11%
Prevalence of severe sciatica (%) 0.2% 0.3% 1.5% 2%
Prevalence of moderate and severe disability (%)
2% 3% 5% 10%
Prevalence of severe disability (%) 1% 2% 3% 6%
The category ‘low back pain with leg pain’ includes severe sciatica. Source: Croft et al, 1997.(27)
Chronic Pain Health Needs Assessment 25
3.45 Hillman et al reported an overall annual incidence rate for the onset of new back problems
during the year, based on self-report from a questionnaire, of 4.7 per 100 (4.1 per 100
among men and 5.4 per 100 among women).(31)
3.46 The South Manchester Back Pain Study estimated a one year cumulative incidence for new
‘consulting’ episodes of 3.1 per 100 for men and 4.7 per 100 for women, and for new non-
consulting’episodes of 30.7 per 100 for men and 32.1 per 100 for women.(39)
3.47 In a German study of patients with chronic lower back pain, Freynhagen et al found 37% to
have predominantly neuropathic pain. These patients showed higher ratings of pain
intensity, with more numerous and more severe co-morbidities such as depression,
panic/anxiety and sleep disorders. The study estimated that 14.5% of all female and 11.4%
of all male Germans suffer from LBP with a predominant neuropathic pain component.(40)
Ankylosing spondylitis
3.48 Ankylosing spondylitis is a form of arthritis that mainly affects the lower back but may also
include other joints or parts of the body. The ligaments of lower spine become inflamed
and may stimulate bone growth resulting in vertebrae in the spine fusing together.
3.49 Studies have reported annual incidence rates for primary and secondary AS of 7.3 per
100,000 in the USA (41) and 8.7 per 100,000 in Norway.(42)
3.50 The Norway study reported point and period prevalence figures of 0.26% and 0.31%
respectively. This compares to another Norwegian study that reported a point prevalence
of 1,100-1,400 per 100,000.(43) A German study reported a point prevalence of 900 per
100,000 among blood donors in Berlin.(44) All studies report incidence/prevalence rates 3
to 6 times higher in men than in women.
3.51 The point prevalence of AS in the UK has been estimated at 1-2% of the population.(45)
Although dated, this figure is consistent with the second Norwegian and the Berlin studies.
The 4th RCGP survey (1991–92) reported an annual period prevalence for primary care
consultations for AS in the UK of 40 per 100,000 (60 per 100,000 among men and 10 per
100,000 among women).(46)
3.52 McQuay et al’s Chronic Pain HNA reviewed pain prevalence in patients with AS and
estimated 25-50% of AS sufferers experience chronic pain.(11) We estimate a point
prevalence of 250 to 1000 AS patients with chronic pain per 100,000 population.
Neck pain
3.53 McQuay et al’s chronic pain health needs assessment identified seven studies reporting the
prevalence of neck pain. Figures ranged from 5,000 to 20,000 per 100,000 population with
most estimates a round 10,000. They concluded that in a PCT population of 100 000
people there would be about 5000 cases.(11)
Whiplash
3.54 Whiplash describes a type of neck injury caused by sudden acceleration then deceleration
of the head resulting in spraining of the neck ligaments. It most commonly occurs as a
result of a road traffic accident, usually a collision from behind.
26 Chronic Pain Health Needs Assessment
3.55 The Association of British Insurers states that 570,000 claims are made a year for whiplash
injuries in the UK, an incidence rate of approximately 900 per 100,000 population.(47) This
figure will be exaggerated by the inclusion of fraudulent claims. In a 2002 paper Galasko
estimates the number of new cases per year in the UK at 250,000 or 400 per 100,000
population.(48)
3.56 A study of whiplash attendances to an emergency department in Southampton found that
1 in 125 new patients had a whiplash associated disorder (WAD) following a road traffic
accident (RTA), and that two thirds of these are likely to have some degree of disability
four to six weeks after injury. Just over half of all the RTA attendances met the inclusion
criteria for WAD.(49)
3.57 In a previous study Galasko et al reported 46% patients attending an emergency
department following injuries sustained in an RTA, were diagnosed with neck sprain.(50)
Osteoarthritis
3.58 Osteoarthritis is an inflammatory disease of the joints that results from the degeneration
of cartilage. It is the most common form of arthritis and commonly affects the hands, feet,
spine, hips and/or knees. Primary osteoarthritis is mostly the result of aging. Secondary
osteoarthritis may also occur as a consequence of other disease or conditions such as
obesity, congenital abnormalities, gout and diabetes.
3.59 It is difficult to determine the exact incidence and prevalence of OA as the structural
changes, usually identified by radiography, do not always correspond with the clinical
syndrome of joint pain and stiffness. The clinical syndrome is more common than
radiographically confirmed osteoarthritis and much radiographic osteoarthritis occurs in
the absence of symptoms. For the purposes of a chronic pain health needs assessment it is
the clinical syndrome that is of relevance.
3.60 Parsons et al have undertaken a review of studies on incidence and prevalence for a
number of musculoskeletal conditions including osteoarthritis.(22) They found incidence
figures reported by the Royal College of General Practitioners Research Surveillance Centre
and the General Practice Research Database. The RCGP RSC reported incidence rates of
patients consulting for the first time with GP diagnosed OA. In 2001, the rate was 700 per
100,000 men and 1,200 per 100,000 women. Incidence increased with age, peaking in the
75+ age group (2,900 per 100,000 men and 3,600 per 100,000 women). Incidence was
higher among women than men in all age groups over 25 years. The GPRD found the
annual incidence of OA to be 1,290 per 100,000 in men and 1,860 per 100,000 among
women aged 40 or over. The same source data sets also provided estimates of period
prevalence. The RCGP RSC reported an annual consulting prevalence in 2001 of 1,800 per
100,000 men and 3,200 per 100,000 women. The GPRD data was used to calculate age-
standardised prevalence rates of 1,200 per 100,000 men and 2,000 per 100,000 women.
3.61 The GP-based prevalence figures from the RCGP RSC and the GPRD are much lower than
those reported in population-based surveys. This suggests that many people with OA do
not consult their GPs.
Chronic Pain Health Needs Assessment 27
3.62 In a 2012 review Suri et al report symptomatic prevalence figures for osteoarthritis from
two studies set in the US. The prevalence in the over 45s for osteoarthritis of the knee
ranged rom 7 to 17%; in the hip 10%; and in the hand 11%.(51)
3.63 A Canadian study using routine administrative health data for British Columbia found a
point all-age prevalence of OA of 10.8% (8.9% for men and 12.6% for women). Prevalence
increased with age from around 10% in 45-49 year olds to over a third in those age d 70-74
years. The overall incidence rate of new cases was reported as 1,170 per 100,000 (1,000 in
men and 1340 in women).(52)
Rheumatoid Arthritis
3.64 Early figures for rheumatoid arthritis prevalence were published in 1961 for a study in
Leigh and Wenslydale. It reported a population prevalence of 1.1%.(53) More recent
figures have been published by the Norfolk Arthritis Register based on primary care
consultations. In 1990 this register reported an annual incidence of new cases of RA of 27
per 100,000 men, and 56 per 100,000 women.(54) The same register has also been used to
produce adult prevalence estimates extrapolated to the UK of 0.8% (0.4% among men and
1.1% among women). The prevalence was higher among women than men for all
groups.(55)
3.65 Similar figures were produced by the RCGP RSC for the year 2001 with one year period
prevalence for primary care consultation for RA of 0.2% among men and 0.6% among
women.(22)
Psoriatic arthritis
3.66 Psoratic arthritis is a type of inflammatory arthritis that occurs in patients with psoriasis. It
causes pain and swelling in the joints and may also affect tendons and ligaments.
3.67 The Norfolk Arthritis Register provides an estimate of psoriatic arthritis incidence for the
UK. In 1990-93 it reported an age adjusted incidence of 3.5 per 100,000 in adult males and
3.4 per 100,000 in adult females. Cases were defined as co-occurring psoriasis and
peripheral inflammatory polyarthritis.(56)
3.68 A study in Minnesota estimated the age and sex adjusted annual incidence of psoriatic
arthritis among adults to be 7.2 per 100,000 (9.1 per 100,000 in men and 5.4 per 100,000
in women).(57) A 2007 review by Cimmino reported incidence from four of studies in the
USA and Europe with rates ranging from 3 to 23 per 100,000.(58)
3.69 In the Minnesota study, the point prevalence of PsA in adults in 2000 was reported as 158
per 100,000 (193 per 100,000 men and 127 per 100,000 women).(59) Cimmino’s review
also included prevalence figures and reported point prevalence figures from six studies in
Europe and the USA ranging from 0.06% to 0.42%.(58)
Polymyalgia rheumatic
3.70 Polymyalgia rheumatic is an inflammatory condition that causes pain and stiffness in the
shoulders, neck and pelvis. Other systemic symptoms include lethargy, weight loss and
depression.
28 Chronic Pain Health Needs Assessment
3.71 A 2008 review of the disease in the BMJ characterised its epidemiology as follows:(60)
The incidence of the disease in patients aged over 50 is about 100 per 100,000.
The average age of onset is just over 70 years of age. It is seldom diagnosed in
people younger than 50 years of age.
Polymyalgia rheumatica (PMR) is seen mainly in people of north European ancestry,
although it can occur in any ethnic group.
Women are more frequently affected than men with a female:male ratio of
approximately 3:1.
3.72 Defining a prevalent case of PMR is difficult, as the disease may be completely suppressed
by successful treatment with steroids. This may help to explain McQuay et al’s finding that
prevalence figures found in their review varied greatly, ranging from 30 per 100,000 to
2,000 per 100,000.(11)
3.73 Parson et al’s review reported prevalence figures from a UK community based study of
1,090 per 100,000 persons aged over 50 years; and annual period consultation prevalence
rates from the RCGP RSC of 140 per 100,000 men and 311 per 100,000 women.(22)
3.74 For their health needs assessment McQuay et al estimated an incidence rate of 50 per
100,000 person years and a point prevalence of 500 per 100,000 persons in a typical PCT
population. (11)
Chronic Widespread Pain (CWP) and Fibromyalgia
3.75 Chronic widespread pain (CWP) is a musculoskeletal disorder characterised by fatigue and
widespread chronic pain in the muscles and fibrous tissues of the body which can be
described as burning, throbbing, shooting, or stabbing. The cause is uncertain and there is
currently no generally accepted cure. The term fibromyalgia is often used as a pseudonym
but which in strict definition terms is a sub-set of CWP. The American College of
Rheumatology (ACR) diagnosis criteria used for fibromyalgia requires the presence on
examination of at least 11 of 18 specific tender points. Only about 20% of patients with
chronic widespread pain will meet these criteria, the remaining 80% are likely to have pain
that is similarly ‘central’ in nature, i.e. pain that is not due to inflammation or trauma.(61)
3.76 Parsons et al reviewed three UK studies looking at the prevalence of CWP in adults. The
point prevalence figures ranged from 7.9 to 9.4% in men and 10.5 to 15.6% in women.
They found no recent UK figures for the prevalence of fibromyalgia but did report two
North American studies with figures of 0.5% and 1.6% for men and 3.4% and 4.9% in
women.(22)
3.77 A single study was reported that investigated the incidence of GP-diagnosed fibromyalgia
based on data from the GPRD. The consulting incidence of fibromyalgia in 2001 was
estimated to be 35 per 100,000 person years. The incidence was reported to be 4 times
higher in women than in men.(62) CWP and fibromyalgia can occur at any age but peak
incidence and prevalence occurs around 50-64 years.(22,63)
Chronic Pain Health Needs Assessment 29
3.78 McQuay et al estimate that in a primary care trust population of 100 000 people there
would be about 10,000 cases of chronic widespread pain, with about 200 to1000 of those
being defined as fibromyalgia.(11)
Knee pain
3.79 In older age groups osteoarthritis is responsible for most cases of knee pain but as
discussed above the epidemiology of joint pain and radiologically confirmed OA is not the
same. Parsons et al identified four studies of the prevalence of knee pain using GP
populations as the sampling frame. Figures reported include a point prevalence of 28.7%
of 40-79 year olds in Nottingham, and 19% of over 18s in the south east; a one month
prevalence of 19% of over 16s in Tameside; and one year period prevalence of 51% of over
50s in Staffordshire.(22,64)
3.80 A review by Peat et al identified five studies in England measuring the prevalence of knee
pain in older adults (various definitions but minimum age was 40 years) with figures
ranging from 13% to 28%.(65)
Shoulder pain
3.81 The prevalence of shoulder pain in the adult population is high. The Parson et al review
reports figures of 7–20% from population based surveys. Surveys in Tameside, Manchester
and South East England all reported prevalence rates of 14% in men and 17% in
women.(22)
3.82 A UK study using the IMS primary care consultation database, reported an incidence rate of
1.47% for adults aged over 18 for all shoulder conditions (1.45% for men, 1.49% for
women). The same study recorded a prevalence of 2.36% (2.28% for men, 2.43% for
women). Only 17% of these shoulder conditions were coded as ‘shoulder joint pain’ or
‘arthralgia – shoulder’, corresponding to a prevalence of 0.24%. Comparison to the
population survey based figures suggests that many people suffering shoulder pain do not
consult their GPs.
Medically unexplained pain syndromes (MUPS) [Query Overlap with musculo-skeletal symptoms
particularly CWP / fibromyalgia]
3.83 There is very little literature on the incidence and prevalence of medically unexplained pain
as a distinct condition. Two Dutch have attempted to quantify the presentation of such
symptoms in general practice. Verhaak et al looked at the consultations for medically
unexplained physical conditions, including a ‘cluster’ of pain conditions. Between 25 to
50% of all the GP consultations were medically unexplained but they included as cases only
those that had a persistent condition, defined by presenting at least 4 times during the
year of the study. Of all patients over 18 years of age who consulted with a GP during the
year, 2.45% had persistent medically unexplained physical symptoms, nearly half of these
(1.2%) had symptoms in the pain cluster.(66)
3.84 The aim of the second study by Kerssens et al was to estimate the prevalence of
unexplained severe chronic pain (USCP) in general practice. Patients were included if they
were aged between 18 and 75 years; and had pain which had lasted at least 6 months, was
30 Chronic Pain Health Needs Assessment
the most prominent aspect in the clinical presentation, was serious enough to justify
clinical attention, and had led to obvious discomfort and disability in their daily life for at
least for 1 month. The overall prevalence was 7.91 per 1000 enlisted patients, ranging
from 1.87 in the youngest to 13.50 in the oldest patients.(67)
Face/head
Migraine
3.85 The reported prevalence rates for migraine vary greatly and depend largely on the case
definition used and age and sex structure of the study population. McQuay et al report
prevalence figures of 5 to 8% of men and 14 to 22% of women in a review of 10
studies.(11)
3.86 Rates were highest for both men and women in the 30-45 age group. The findings are
consistent with those reported in a meta-analysis of 18 studies of all ages and from all
countries.(68) Only about one in five or six people who suffer from migraine will seek
medical care.(69)
3.87 McQuay et al estimate that a primary care trust of 100 000 people will have about 10 000
women and 2000 men who suffer from migraine.(11)
Headache
3.88 Tension type headaches are the most common form of headache. McQuay et al identified
5 studies of chronic tension type headache –i.e. where a tension type headache occurs on
15 or more days per month. All of the studies used validated methods such as clinical
examination, telephone interview or self-assessed questionnaires. Four of these studies
reported one-year prevalence figures of between 1 and 3%, with higher rates in women
than in men.(11)
3.89 Cluster headaches are rare, extremely painful and debilitating headaches that occur in
groups or clusters. A review of the limited epidemiological studies by Torelli et al identified
5 studies with prevalence rates ranging from 56 to 326 per 100,000. There own study in
Parma reported a rate of 279 per 100,000 population aged over 14 years (338 per 100,000
men and 227 per 100,000 women).(70)
Trigeminal neuralgia
3.90 Trigeminal neuralgia is rare and there are very few epidemiological studies reporting its
incidence or prevalence. A Minnesota study reported an annual incidence rate of a first
episode of trigeminal neuralgia of 4.7 per 100,000 (3.4 per 100,000men and 5.9 per
100,000 women). The incidence rate rose with age with a peak in the 50-70 years age
group. The authors estimated a prevalence rate for current or recent attack in the 50-70
year age group of 400 per 100,000.(71)
3.91 A large study in Carlisle in the 1950s reported an incidence rate of 2.1 per 100,000 but the
authors noted that this was likely to be an underestimate as data from local ENT hospitals
were not included.(72)
Chronic Pain Health Needs Assessment 31
Neuropathic pain
3.92 The overall prevalence of neuropathic pain in the general population is difficult to quantify,
due to the large number of underlying causes and the lack of standardised measurement
methods. However, two surveys suggest a prevalence rate of 6-8% of the general
population report chronic neuropathic pain.(73,74)
3.93 It has been estimated that half of such patients will require medication and regular support
to manage their pain.(75)
3.94 A study of primary care records from the Netherlands estimated the annual incidence of
neuropathic pain in the general population to be almost 1%.(76)
Diabetic neuropathy
3.95 In a community-based study from northwest England of 15,692 patients with diabetes, the
prevalence of clinical neuropathy was 49%, the prevalence of painful neuropathic
symptoms was 34% and the prevalence of painful neuropathy symptoms accompanied by
clinical neuropathy was 21%. The risk of painful neuropathy was increased in patients with
type 2 diabetes, women, and those of South Asian ethnicity.(77) studies have estimated
the prevalence of painful diabetic neuropathy in persons with diabetes to be between 16%
and 26%.(78,79,80)
3.96 The prevalence of diabetes in England in 2011 was 5.5%.(81) From these figures we
estimates that in a typical PCT population of 100,000 there are in the region of 5,500
people with diabetes, of whom approximately 1,850 have painful neuropathic symptoms
and of those 1,100 have clinical diabetic neuropathy.
3.97 Hall and colleagues have undertaken two studies of the incidence of painful diabetic
neuropathy using similar methods but two different UK primary care databases. They
reported incidence rates of 15.3 and 26.7 per 100 000 person years.(82,83)
Postherpetic neuralgia
3.98 Studies identified by McQuay et al estimate that Herpes zoster occurs in the general
population at a rate of about 340 per 100,000 person years. Postherpetic neuralgia (PHN)
is a common complication of herpes zoster, occurring in about 13–26% of cases. In the
studies reviewed, painful neuropathy in over 40% of people with herpes zoster aged over
50 was a common finding.(11)
3.99 A review of neuropathic pain epidemiology studies by Smith et al (84) found incidence
figures of 3, 27.3 and 40.2 per 100,000 person years. (85,86,87) A further study reported
an incidence rate for primary care consultation for postherpetic neuralgia of 34 per
100,000 person years.(88)
Multiple sclerosis (MS)
3.100 The crude incidence rate of MS in the UK has been estimated at 3.4 per 100,000 person
years for men and 7.4 for women.(89)
32 Chronic Pain Health Needs Assessment
3.101 Based on a review of prevalence studies Richards et al estimated the prevalence rate of MS
in England & Wales for 2000 to be between 107 and 117 per 100,000 population.(90)
3.102 McQuay et al reviewed a number of studies examining the prevalence of chronic pain in
patients with MS. The definitions of chronic pain differed and but in all studies pain was
common, prevalence figures ranged from 29% to 65%.(11)
3.103 Based on the above figures we estimate a typical PCT population of 100,000 people in
England or Wales could expect to have about 55 patients with multiple sclerosis and
chronic pain and 3 new cases with pain each year.
Chronic post-stroke pain
3.104 Estimates of the incidence of stroke from two studies in England varied from 116 to 152
per 100,000 person years for men and from 135 to 171 for women.(91,92) A third study
reported a lower incidence of 104 per 100,000 person years for both genders
combined.(93)
3.105 Estimates for the prevalence of stroke in England vary depending on the source. Estimates
based on GP records suggest an all age prevalence of about 0.7%. (92),(93) Population
survey-based and modelled estimates suggest a prevalence figure around 3 times higher at
around 2 to 2.5%.(94,95)
3.106 In two studies identified by McQuay et al the prevalence of chronic pain in patients who
had had a stroke varied from 2% to 8.4%.(11)
3.107 In a primary care trust of 100 000 people we estimate there could be as many as 40 to 200
people living with chronic post-stroke pain.
Complex Regional Pain Syndrome (CRPS)
3.108 Complex regional pain syndrome (CRPS) is a type of chronic limb pain with clinical features
that include sensory, sudo- and vasomotor disturbances, trophic changes and impaired
motor function. The major characteristics are the presence of pain that is severe, diffuse,
non-dermatomal, and associated with allodynia (pain response to a non-painful stimulus).
The disease course varies from relatively mild and self-limiting to chronic disease with a
high impact on daily functioning and quality of life. CRPS most commonly affects a single
limb but involvement of other limbs by a spread of the process from the original affected
limb is known to occur.
3.109 The International Association for the Study of Pain divides CRPS into two types based on
the presence of nerve lesion following the original injury.
Type I, also known as Sudeck's atrophy, reflex sympathetic dystrophy (RSD), reflex
neurovascular dystrophy (RND), or algoneurodystrophy, does not have
demonstrable nerve lesions.
Type II, also known as causalgia, has evidence of obvious nerve damage.
3.110 Two population based studies have attempted to measure the incidence and prevalence of
CRPS in the general population. The first, set in Rochester, Minnesota over the period
1989-99 reported an incidence rate for CRPS I of 5.46 per 100,000 person years.(96)
Chronic Pain Health Needs Assessment 33
Women were much more likely to be affected than men with incidence rates of 8.57 and
2.16 per 100,000 respectively. One-year period prevalence was also reported with a figure
of 20.57 per 100,000 population overall and 35.33 and 5.06 for males and females
respectively. Onset could occur at any age but the incidence increased to a peak in the 50-
69 age groups and decreased again thereafter. Incidence and one-year period prevalence
rates for CRPS II were found of 0.82 per 100,000 person years and 4.2 per 100,000 persons
respectively with no significant difference observed between genders. The study also
found that 74% of the CRPS cases underwent resolution, often spontaneously.
3.111 The second, more recent study was undertaken in the Netherlands over the period 1996-
2005 using a primary care research database. (97) The estimated overall incidence rate of
CRPS was over four times higher than the American study at 26.2 per 100,000 person
years. Females were affected at least three times more often than males (ratio: 3.4). The
highest incidence occurred in the 61-70 years age group. The study did not report
prevalence.
Vascular pain
3.112 There is substantial information on the incidence and prevalence of cardiovascular disease
due to its high mortality and morbidity. There is limited information about the incidence
and prevalence of painful symptoms associated with these conditions.
Intermittent claudication
3.113 Population studies have found that about 20% of people aged over 60 years have some
degree of PAD, and the most common initial symptom is pain in the leg on walking known
as intermittent claudication.(98)
3.114 A Dutch study of the prevalence of intermittent claudication reported a point prevalence in
an over 55 years population of 1.6% (2.2% of men and 1.2% of women). The same study
undertook a review of a further 13 population based surveys for similar age groups with
figures of the order of 1 to 2%.(99) A further Dutch study estimated the incidence rate of
IC as 640 per 100,000 person years in the over 55s.(100) The Framingham Heart Study in
Massachusetts reported a lower incidence of 225 per 100,000 person years in those aged
over 40 during the 1990s.(101)
3.115 A typical primary care trust of 100 000 people might expect to have 529 400–800 people
with intermittent claudication, and see 100-180 new cases a year.
Raynaud’s phenomenon
3.116 McQuay et als health needs assessment identified four population studies measuring the
prevalence of Raynaud’s phenomenon. The figures ranged from 2% to 15% but depended
to a large extent on the disease definition used.(11)
3.117 An additional 7-year study of Raynaud’s phenomenon based on the Framington Heart
Study in Massachusetts showed baseline prevalence rates of 11% in women and 8% in
men.(102)
34 Chronic Pain Health Needs Assessment
3.118 We estimate a typical PCT population of 100,00 might expect to have of the order of 1,800
to 13,000 people with Raynaud’s phenomenon but cannot quantify how many of these will
be suffering from chronic pain.
Angina
3.119 The British Heart Foundation (BHF) report lifetime prevalence (having ever been diagnosed
with) angina in England 2009 based on data from the GPRD.(94) Male prevalence increases
from 0.1% in 0-44 year olds to 16.7% in the over 75s with an all age prevalence of 2.0%.
Female prevalence increases from 0.1% in 0-44 year olds to 11.5% in the over 75s with an
all age prevalence of 21.2%. These GP-based prevalence figures are lower than those
reported by population surveys. The Health Survey for England 2006 reports lifetime
prevalence rates in males from 0.1% in 16-24 year olds to 22.7% in the over 75s with an all
age proportion of 4.8%. For females, proportions increase from 0.1% in the 16-24 year olds
to 15.9% in the over 75s, with an all age figure of 3.3%.(103)
3.120 McQuay et al identified 4 population survey based studies which provide reliable
prevalence estimates for angina in the UK and estimated a figure of 5% in all adults.(11)
3.121 The BHF also report incidence rates for angina in England 2009 based on the same GPRD
source. Male rates increase from 54 per 100,000 person years in the 45-54 age group to
194 in the 65-74 year olds. Female rates are lower and increase from 30 per 100,000
person years in the 45-54 age group to 128 in the 65-74 year olds. All age incidence rates
are 45 per 100,000 person years for men and 25 for women. These incidence rates appear
low compared to the prevalence levels reported.
3.122 Neither of the above measures reported above lifetime prevalence or incidence of angina
provide information that readily quantifies the expected need for chronic pain services
related to angina.
3.123 A primary care trust with a population of 100 000 might expect to have about 4000 people
who have or have had angina.
Chronic postoperative pain
3.124 The lack of an accepted definition for chronic postoperative pain is a major barrier for
quantifying its incidence and/or prevalence from the literature. Poor study design and
variations in the definitions of time after surgery, severity of pain, and its effect on quality
of life and function are largely responsible for the wide range in the published incidence
figures for given procedures. However it is clear from the scale of the estimates that
chronic postoperative pain is a significant problem. The best estimates for chronic pain
following major surgery are of the order of 10 to 50% of which between 2 to 10% are likely
to be severe.(104)
3.125 In most affected patients, postoperative chronic pain closely resembles neuropathic pain.
Major nerves trespass the surgical field of most of the surgical procedures associated with
chronic pain, and damage to these nerves is probably a prerequisite for the development
of postoperative chronic pain. In a subset of patients, a continuous inflammatory
Chronic Pain Health Needs Assessment 35
response, such as after inguinal mesh hernia repair, can contribute to a maintained
inflammatory pain. Differentiation of neuropathic from non-neuropathic causes of
postsurgical pain is essential for the design of effective strategies to prevent and treat the
conditions.
3.126 Table 6 summarises the incidence estimates for selected surgical procedures from a
number of reviews and studies. In his review Macrae estimated a total incidence of new
cases of postoperative chronic pain for his included procedures to be between 41,000 and
103,000 in the UK, based on the number of procedures being undertaken.(105)This is
equivalent to 65 to 165 new cases per 100,000 population.
Pain after amputation (phantom limb pain)
3.127 The reviews suggest anywhere from 10% to 85% of patients undergoing an amputation will
suffer from chronic postoperative pain.
3.128 McQuay et al’s health needs assessment differentiates estimates for phantom limb pain
and stump pain. They reported phantom limb pain occurring in half to three-quarters of
amputees and that the pain can continue to persist long after the surgery (7 years). In one
study 7.5% experienced constant pain in the phantom limb. Studies on stump pain
reported rates of chronic pain from 49% to 62%.(11)
3.129 From data from a Dutch and a Finnish study McQuay et al estimates a prevalence of 25
amputees in a typical PCT population of 100,000 most of whom will have phantom limb
and/or stump pain.
3.130 A UK primary care based study has reported an incidence rate of 0.8 per 100,000 person
years for phantom limb pain.(106)
Chronic postoperative breast pain
3.131 McQuay et al reviewed 8 studies reporting the occurrence of chronic pain after breast
surgery. There was some variation because of time after surgery and whether the
definition included lumpectomy or only full mastectomy, but typically 20 to 50% of
patients reported chronic pain. Between 5 and 10% reported severe disabling pain.(11) A
wider range for chronic pain prevalence of 13 to 69% was reported by a second
review.(107)
3.132 Despite changes in surgical practice that have reduced the number of radical mastectomies
and replaced them with less invasive techniques the rate of chronic postoperative pain
remains high. A 2007 study of sentinel lymph node biopsy or axillary lymph node
dissection reported a prevalence of 22% and 55% respectively for numbness at 5 years
after surgery. (108)
Chronic postoperative thoracotomy pain
3.133 Chronic pain after thoracotomy was common occurring in 5 to 65% of patients. Estimates
for the occurrence of severe pain ranged from 10% to 15% to 25%.(11,109) It is difficult to
quantify the number of thoracotomy procedures performed in England as the routine HES
36 Chronic Pain Health Needs Assessment
statistics report on the main procedure in an episode. Thoracotomy is unlikely to be
recorded as the main procedure.
Chronic postoperative cholecystectomy pain
3.134 McQuay et al reported two prospective studies investigating the occurrence of chronic scar
pain following open cholecystectomy. At 12 months occurrence of chronic pain at the
incision site was 27%, and at 24 months 21%. Two further studies attempted to compare
the occurrence of chronic pain after between open and laparoscopic cholecystectomy. Stiff
et al. reported a occurrence of 3.4% after laparoscopic compared with 9.7% after open
procedure. Wilson and Macintyre found a similar occurrence of 7% in both
groups.(110,111)
Other postoperative pain
3.135 Poobalan et al’s review of pain following inguinal hernia repair concluded that 30% of
patients report chronic pain of which a third (10%) are moderate to severe. The reported
pain was predominantly neuropathic in character.(112) A second inguinal hernia review by
Aasvang and Kehlet estimated 12% of patients will suffer from chronic postoperative
pain.(113)
3.136 Studies investigating postoperative pain following orthopaedic surgery have reported an
incidence of chronic pain between 8 and 28% for hip replacement with pain limiting daily
activities to a moderate, severe or very severe degree in 12.1%.(114,115) An incidence of
35% has been reported for knee replacement.(116)
3.137 There have been very few studies of chronic pain following minor orthopaedic surgery. One
study in France has reported chronic postoperative pain incidence of 22% in patients
undergoing surgery for Carpal Tunnel Syndrome, a rate similar to those reported above for
major surgeries.(117)
Table 6: Estimated incidence of chronic postoperative pain and disability after selected surgical procedures
Procedure Kehlet 2006 (118) NHS QI
Scotland
2006
(119)
Macrae
2008
(120)
McQuay
2007 (11)
Selected
Other
(121,122,
123)
Main
procedure
episodes
England
2011/12
(124,125)
Chronic
pain
Severe
(dis-
abling)
pain
Amputation 30-50% 5-10% 30-85% 50–85% 51-85% 15,000
Breast surgery
(lumpectomy and
mastectomy)
20-30% 5-10% 11-57% 20–50% 25-50% 58,000
Thoracotomy 30-40% 10% 5-67% 5–65% 14-67%
Cholecystectomy 3-56% 5–50% 3-27% 69,000
Inguinal hernia repair 10% 2-4% 0-63% 5–35% 30% 81,000
Chronic Pain Health Needs Assessment 37
Caesarean section 10% 4% 6% 166,000
Cardiac surgery 30–55% 41,000
Coronary artery
bypass surgery
30-50% 5-10% 20,000
Hip replacement 12% 8-22% 83,000
Knee replacement 35% 79,000
THE NATURAL HISTORY OF CHRONIC PAIN
3.138 Chronic pain is not yet formally recognised as a separate disease entity and therefore not
recorded as such. Clinical data systems record the underlying disease and therefore there
is not much readily available information on the course of chronic pain over time. There is
therefore a paucity of good data on which to base robust conclusions about the natural
history of chronic pain. Research studies too are scarce since chronic pain is a field that has
only recently been opened up to epidemiological investigations.
3.139 One of the few good follow-up studies is that by Elliott(126), who reported a 4 year follow-
up study based on the original cohort that was assembled in 1996 for their prevalence
study reported earlier(127). They achieved a response rate of 83% of the original
respondents. 79% of those with chronic pain at baseline still had it at follow-up with an
average annual recovery rate of 5.4%. Older people (aged 45-74) with chronic pain were
less likely to recover than those aged 25-34.
3.140 The course of chronic widespread pain (CWP) has been reported in a follow-up study from
Manchester(128). A postal survey was carried out of 2334 adults registered with 2 general
practices and repeated again 7 years later with those of the initial responders who were
still registered with the same practices. While CWP prevalence was broadly similar on both
occasions (11% and 10% respectively), the interesting finding was of the persistence of
CWP. Of those with CWP initially, a third recorded CWP on the follow-up survey, while only
2% of subjects with no initial pain recorded CWP on the subsequent survey. Age was an
important factor in the persistence of CWP. Among subjects with CWP in the initial survey
who were aged over 50, 77% reported CWP 7 years later. Pain once established is likely to
persist or recur and older age appears to be a risk factor.
3.141 In a one year follow-up study of subjects with CWP identified in a survey of people
sampled from a population-based register, researchers from the same unit in Manchester
found that CWP persisted in 56% of patients at 1 year. This is a useful finding since the
impression gained from clinic based cohorts is that the persistence of pain is much more
frequent. Persistence of pain symptoms was also found to be associated with a pattern of
illness behaviour characterised by frequent visits to the doctor and high baseline test
scores for psychological distress and fatigue.
38 Chronic Pain Health Needs Assessment
4 THE ECONOMIC COSTS OF CHRONIC PAIN
4.1 The CMO report of 2008(2) reported a figure of £12.3 billion as the total cost of back pain
alone. This figure included not only the direct costs of investigating and treating the
underlying disease and the pain itself but also the indirect costs incurred due to lost
productivity arising from sickness absence, compensation payments, and welfare benefits.
Of the direct costs of chronic pain, prescriptions of pain relieving drugs account for an
expenditure of £584 million each year.
4.2 Phillips(129) provides a concise summary of the available research from different countries
into the economic impacts of pain. For the UK, the indirect (lost productivity) cost of back
pain was estimated to be between £5 billion and £10.7 billion in 1998 depending on the
assumptions made.
4.3 The link between a health related problem and employment was explored exhaustively in
the report by Dame Carol Black(130). Back pain is the fourth most common cause of short
duration sickness absence (up to one week), after colds, flu and diarrhoea and sickness.
Back pain and other pain related ‘problems with joints or muscles’ each accounted for 10%
of absences of between 1 and 4 weeks.
4.4 A clear distinction is necessary between painful conditions (injury, joint and muscle pain,
low back pain) and chronic pain. Specialist pain services see the most severe cases of
chronic pain; these are difficult to treat and rehabilitate and so they may have the
impression that a return to work is not the norm. However, more systematic studies show
that 85% of those off work due to musculoskeletal injuries and 83% of those with back
pain actually return to work after and absence of 4 weeks or more.
4.5 Of the 4 leading causes of long term sickness absence, two (musculo-skeletal conditions,
and back pain) are related to chronic pain. The other two are stress/anxiety/depression,
and cancer-related illnesses, where too there may be an overlay of pain as a leading cause
of loss of functional ability.
NHS EXPENDITURE ON CHRONIC PAIN
4.6 The Department of Health’s Programme Budget project provides a source of information
on where the NHS is spending its budget. Since 2003/4 annual data have been supplied by
Primary Care Trusts detailing their expenditure by specific healthcare conditions or
categories. The programme budgeting collection for 2010/11 comprised 23 categories,
most of which are based on the World Health Organization’s International Classification of
Disease version 10 chapter headings. Examples include: Cancers & Tumours, Mental Health
Disorders, and Problems of Circulation. Each of the categories is further divided down into
more specific sub-categories. Budgets spent on chronic pain are assigned to the category
7-Neurological Problems and the sub-category 7A-Chronic Pain.
4.7 In addition the data set for 2010/11 also saw the introduction, for the first time, of a
breakdown of the programme budget category data by 12 care settings.(131) These
settings are described in Table 7.
Chronic Pain Health Needs Assessment 39
Table 7: Programme Budget care settings
Care setting name Description
Prevention & health promotion
Primary & secondary prevention, health promotion, family planning, school health services, national screening programmes, public health programmes for communicable and non-communicable disease, epidemiological surveillance and public health administration.
Primary care Primary care costs relating to services provided by GPs, primary dental services and primary ophthalmic services excluding those which relate to prevention/health promotion.
Primary prescribing Primary care activity relating to prescribing or pharmaceutical services, excluding those which relate to prevention/health promotion.
Inpatient: Elective & Daycase
Admitted patient care activity which takes place in a hospital setting where the admission was elective or as a day-case.
Inpatient: Non-elective
Admitted patient care activity which takes place in a hospital setting where the admission was as an emergency/non-elective.
Outpatient Outpatient attendances or procedures.
Other secondary care Activity included with this setting will include direct access services, unbundled services (excluding critical care) and secondary care services which cannot be allocated to more specific settings. Mental Health secondary care services should also be included within this care setting.
Ambulance Urgent and emergency transport, i.e. Ambulance activity and 111 expenditure.
A&E All activity which takes place within A&E departments and minor injury units.
Community care Care delivered outside of a hospital and within local communities. Inpatient and outpatient activity carried out within community hospitals should be classified as secondary care activity. All other activity carried out in community hospitals should be classified as community care.
Care provided in other setting
All other health and social care services which are not included within the other health settings. Includes prison healthcare, nursing homes, hospice care. Continuing care, intermediate care, respite care, free nursing care should be included within this setting. Social care and learning disability services should be included within this setting unless otherwise specified by the mappings.
Non health / social care Expenditure which is not related to the commissioning or provision of health/social care services (e.g. costs relating to facilities & estates).
4.8 Mapping activity and budget data to programme budget categories and care settings is a
detailed process. Guidance documentation is provided to PCTs by the Department of
Health (131) and PCTs are encouraged to adhere to the outlined mappings even where
local knowledge may enable more accurate allocations. If uniform allocation is achieved
then variation of expenditure between PCTs is less likely to reflect coding and calculation
differences.
4.9 Spend and activity mapping to sub-category 7A-Chronic Pain for the main care settings of
primary prescribing, outpatient and inpatient settings data are outlined below:
Primary prescribing
40 Chronic Pain Health Needs Assessment
4.10 The mapping of the spend on drugs prescribed in primary care to Programme Budget sub-
category is not undertaken at the patient or script level, i.e. it is not possible to assign
individual scripts to a sub-category based on the indication for which it was written.
Instead, British National Formulary classifications are used to map the total PCT spend on
each type of drug to the sub-categories. Where drugs have indications from across more
than one sub-category, the expenditure is allocated to those categories on a defined split
basis.
4.11 Table 8 lists those drugs from BNF classification section 4.7 – Central Nervous system:
Analgesics that are allocated to 7A–Chronic pain, together with their splits.
Table 8: Primary care prescribing – drugs mapped to Programme Budgeting sub-category 7A-
Chronic Pain
BNF Section Sub-section Chemical substance Programme Budget Sub-
category (% split)
4 Central nervous system
4.7: Analgesics
4.7.1 Non-opioid analgesics 7A/15X/16X (5:75:20)
4.7.2 Opioid analgesics
Buprenorphine 7A/2X (50:50)
Codeine phosphate 7A/13B/15X/16X (50:5:35:10)
Dihydrocodeine tartrate 7A/15X/16X (50:40:10)
Tramadol hydrochloride 7A/15X/16X (50:40:10)
4.7.3 Neuropathic pain 7A
Source: Programme Budgeting mappings and definitions, Department of Health.(132)
4.12 The spend on primary care prescribed drugs for chronic pain includes 5% of all non-opioid
analgesics; 50% of the opioid analgesics buprenorphine, codeine phosphate,
dihydrocodeine tartrate and tramadol hydrochloride; and all neuropathic pain drugs
(though many of these preparations share additional indications).
Outpatients - attendances 4.13 Outpatient activity is mapped to Programme Budgeting sub-category at the level of
individual attendance based on its treatment function code (clinic or specialty code). Two
treatment function codes are mapped to 7A Chronic Pain and these are 191 Pain
Management and 241 Paediatric Pain Management.
4.14 Mandatory national tariffs apply for Pain Management attendances as outlined in Table 9.
The actual local tariff will include a local market forces factor. Paediatric Pain Management
Chronic Pain Health Needs Assessment 41
attendances are excluded from the national tariffs and prices are agreed locally.
Table 9: Pain Management outpatient attendance tariffs
Attendance type 2010/11 £
2011/12 £
First Attendance - Single Professional 160 156
First Attendance - Multi Professional 231 220
Follow Up Attendance - Single Professional 84 83
Follow Up Attendance - Multi Professional 95 98
Source: NHS Payment by Results 2010-11 National Tariff Information, Department of Health.(133)
Outpatients - Procedures 4.15 Spends associated with certain procedures performed in outpatients are also mapped to
Programme Budget sub-categories. These are assigned at the individual activity level based
on the Health Resource Group (HRG) code to which the procedure is mapped. There are 2
HRG codes mapped to 7A-Chronic Pain:
4.16 AB05Z - Intermediate Pain Procedures
4.17 AB06Z - Minor Pain Procedures
4.18 The procedures that are mapped to these two HRG codes are listed in appendix I.
4.19 Both of these HRG codes are allocated a cost of £202 (FY 2010/11) and £229 (FY2011/12)
within the national tariff. (133)
Inpatient spells 4.20 Inpatient activity is mapped to Programme Budgeting sub-category at the level of
individual spell based on the spell’s primary diagnosis code. There are 90 ICD10 diagnosis
codes identified by the guidance that are mapped to 07A Chronic Pain (Table 10).(132)
Unlike for outpatient activity, it is not possible to provide a simple list of costs associated
with the inpatient spells that are assigned to Chronic Pain. The cost of each spell is
assigned according to the spell’s HRG code and whether the activity was undertaken as an
elective or emergency admission. HRG codes are assigned primarily on the basis of the
procedure(s) undertaken, and not on the diagnosis. Consequently there is no direct
mapping of HRG and associated cost to programme budgeting categories.
4.21 There are a number of HRG codes that relate specifically to the care of pain and the tariffs
for these give an idea of the cost involved in individual treatments. Not all of the activity
assigned with these HRG codes will be assigned to Chronic Pain Programme Budget sub-
category (e.g. some might be assigned to 15-Problems of the musculoskeletal system or
04A Diabetes) but a significant proportion of the Chronic Pain sub-category is likely to
consist of these HRG codes. The codes and their associated costs are given in Table 11.
[Are these HRGs likely to be used in the management of Acute Pain?]. For example, in
2011/12, a complex major pain procedure carries a tariff of £708 for a daycase/elective
admission and £5,025 for a non-elective admission. For both elective and non-elective
42 Chronic Pain Health Needs Assessment
admissions for this HRG, a trim point of 5 days is assigned after which a further £227 per
day is costed. (133)
Table 10: Inpatient primary diagnosis codes mapped to Programme Budget sub-category 07A Chronic Pain
ICD10 ICD Text ICD10 ICD Text
B330 Epidemic myalgia G636 Polyneuropathy in other musculoskeletal disorders
G440 Cluster headache syndrome G638 Polyneuropathy in other diseases classified elsewhere
G441 Vascular headache G64X Other disorders of peripheral nervous system
G442 Tension-type headache H571 Ocular pain
G443 Chronic post-traumatic headache H920 Otalgia
G444 Drug-induced headache K146 Glossodynia
G448 Other specified headache syndromes M255 Pain in joint-Site unspec
G500 Trigeminal neuralgia M315 Giant cell arteritis with polymyalgia rheumatica
G501 Atypical facial pain M353 Polymyalgia rheumatica
G521 Disorders of glossopharyngeal nerve M541 Radiculopathy-Site unspe
G546 Phantom limb syndrome with pain M542 Cervicalgia-Site unspe
G564 Causalgia M543 Sciatica-Site unspe
G570 Lesion of sciatic nerve M544 Lumbago with sciatica-Site unspe
G571 Meralgia paraesthetica M545 Low back pain-Site unspe
G572 Lesion of femoral nerve M546 Pain in thoracic spine-Site unspe
G573 Lesion of lateral popliteal nerve M548 Other dorsalgia-Site unspe
G574 Lesion of medial popliteal nerve M549 Dorsalgia
G575 Tarsal tunnel syndrome M774 Metatarsalgia-Site unspec
G576 Lesion of plantar nerve M791 Myalgia-Site unspec
G578 Other mononeuropathies of lower limb M792 Neuralgia and neuritis
G579 Mononeuropathy of lower limb M796 Pain in limb-Site unspec
G580 Intercostal neuropathy M913 Pseudocoxalgia-Site unspec
G587 Mononeuritis multiplex N644 Mastodynia
G588 Other specified mononeuropathies N940 Mittelschmerz
G589 Mononeuropathy R070 Pain in throat
G600 Hereditary motor and sensory neuropathy R071 Chest pain on breathing
G601 Refsum's disease R072 Precordial pain
G602 Neuropathy in association with hereditary ataxia R073 Other chest pain
G603 Idiopathic progressive neuropathy R074 Chest pain
G608 Other hereditary and idiopathic neuropathies R101 Pain localized to upper abdomen
G609 Hereditary and idiopathic neuropathy R102 Pelvic and perineal pain
G610 Guillain-Barr‰ syndrome R103 Pain localized to other parts of lower abdomen
G611 Serum neuropathy R104 Other and unspecified abdominal pain
G618 Other inflammatory polyneuropathies R200 Anaesthesia of skin
G619 Inflammatory polyneuropathy R201 Hypoaesthesia of skin
G620 Drug-induced polyneuropathy R202 Paraesthesia of skin
G621 Alcoholic polyneuropathy R203 Hyperaesthesia
G622 Polyneuropathy due to other toxic agents R208 Other and unspecified disturbances of skin sensation
G628 Other specified polyneuropathies R300 Dysuria
G629 Polyneuropathy R309 Painful micturition
G630 Polyneuropathy in infectious and parasitic diseases EC
R51X Headache
G632 Diabetic polyneuropathy R520 Acute pain
G633 Polyneuropathy in other endocrine and metabolic diseases
R521 Chronic intractable pain
G634 Polyneuropathy in nutritional deficiency R522 Other chronic pain
G635 Polyneuropathy in systemic connective tissue disorders
R529 Pain
Source: Programme Budgeting mappings and definitions, Department of Health.(132)
Chronic Pain Health Needs Assessment 43
4.22 One clear characteristic of the tariffs is the difference between elective and non-elective
costs. For the 2011/12 financial year the non-elective costs are between 2 and 7 times
higher than the equivalent daycase/elective.
Table 11: Pain related HRG codes and national tariffs, FYs 2010/11 and 2011/12
HRG code
HRG name Combined Daycase / Elective tariff (£)
Elective long stay trim point
(days)
Non-elective
spell tariff (£)
Non-elective
long stay trim point
(days)
Per day long stay payment (for days
exceeding trim
point) (£)
Eligible for
Specialist Top-up
National Tariff 2010/11
AB01Z Complex Neurosurgical Pain Procedures
1,980 3 5,940 3 307 Yes
AB02Z Complex Major Pain Procedures
743 1 4,355 1 231 Yes
AB03Z Complex Pain Procedures
668 1 3,661 41 227 Yes
AB04Z Major Pain Procedures 643 1 2,475 21 222 Yes
AB05Z Intermediate Pain Procedures
544 1 2,079 39 202 Yes
AB06Z Minor Pain Procedures 463 1 1,449 14 239 Yes
National Tariff 2011/12
AB01Z Complex Neurosurgical Pain Procedures
2,503 9 5,574 9 209 Yes
AB02Z Complex Major Pain Procedures
708 5 5,025 5 209 Yes
AB03Z Complex Pain Procedures
636 5 4,225 29 209 Yes
AB04Z Major Pain Procedures 612 5 2,856 26 209 Yes
AB05Z Intermediate Pain Procedures
518 5 2,400 41 209 Yes
AB06Z Minor Pain Procedures 229 5 1,672 14 209 Yes
Source: NHS Payment by Results 2010-11 National Tariff Information, Department of Health.(133)
4.23 A full list of the individual procedures allocated to each of the pain management HRG
codes is given in Appendix I.
NHS CHRONIC PAIN EXPENDITURE IN THE WEST MIDLANDS
4.24 Data from the 2010/11 Programme Budgeting PCT benchmarking tool (134) reported a
total expenditure by PCTs in England of £92 billion, of which £1.2 billion were spent on the
7A-Chronic Pain sub-category. The equivalent figures for the PCTs in the West Midlands
were a total spend of £9.7 billion of which £119 million (1.2%) were spent on chronic pain.
44 Chronic Pain Health Needs Assessment
4.25 Table 12 provides the breakdown of the West Midlands spend on chronic pain in 2010/11
by PCT and care setting. Within the West Midlands as a whole the care setting with the
largest spend was the inpatient non-elective setting with £55.8 million (47%), followed by
inpatient elective and daycase with £29.5 million (25%), primary care prescribing £8.2
million (7%) and outpatients £7.3 million (6%). There was also significant expenditure in
community care, ambulance, non-health and social care settings and health and social care
provided in other settings. Prevention and health promotion, GP, dental and ophthalmic,
and accident and emergency settings recorded no or miniscule expenditure.
4.26 The population of the West Midlands is approximately one-tenth of that of England. In
order to compare in expenditure in the West Midlands to that across the country as a
whole the figures need to be presented on a per capita basis. Table 13 presents the
expenditure per 100,000 unified weighted population, which takes into account the
population’s need for hospital and community health services, prescribing and primary
medical services. The total expenditure on chronic pain for West Midlands was £2.1 million
per 100,000 compared to the national average of £2.4 million. The West Midlands
expenditure was lower than national in all care settings other than ambulance, community
care, and health and social care. West Midlands expenditure was particularly low in the
prevention and health promotion, GP, dental and ophthalmic, outpatient, and other
secondary care settings.
4.27 There are marked variations in the expenditure on chronic pain between the West
Midlands PCTs, both in terms of the total amounts and the splits between the care
settings. Total expenditure varied from £2.6 million in Herefordshire PCT to £14.8 million
in South Staffordshire PCT (Figure 1). The variation persists even after expressing the
expenditure per 100,000 population weighted for need for hospital and community
services. Herefordshire PCT’s spend was the lowest in the region at £1.5 million per
100,000 unified weighted population. Stoke on Trent PCT had the highest spend of £2.7
million per 100,000 - nearly twice that of Herefordshire. The regional average is £2.1
million per 100,000 (Figure 2).
4.28 All of the 17 West Midlands PCTs allocated expenditure for chronic pain to the key care
settings, i.e. primary care prescribing, elective and non-elective inpatients, outpatients and
ambulance settings. Only 10 PCTs allocated spend to other secondary care, 12 to
community care and 6 to health and social care provided in another setting. The
percentage splits for each PCT are illustrated in Figure 3.
Chronic Pain Health Needs Assessment 45
Figure 1: Total expenditure on Programme Budget sub-category 7A-Chronic Pain, West Midlands PCTs, FY 2010/11
Figure 2: Total expenditure per 100,000 unified weighted population on Programme Budget sub-
category 7A-Chronic Pain, West Midlands PCTs, FY 2010/11
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000
Herefordshire PCT
Telford and Wrekin PCT
Walsall Teaching PCT
North Staffordshire PCT
Solihull Care Trust
Heart of Birmingham Teaching PCT
Wolverhampton City PCT
Dudley PCT
South Birmingham PCT
Shropshire County PCT
Sandwell PCT
Coventry Teaching PCT
Stoke On Trent Teaching PCT
Birmingham East and North PCT
Worcestershire PCT
Warwickshire PCT
South Staffordshire PCT
Expenditure (£ thousands)
PC
T
Source: Programme Budgeting benchmarking tool 2010/11, Department of Health
0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000
Herefordshire PCT
Walsall Teaching PCT
Heart of Birmingham Teaching PCT
South Birmingham PCT
Birmingham East and North PCT
Sandwell PCT
Worcestershire PCT
Dudley PCT
North Staffordshire PCT
Wolverhampton City PCT
Coventry Teaching PCT
Telford and Wrekin PCT
Warwickshire PCT
Solihull Care Trust
Shropshire County PCT
South Staffordshire PCT
Stoke On Trent Teaching PCT
West Midlands
England
Expenditure (£s) per 100,000 unifed weighted population
PC
T
Source: Programme Budgeting benchmarking tool 2010/11, Department of Health.
46 Chronic Pain Health Needs Assessment
4.29 Notable variations in the proportional split between the care settings include:
Telford and Wrekin PCT spent a negligible proportion of its chronic pain expenditure
on non-elective inpatient care (1% vs. a regional average of 47%) but a very large
proportion on inpatient elective care (77% vs. a regional average of 25%).
Solihull PCT spent 16% of its expenditure on health and social care provided in other
setting (compared to a regional average of 3%).
Shropshire County PCT allocated 25% of its expenditure to community service
compared to a regional average of 4%.
Stoke on Trent Teaching PCT allocated 14% and 26% of its expenditure to community
care and health and social care in other settings respectively, compared to regional
averages of 4% and 3%.
Sandwell spent virtually nothing in the community and other settings compared to a
regional average of 10%.
Figure 3: Proportion of expenditure on Programme Budget sub-category 7A Chronic Pain by care setting, West Midlands PCTs, FY 2010/11
4.30 Table 13 shows how the total expenditure and the proportional split by care setting for
each PCT translate into actual spend in each setting per weighted population. Additional
variations highlighted by this table include:
Low primary care prescribing expenditure in Heart of Birmingham Teaching PCT.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Herefordshire PCT
Telford and Wrekin PCT
Walsall Teaching PCT
North Staffordshire PCT
Solihull Care Trust
Heart of Birmingham Teaching PCT
Wolverhampton City PCT
Dudley PCT
South Birmingham PCT
Shropshire County PCT
Sandwell PCT
Coventry Teaching PCT
Stoke On Trent Teaching PCT
Birmingham East and North PCT
Worcestershire PCT
Warwickshire PCT
South Staffordshire PCT
Total West Midlands PCTs
PC
T
Prevention & Health Promotion GP, dental & ophthalmic Primary prescribing & pharma services
Inpatient: Elective and Daycase Inpatient: Non-elective Outpatient
Other secondary care Ambulance A&E (inc. MIU & WIC)
Community Care Health & social care provided in other setting Non-health / social care
Source: Programme Budgeting benchmarking tool 2010/11, Department of Health.
Chronic Pain Health Needs Assessment 47
High primary care prescribing expenditure in Stoke on Trent Teaching PCT.
High elective inpatient expenditure in South Staffordshire PCT.
Low elective inpatient expenditure in Birmingham East and North, Heart of
Birmingham, South Birmingham, Stoke on Trent and Walsall PCTs.
Low outpatient expenditure in North Staffordshire, South Staffordshire, Walsall and
Wolverhampton PCTs.
An expenditure on ambulances three times the regional average in South
Staffordshire PCT.
NOTES ON PROGRAMME BUDGET DATA QUALITY AND LIMITATIONS
4.31 There are concerns as to how well the data collected and published by the Programme
Budget project accurately reflect the true allocation of expenditure. It is unclear how much
of the variation described above reflects real differences in activity or service models and
how much is an artefact of differential coding or erroneous reporting. The Audit
Commission has identified and described issues with NHS data definitions and how they
are implemented by local providers and commissioners. (135). These issues affect the
collection of data for Payment by Results (PbR) but are also a concern for secondary uses
of data such as for the Programme Budget project. Two key problems are:
Defining short stay activity as a daycase admission or an outpatient attendance
Defining a short period of observation as a non-elective admission or a ward
attendance (which is treated as an outpatient attendance).
4.32 The existing commissioning data sets do not allow the recording of information in the same
manner in different settings and do not necessarily reflect the current delivery of care.
When activity takes place in inpatients the data recorded is exhaustive. If this activity
moves to outpatients much of this detail disappears, including that on diagnosis. If this
activity then moves to a community or primary care setting it can vanish completely, and
without detailed local knowledge it would appear this activity no longer takes place. The
difference in tariff between elective, non-elective and outpatient settings for what may be
the same activity can also act as a disincentive to record activity accurately and to properly
align costs with activity.
4.33 The majority of activity carried out by Pain Management specialists is delivered in
outpatients. However, the focus for clinical coding in the NHS has been concentrated on
admitted patients, because there are both time and resource implications in coding
significant amounts of outpatient activity. Pain Management services need to understand
if and how their data is coded and ensure that their activity is correctly recorded on their
patient administration system (PAS).(136) The NHS Information Centre (NHSIC) report that
their Expert Working Group for Pain Management have reviewed national patient activity
and found that some Pain Management services are unaware that their activity could and
should be captured in a more appropriate way. This could be due to a lack of awareness of
48 Chronic Pain Health Needs Assessment
the coding systems and the reasons why coding is important. This inaccuracy can lead to
underreporting of the actual total costs submitted for calculating the PbR tariffs as well
underreporting and misclassification of expenditure for the Programme Budget project.
Chronic pain health needs assessment 49
Table 12: Expenditure (£ thousands) on Programme Budget sub-category 7A-Chronic Pain by care setting, West Midlands PCTs, FY 2010/11
PCT PCT Name Care setting Total expenditure
Prevention & health
Promotion
Primary care Secondary care Urgent / emergency care Community care
Health & social care provided in
other setting
Non-health / social
care GP, dental &
ophthalmic
Primary prescribing & pharma services
Inpatient: elective
and daycase
Inpatient: non-
elective
Outpatient Other secondary
care
Ambulance A&E (inc. MIU & WIC)
5PG Birmingham East and North PCT
- - 547 1,287 5,403 808 - 255 - 3 253 124 8,680
5MD Coventry Teaching PCT - - 513 2,184 4,057 349 - 207 - - - 214 7,524
5PE Dudley PCT - - 473 1,409 3,568 460 23 160 - - - 205 6,298
5MX Heart of Birmingham Teaching PCT
- - 287 674 3,261 471 78 243 - - 29 207 5,250
5CN Herefordshire PCT - - 189 523 1,343 178 9 115 - 148
- 80 2,585
5PH North Staffordshire PCT - - 370 1,399 2,134 104 124 - 45 - 224 4,400
5PF Sandwell PCT - - 587 1,721 3,510 645 449 198 - - - 1 7,111
5M2 Shropshire County PCT - - 407 1,029 2,722 246 378 182 - 1,706 15 129 6,814
TAM Solihull Care Trust - - 249 732 2,182 411 - 117 - 720 132 4,543
5M1 South Birmingham PCT - - 477 1,071 4,040 762 - 219 - 37 - 184 6,790
5PK South Staffordshire PCT - - 961 5,884 6,027 244 - 952 - 230 - 530 14,828
5PJ Stoke On Trent Teaching PCT
- - 615 652 2,892 568 - 174 - 1,194 2,263 255 8,613
5MK Telford and Wrekin PCT 2 8 247 2,793 20 278 4 101 - 72 - 91 3,616
5M3 Walsall Teaching PCT - - 477 832 2,476 176 20 164 - 2 2 114 4,263
5PM Warwickshire PCT - - 734 3,271 4,729 520 524 302 - 610 - 550 11,240
5MV Wolverhampton City PCT - - 387 806 3,363 195 232 166 - 416 - 231 5,796
5PL Worcestershire PCT - - 675 3,227 4,076 850 85 334 - 716 - 375 10,338
Q34 West Midlands 2 8 8,195 29,494 55,803 7,265 1,802 4,013 - 5,179 3,282 3,646 118,689
Eng England 187 475 78,647 296,341 610,377 103,453 53,350 29,585 - 35,957 11,449 44,081 1,263,902
Source: 2010-11 Programme budgeting PCT benchmarking tool, Department of Health. (134)
50 Chronic Pain Health Needs Assessment
Table 13: Expenditure (£) per 100,000 unified weighted population on Programme Budget sub-category 7A-Chronic Pain by care setting, West Midlands PCTs, FY 2010/11
PCT PCT Name Care setting Total expenditure
Prevention & health
Promotion
Primary care Secondary care Urgent / emergency care Community care
Health & social care provided in
other setting
Non-health / social
care GP, dental &
ophthalmic
Primary prescribing & pharma services
Inpatient: elective
and daycase
Inpatient: non-
elective
Outpatient Other secondary
care
Ambulance A&E (inc. MIU & WIC)
5PG Birmingham East and North PCT
- - 120,929 284,526 1,194,479 178,630 - 56,375 - 663 55,933 27,414 1,918,949
5MD Coventry Teaching PCT - - 147,589 628,331 1,167,188 100,406 - 59,553 - - - 61,567 2,164,634
5PE Dudley PCT - - 150,516 448,367 1,135,395 146,379 7,319 50,915 - - - 65,234 2,004,125
5MX Heart of Birmingham Teaching PCT
- - 92,500 217,229 1,051,016 151,803 25,139 78,319 - - 9,347 66,716 1,692,068
5CN Herefordshire PCT - - 109,334 302,549 776,909 102,971 5,206 66,526 - 85,616 - 46,279 1,495,390
5PH North Staffordshire PCT - - 172,968 654,005 997,603 48,618 - 57,968 - 21,037 - 104,716 2,056,914
5PF Sandwell PCT - - 162,210 475,577 969,944 178,238 124,076 54,715 - - - 276 1,965,035
5M2 Shropshire County PCT - - 144,331 364,906 965,282 87,237 134,047 64,541 - 604,986 5,319 45,746 2,416,397
TAM Solihull Care Trust - - 129,921 381,935 1,138,501 214,447 - 61,047 - - 375,674 68,874 2,370,399
5M1 South Birmingham PCT - - 124,393 279,297 1,053,557 198,715 - 57,111 - 9,649 - 47,984 1,770,705
5PK South Staffordshire PCT - - 166,525 1,019,597 1,044,376 42,281 - 164,965 - 39,855 - 91,840 2,569,439
5PJ Stoke On Trent Teaching PCT
- - 195,923 207,710 921,317 180,950 - 55,432 - 380,378 720,934 81,236 2,743,881
5MK Telford and Wrekin PCT 1,213 4,852 149,811 1,694,015 12,130 168,613 2,426 61,259 - 43,670 - 55,193 2,193,182
5M3 Walsall Teaching PCT - - 167,741 292,579 870,705 61,892 7,033 57,672 - 703 703 40,089 1,499,118
5PM Warwickshire PCT - - 148,637 662,385 957,633 105,301 106,111 61,156 - 123,526 - 111,376 2,276,124
5MV Wolverhampton City PCT - - 141,127 293,923 1,226,382 71,110 84,603 60,535 - 151,702 - 84,239 2,113,621
5PL Worcestershire PCT - - 129,968 621,344 784,815 163,664 16,366 64,310 - 137,863 - 72,205 1,990,535
Q34 West Midlands 35 141 144,843 521,295 986,296 128,406 31,850 70,928 - 91,537 58,008 64,442 2,097,781
Eng England 357 907 150,177 565,865 1,165,519 197,544 101,872 56,493 - 68,660 21,862 84,173 2,413,430
Source: 2010-11 Programme budgeting PCT benchmarking tool, Department of Health. (134)
Chronic Pain Health Needs Assessment 51
52 Chronic Pain Health Needs Assessment
5 HEALTH SERVICE UTILISATION - OUTPATIENT ACTIVITY
COMMISSIONER PERSPECTIVE
5.1 This section describes the growth in out-patient activity in pain services provided by
secondary care facilities. Outpatient commissioning data sets (CDS) for the financial
years 2007/8 to 2011/12, accessed via Healthcare Commissioning Services, Dudley. The
Outpatient CDS carries the data for an outpatient attendance or a cancelled/missed
appointment. It covers all NHS and private outpatient activity taking place under the
care of a consultant, midwife or nurse in any:
Acute, community or mental health NHS Trust Primary Care Trust Other NHS hospital Non-NHS hospitals or institutions where the care delivered is NHS-funded.
5.2 Providers of NHS commissioned care must submit and make available the CDSs to
commissioners. Within the West Midlands the data sets are submitted to, stored and
accessed via a data warehouse managed by Healthcare Commissioning Services (HCS),
based in Dudley. Two outpatient data requests were submitted to HCS for counts of
attendances of adults aged 16 years and over to pain management clinics where the
patient attended and was seen for the financial years 2007/8 to 2011/12.
5.3 For patients resident in West Midlands PCTS: counts were broken down by financial
year, gender, first attendance status and PCT. For patients attending the West Midlands
providers: counts broken down by financial year, gender, first attendance status and
Provider Trust. The resulting outputs included counts where the first attendance status
was for first or follow-up tele-consultations. These counts were excluded from the
further analysis – only first and follow-up face to face consultations were included.
5.4 There were a total of 245,331 attendances at outpatient pain management clinics for
adults resident in the West Midlands and treated by any provider during the 5-year
period 2007/8 to 2011/12 (Table 14 ). Of these 76,830 (31%) were first attendances and
168,501 (69%) were follow-up attendances. The total number of attendances increased
from 44,700 in 2007/8 to 51,587 in 2011/12, a rise of 15%. The rate of increase over the
period was greater for first attendances (35%) compared to follow-up attendances (8%)
(figure 2). Consequently the proportion of first attendances also increased over the 5
years, from 29% in 2007/8 to 33% in 2011/12.
Chronic Pain Health Needs Assessment 53
Table 14. Pain management outpatient clinic attendances for residents in West Midlands aged 16+ years by gender by attendance type, FYs 2007/08 to 2011/12.
Gender Attendance type
Financial year Total
all years 2007/08 2008/09 2009/10 2010/11 2011/12
Male First attendance face to face 4,563 5,090 5,548 5,956 5,977 27,134
Male Follow-up attendance face to face 10,467 10,608 11,115 11,332 11,085 54,607
Male Total 15,030 15,698 16,663 17,288 17,062 81,741
Female First attendance face to face 8,228 8,986 10,266 10,949 11,267 49,696
Female Follow-up attendance face to face 21,442 21,628 23,633 23,933 23,258 113,894
Female Total 29,670 30,614 33,899 34,882 34,525 163,590
Persons First attendance face to face 12,791 14,076 15,814 16,905 17,244 76,830
Persons Follow-up attendance face to face 31,909 32,236 34,748 35,265 34,343 168,501
Persons Total 44,700 46,312 50,562 52,170 51,587 245,331
Persons Percentage of first attendances 28.6% 30.4% 31.3% 32.4% 33.4% 31.3%
Persons 95% confidence interval lower limit [1] 28.2% 30.0% 30.9% 32.0% 33.0% 31.1%
Persons 95% confidence interval upper limit [1] 29.0% 30.8% 31.7% 32.8% 33.8% 31.5%
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services Notes: [1] based on the Wilson score method.
Figure 4. Pain management outpatient clinic attendances for residents in West Midlands aged 16+ by attendance type, FYs 2007/8 to 2011/12. The blue line shows first attendances, the red line shows follow-up attendances and the green line shows the total attendances. The black dotted line shows the % of the total that are first attendances (right hand axis)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
0
10
20
30
40
50
60
2007/08 2008/09 2009/10 2010/11 2011/12
Co
un
t o
f at
ten
dan
ces
(th
ou
san
ds)
Financial year Source: Outpatient Commissioning Data Set,
Chronic pain health needs assessment 54
Table 15: Pain management outpatient clinic attendances for West Midlands residents aged 16+ by Primary Care Trust and attendance type, FYs 2007/8 to 20011/12.
Primary Care Trust / Cluster Population years at risk [1]
First attendance face to face
Follow-up attendance face to face
Total Percentage of first attendances Crude first attendance rate [2] Crude total attendance rate [2]
Percent 95% CI limits [3] Rate 95% CI limits [4] Rate 95% CI limits [4]
Lower Upper Lower Upper Lower Upper
5PG Birmingham East and North PCT 1,565,426 7,732 19,545 27,277 28.3% 27.8% 28.9% 4.9 4.8 5.1 17.4 17.2 17.6
5MD Coventry Teaching PCT 1,256,540 5,084 7,795 12,879 39.5% 38.6% 40.3% 4.0 3.9 4.2 10.2 10.1 10.4
5PE Dudley PCT 1,244,319 4,729 11,654 16,383 28.9% 28.2% 29.6% 3.8 3.7 3.9 13.2 13.0 13.4
5MX Heart of Birmingham Teaching PCT
1,051,302 5,299 13,821 19,120 27.7% 27.1% 28.4% 5.0 4.9 5.2 18.2 17.9 18.4
5CN Herefordshire PCT 739,725 1,695 3,225 4,920 34.5% 33.1% 35.8% 2.3 2.2 2.4 6.7 6.5 6.8
5PH North Staffordshire PCT 878,079 1,218 1,965 3,183 38.3% 36.6% 40.0% 1.4 1.3 1.5 3.6 3.5 3.8
5PF Sandwell PCT 1,146,991 7,784 19,675 27,459 28.3% 27.8% 28.9% 6.8 6.6 6.9 23.9 23.7 24.2
5M2 Shropshire County PCT 1,197,926 3,596 6,897 10,493 34.3% 33.4% 35.2% 3.0 2.9 3.1 8.8 8.6 8.9
5QW Solihull PCT 827,616 4,746 11,275 16,021 29.6% 28.9% 30.3% 5.7 5.6 5.9 19.4 19.1 19.7
5M1 South Birmingham PCT 1,381,884 6,551 23,290 29,841 22.0% 21.5% 22.4% 4.7 4.6 4.9 21.6 21.4 21.8
5PK South Staffordshire PCT 2,486,734 2,716 4,993 7,709 35.2% 34.2% 36.3% 1.1 1.1 1.1 3.1 3.0 3.2
5PJ Stoke On Trent PCT 1,000,465 2,351 3,212 5,563 42.3% 41.0% 43.6% 2.3 2.3 2.4 5.6 5.4 5.7
5MK Telford and Wrekin PCT 643,451 2,543 4,781 7,324 34.7% 33.6% 35.8% 4.0 3.8 4.1 11.4 11.1 11.6
5M3 Walsall Teaching PCT 1,011,340 921 1,965 2,886 31.9% 30.2% 33.6% 0.9 0.9 1.0 2.9 2.8 3.0
5PM Warwickshire PCT 2,180,531 6,483 11,767 18,250 35.5% 34.8% 36.2% 3.0 2.9 3.0 8.4 8.2 8.5
5MV Wolverhampton City PCT 959,676 2,767 4,204 6,971 39.7% 38.6% 40.8% 2.9 2.8 3.0 7.3 7.1 7.4
5PL Worcestershire PCT 2,273,231 10,615 18,437 29,052 36.5% 36.0% 37.1% 4.7 4.6 4.8 12.8 12.6 12.9
Arden 3,437,071 11,567 19,562 31,129 37.2% 36.6% 37.7% 3.4 3.3 3.4 9.1 9.0 9.2
Birmingham and Solihull 4,826,227 24,328 67,931 92,259 26.4% 26.1% 26.7% 5.0 5.0 5.1 19.1 19.0 19.2
Black Country 4,362,326 16,201 37,498 53,699 30.2% 29.8% 30.6% 3.7 3.7 3.8 12.3 12.2 12.4
Staffordshire 4,365,277 6,285 10,170 16,455 38.2% 37.5% 38.9% 1.4 1.4 1.5 3.8 3.7 3.8
West Mercia 4,854,333 18,449 33,340 51,789 35.6% 35.2% 36.0% 3.8 3.7 3.9 10.7 10.6 10.8
Total All West Midlands PCOs 21,845,235 76,830 168,501 245,331 31.3% 31.1% 31.5% 3.5 3.5 3.5 11.2 11.2 11.3
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
[1] Based on ONS mid-year population estimates for the years 2007 to 2010, current as of September 2011. Estimates for 2010 are also used as proxies for 2011 as data for this year are yet to be published.
[2] Rates are expressed per 1,000 population years at risk.
[3] Based on the Wilson score method(137).
[4] Based on Byar's approximation to the Poisson distribution(138)
Chronic pain health needs assessment 55
5.5 Table 15 shows the detailed data on first and follow-up outpatient attendances and the
crude attendance rate (per 1000 person- years) for each of the Primary Care Trusts in
the West Midlands. Since we used 5 years of data to calculate the crude attendance
rate, we used person-years at risk as the denominator. In effect this can be regarded as
the rate per 1000 residents who are have sufficiently severe and disabling chronic pain
to be seen in a secondary care pain clinic. There is considerable variation between PCTs.
For first attendances it varies more than 7-fold from 0.9 per 1000 in Walsall to 6.8 per
1000 in Sandwell. We did not investigate the reasons for this variation but almost
certainly it results from a combination of availability of services, ability of general
practices to manage chronic pain, referral threshold and traditional referral practices. It
appears unlikely that true variation in the incidence or prevalence of chronic pain
accounts for more than a small part of this variation.
5.6 The trend in outpatient attendances by PCT Cluster, and crude attendance rate are
shown in Table 16. Once again there is considerable variation between clusters, and this
is shown in Figure 5; Birmingham and Black Country cluster have the highest rate, about
4 times the rate of Staffordshire.
Table 16. Crude rate of all attendances to pain management outpatient clinics for West Midlands residents aged 16+ years by PCT Cluster, FYs 2007/08 to 2011/12.
PCT Cluster Financial year Total all years 2007/08 2008/09 2009/10 2010/11 2011/12
Total attendances Arden 5,407 5,999 6,766 6,519 6,438 31,129 Birmingham and Solihull 17,638 17,565 19,341 19,537 18,178 92,259 Black Country 11,109 10,046 11,352 10,740 10,452 53,699 Staffordshire 2,451 2,936 3,479 3,877 3,712 16,455 West Mercia 8,095 9,766 9,624 11,497 12,807 51,789 Total West Midlands
residents 44,700 46,312 50,562 52,170 51,587 245,331
Crude attendance rate Arden 8.0 8.8 9.8 9.4 9.3 9.1 Birmingham and Solihull 18.5 18.3 20.0 20.1 18.7 19.1 Black Country 12.8 11.5 13.0 12.3 11.9 12.3 Staffordshire 2.8 3.4 4.0 4.4 4.2 3.8 West Mercia 8.4 10.1 9.9 11.8 13.1 10.7 Total West Midlands
residents 10.3 10.6 11.6 11.9 11.7 11.2
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
56 Chronic Pain Health Needs Assessment
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services. Figure 5. Crude rates of attendance at pain management clinics by residents in West Midlands aged 16+ by PCT Cluster, FYs 2007-8 to 2011-12.
5.7 The variation in rates of outpatient attendance between PCTs and Clusters is shown in
the funnel plots (Figure 6, Figure 7 and Figure 8). These charts show the dispersion of
PCT and cluster rates around the average rate for the West Midlands with the +/- 2 SD
and +/- 3 SD control limits denoting the expected common cause variation due to
statistical chance alone.
0
5
10
15
20
25
2007/08 2008/09 2009/10 2010/11 2011/12
Cru
de
rate
p
er 1
,00
0 p
op
ula
tio
n y
ears
at
risk
Financial year
Arden Birmingham and Solihull Black Country
Staffordshire West Mercia West Midlands average
Chronic Pain Health Needs Assessment 57
Figure 6. Funnel plot of crude rate of all attendances to pain management outpatient clinics , West Midlands residents aged 16+ by PCT and Cluster, FYs 2007/8 to 2011/12.
Figure 7. Funnel plot of crude rte of first attendances to pain management outpatient clinics West Midlands residents aged 16+ by PCT and Cluster, FYs 2007/8 to 2011/12.
0
5
10
15
20
25
0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000
Cru
de
rate
p
er 1
,00
0 p
op
ula
tio
n y
ears
at
risk
Population years at risk
West Midlands average
2SD limits
3SD Limits
PCTs
PCT Clusters
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population
0
1
2
3
4
5
6
7
8
0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000
Cru
de
rate
p
er 1
,00
0 p
op
ula
tio
n y
ears
at
risk
Population years at risk
West Midlands average 2SD limits 3SD Limits PCTs PCT Clusters
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population
58 Chronic Pain Health Needs Assessment
Figure 8. Funnel plot of First attendances as a percentage of all attendances to Pain management out-patient clinics, West Midlands residents aged 16+ by PCT and PCT cluster, FYs 2007/8 to 2011/12.
OUT-PATIENT ACTIVITY – PROVIDER PERSPECTIVE
5.8 Table 17 shows the attendances to outpatient pain management clinics for each of the
West Midlands Provider Trusts. It includes all patients treated at the Trusts, including
those residents outside of the West Midlands region. There were a total of 229,736
attendances to the West Midlands providers. This is over 15,000 fewer attendances than
reported for the West Midlands residents. This suggests a net flow of patients being
treated by providers outside the region. Three Trusts undertook significantly larger
volumes of activity: The Royal Orthopaedic Hospital NHS Trust in south Birmingham
(47,514), Sandwell and West Birmingham Hospitals NHS Trust (39,889) and the Heart of
England NHS Foundation Trust in east Birmingham and Solihull (32,245).
5.9 The average percentage of first attendances across the regional providers was 31.1%,
which matches that seen for the West Midlands resident patients. Percentages varied
from a low of 17.3% at the Royal Orthopaedic Hospital NHS Trust to 45.1% at the
Worcestershire Acute Hospitals NHS Trust. The distribution of the percentage of first
attendances by provider trust displays over-dispersion when compared to the control
limits around the regional average (Figure 9).
0
5
10
15
20
25
30
35
40
45
0 20,000 40,000 60,000 80,000 100,000
Pe
rcen
tage
of
firs
t at
ten
dan
ces
Number of attendances
West Midlands average 2SD limits 3SD Limits PCTs PCT Clusters
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services.
Chronic Pain Health Needs Assessment 59
Table 17. Pain management outpatient clinic attendances for West Midlands provider patients aged 16+ years by Provider Trust by attendance type, FYs 2007/08 to 2011/12
Provider Trust First attendance face to face
Follow-up attendance face to face
Total Percentage of first attendances
Percent 95% CI limits [1]
Lower Upper
RJC SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
2,410 3,339 5,749 41.9% 40.7% 43.2%
RJE UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST
3,687 5,203 8,890 41.5% 40.5% 42.5%
RKB UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST
6,158 8,075 14,233 43.3% 42.5% 44.1%
RL1 THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST
1,048 4,258 5,306 19.8% 18.7% 20.8%
RL4 THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST
3,301 4,669 7,970 41.4% 40.3% 42.5%
RLT GEORGE ELIOT HOSPITAL NHS TRUST 1,996 6,000 7,996 25.0% 24.0% 25.9%
RNA THE DUDLEY GROUP NHS FOUNDATION TRUST 5,700 13,289 18,989 30.0% 29.4% 30.7%
RR1 HEART OF ENGLAND NHS FOUNDATION TRUST 10,998 21,247 32,245 34.1% 33.6% 34.6%
RRJ THE ROYAL ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST
8,230 39,284 47,514 17.3% 17.0% 17.7%
RRK UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST
5,281 7,829 13,110 40.3% 39.4% 41.1%
RWP WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 6,836 8,334 15,170 45.1% 44.3% 45.9%
RXK SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST
10,740 29,149 39,889 26.9% 26.5% 27.4%
RXW SHREWSBURY AND TELFORD HOSPITAL NHS TRUST
5,033 7,642 12,675 39.7% 38.9% 40.6%
Total All West Midlands Providers 71,418 158,318 229,736 31.1% 30.9% 31.3%
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services. Notes: [1] Based on the Wilson score method(137).
60 Chronic Pain Health Needs Assessment
Figure 9. Funnel plot of first attendances as a percentage of all attendances to pain management outpatient clinics West Midlands provider patients aged 16+ by provider Trust, FYs 2007/8 to 2011/12.
5.10
5.11 A note on over- dispersion. We have used funnel plots to show the extent of variation
between PCTs and between provider units in this and the following sections. Funnel
plots present control limits that display ‘common-cause’ or process variation. This is the
variation that can be expected to occur in a process that is stable or ‘under control’. The
limits are calculated under the assumption that the only source of common-cause
variation in the process is that of random variation. Variation outside these limits is
often called special-cause or extra-process variation and is the result of systematic or
unusual deviations in the process. In the funnel plots above, the distributions show
much greater variation than that of the expected ‘common-cause’. This is known as
over-dispersion and often occurs when there are large numbers of events, and
confounding factors that influence the process are not accounted for. Whether these
factors are considered legitimate and should be included as source of common-cause
variation or remain as special causes is a matter of judgement and will depend on the
purpose of the monitoring. For example, in performance management the purpose is to
identify differences in organisational performance and consequently it is usual to adjust
the control limits or the data to eliminate potential sources of variation, such as case-
mix and demography. In public health the purpose is often to highlight the sources of
such variation for their own sake so the control limits are left unaltered. The APHO
monograph(139) on statistical process control charts gives more detail on the
methodology and interpretation.
0
5
10
15
20
25
30
35
40
45
50
0 10,000 20,000 30,000 40,000 50,000
Pe
rcen
tage
of
firs
t at
ten
dan
ces
Number of attendances
West Midlands average 2SD limits 3SD Limits PCTs PCT Clusters
Source: Outpatient Commissioning Data Set, Healthcare Commissioning Services.
Chronic Pain Health Needs Assessment 61
6 HEALTH SERVICE UTILISATION – INPATIENT AND DAY CASE PROCEDURES
6.1 This chapter describes the growth in hospital-based clinical activity for chronic pain.
Surgical and other interventional procedures are carried out either as day cases or as
inpatient episodes of care. The analysis presented here relates to clinical work
undertaken on West Midlands residents (regardless of where it was done); and,
separately, work done by West Midlands provider Trusts (regardless of the geographic
residence of patients.
DATA SOURCES AND METHODS
6.2 The source of data was the Admitted Patient commissioning data sets (CDS) for the
financial years 2007/8 to 2011/12, accessed via Healthcare Commissioning Services,
Dudley. This data set records clinical details for every finished consultant episode. ). It
covers all NHS and private inpatient activity taking place under the care of a consultant,
midwife or nurse in any:
Acute, community or mental health NHS Trust Primary Care Trust Other NHS hospital Non-NHS hospitals or institutions where the care delivered is NHS-funded.
6.3 Providers of NHS commissioned care must submit and make available the CDSs to
commissioners. Within the West Midlands the data sets are submitted to, stored and
accessed via a data warehouse managed by Healthcare Commissioning Services (HCS),
based in Dudley. Four inpatient data requests were submitted to HCS for counts of FCEs
of adults aged 16 years and over where the primary procedure recorded for the episode
was a pain management procedure and the episode was completed during the financial
years 2007/8 to 2011/12.
Patients treated by the West Midlands providers: counts broken down by financial year, gender, admission method, patient classification and Provider Trust. Patients treated by the West Midlands providers: counts broken down by financial year, gender, primary procedure and Provider Trust. Patients resident in West Midlands PCTS: counts broken down by financial year, gender, admission method, patient classification and PCT. Patients resident in West Midlands PCTS: counts broken down by financial year, gender, primary procedure and PCT.
6.4 Full details of the specifications are given in Appendix I. The list of pain management
procedures is given in Appendix II, specified by OPCS4 procedure codes at the 4-digit
level.
6.5 Obvious data errors were found by inspection of the output counts. These related to the
fields on patient classification and method of admission, where the codes clearly
showed that the relevant FCE were maternity or delivery episodes. For the provider
patients based output (output 1) this represented a total count of 206 out of 154,097
FCEs. For the resident based output (output 3) this represented a total count of 212 out
62 Chronic Pain Health Needs Assessment
of 161,782 FCEs. These categories were excluded from all further analyses of these
outputs. Ideally the episodes with these methods of admission and/or patient
classification would also be excluded from the corresponding outputs of counts broken
down by procedure (outputs 2 and 4). This was not possible as these outputs do not
contain the method of admission and patient classification breakdown needed to
identify them. However, given the very small number of episodes involved the inclusion
of these episodes in the procedure based analyses is negligible.
RESULTS
6.6 Pain management inpatient procedure episodes.
There were a total of 161,570 inpatient episodes for pain management procedures for
adults resident in the West Midlands and treated by any provider during the 5-year
period 2007/8 to 2011/12 (Table 18). Of these, 86% were elective day cases, 8% were
elective ordinary admissions, 2% elective regular attenders and 4% were emergency
admissions (Figure 10). Women accounted for 62% of episodes compared to 38% for
men.
Elective episodes.
The main interest of this report is elective activity. Over the five years a total of 154,478
(96%) of the episodes were for elective procedures. The episode count increased from
26, 523 in the year 2007/8 to 33, 583 in 2009/10 but since then has fallen again to
30,863 in 2011/12 (Table 18, Figure 11). Over the 5-year period, day cases accounted for
89.7% of the elective activity. This proportion slowly increased from 87.4% in 2007/8 to
92.0% in 2011/12. The trend in the number of day cases follows that described for all
elective activity (Figure 11)
6.7 Table 18 also presents the volume of elective pain management procedure episodes as
a rate against the denominator resident population. Overall there were 7.1 elective
episodes for every 1,000 population years at risk. Over the five years the adult
population of the West Midlands increased only marginally (by less than 2%).
Consequently the annual trend in the rate over the five years mirrors that of the simple
counts described in figure 3. The rate increased from 6.1 in 2007/8 to 7.7 in 20089/10
and has since fallen to 7.0 in 2011/12 (Figure 12).
Chronic Pain Health Needs Assessment 63
Table 18. Pain management inpatient procedure episodes for West Midlands residents aged 16+ years by gender, method of admission and patient classification, FYs 2007/08 to 2011/12
Gender Method of Admission
Patient Classification
Financial year Total all years
2007/08 2008/09 2009/10 2010/11 2011/12
Male Emergency Total 499 588 767 777 790 3,421
Male Elective Total 9,666 11,373 12,454 11,933 11,470 56,896
Male Elective Day case 8,291 9,722 11,112 10,722 10,382 50,229
Male Elective Ordinary admission
1,144 1,197 982 988 1,029 5,340
Male Elective Regular attender 231 454 360 223 59 1,327
Other and unspecified 70 57 81 82 86 376
Male Total 10,235 12,018 13,302 12,792 12,346 60,693
Female Emergency Total 531 580 594 606 642 2,953
Female Elective Total 16,856 19,991 21,102 20,204 19,390 97,543
Female Elective Day case 14,877 17,551 19,172 18,671 18,007 88,278
Female Elective Ordinary admission
1,544 1,593 1,293 1,156 1,286 6,872
Female Elective Regular attender 435 847 637 377 97 2,393
Other and unspecified 71 69 72 67 63 342
Female Total 17,458 20,640 21,768 20,877 20,095 100,838
Persons Emergency Total 1,030 1,168 1,361 1,383 1,432 6,374
Persons Elective Total 26,523 31,366 33,583 32,143 30,863 154,478
Persons Elective Day case 23,169 27,275 30,311 29,399 28,392 138,546
Persons Elective Ordinary admission
2,688 2,790 2,275 2,144 2,315 12,212
Persons Elective Regular attender 666 1,301 997 600 156 3,720
Other and unspecified 141 126 153 149 149 718
Persons Total 27,694 32,660 35,097 33,675 32,444 161,570
Persons Population
4,325,911
4,353,750
4,374,393
4,395,591
4,395,591
21,845,235
Persons Crude elective episode rate [1] 6.1 7.2 7.7 7.3 7.0 7.1
Persons 95% confidence interval lower limit [2]
6.1 7.1 7.6 7.2 6.9 7.0
Persons 95% confidence interval upper limit [2]
6.2 7.3 7.8 7.4 7.1 7.1
Persons Day case as a % of all elective episodes
87.4% 87.0% 90.3% 91.5% 92.0% 89.7%
Persons 95% confidence interval lower limit [3]
86.9% 86.6% 89.9% 91.2% 91.7% 89.5%
Persons 95% confidence interval upper limit [3]
87.7% 87.3% 90.6% 91.8% 92.3% 89.8%
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
Notes:
[1] Rates are expressed per 1,000 population years at risk.
[2] Based on Byar's approximation to the Poisson distribution. (138)
[3] Based on the Wilson score method(137)
Chronic pain health needs assessment 64
Figure 10. Pain management in-patient procedure episodes f0or West Midlands residents aged 16+ by method of admission and pat8ient classification, FY’s 2007/8 to 2011/12.
Figure 11. Elective pain management in-patient procedure episodes for West Midlands residents aged 16+ by method of admission and patient classification, FYs 2007/8 to 2011/12.
Emergency 6,374
4% Other and
unspecified 718 0%
Day case 138,546
86%
Ordinary admission
12,212 8%
Regular attender 3,720
2%
Source: Admitted Patient Commissioning Data Set, Healthcare
0
5
10
15
20
25
30
35
40
2007/08 2008/09 2009/10 2010/11 2011/12
Co
un
t o
f e
pis
od
es (
tho
usa
nd
s)
Financial year
Elective - Total Elective - day case Elective - ordinary admission
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
Chronic Pain Health Needs Assessment 65
Figure 12. Crude episode rates for elective pain management in-patient procedures for West Midlands residents aged 16+ by FYs 2007/8 to 2011/12.
6.8 Table 19. Provides a breakdown of the episode count and crude population episode rate
for the 5-year period by Primary Care Trust (PCT) and PCT Cluster. At PCT level, there is
a large variation in the total number of elective episodes ranging from 2,712 in Telford &
Wrekin PCT to 18,673 in Dudley PCT. This variation in the counts is not simply due to the
different population sizes of the PCTs. When expressed as a crude rate per 1,000
population years at risk the crude elective admission rates for PCTs exhibit almost
four-fold variation (from 4.1 in Heart of Birmingham PCT to 15.0 in Dudley PCT).
6.9 Figure 13. Displays these rates against a funnel plot of the control limits based on West
Midlands average rate of 7.1 and the expected ‘common-cause’ variation due to chance
alone. The observed distribution shows clear over-dispersion beyond the control limits.
Similar over-dispersion is seen at PCT Cluster level with rates ranging from 6.0 in
Birmingham and Solihull cluster to 9.4 in the Black Country.
6.10 The proportion of elective episodes that are treated as day cases may highlight
differences in practice for the care commissioned by the PCTs. For the West Midlands
region as a whole, day cases comprised 89.7% of elective episodes. At PCT level this
ranged from a low of 81.4% in Shropshire PCT to 95.0% in Warwickshire PCT. Cluster
level values ranged from 86.5% in West Mercia to 94.4% in Arden. The PCT and Cluster
distributions display over-dispersion when compared to the control limits around the
West Midlands regional average (Figure 14)
0
1
2
3
4
5
6
7
8
9
2007/08 2008/09 2009/10 2010/11 2011/12
Cru
de
rate
per
1,0
00
po
pu
lati
on
Financial year
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
I = 95% confidence interval
Chronic pain health needs assessment 66
Table 19. Pain management inpatient procedure episodes for West Midlands residents aged 16+ years by Primary Care Trust by admission method and patient classification, FYs 2007/08 to 2011/12
Primary Care Trust \ Cluster Population years at risk [1]
Emergency episodes
Elective episodes Other and unspecif’d episodes
Total episodes
Day case as % of elective Crude elective rate [2]
Day cases
Ordinary Regular Total Percent 95% CI [3] Rate 95% CI [4]
LL UL LL UL
5PG Birmingham East and North PCT 1,565,426 310 7,339 436 504 8,279 31 8,620 88.6% 87.9% 89.3% 5.3 5.2 5.4
5MD Coventry Teaching PCT 1,256,540 424 11,012 728 20 11,760 38 12,222 93.6% 93.2% 94.1% 9.4 9.2 9.5
5PE Dudley PCT 1,244,319 547 16,854 1,767 52 18,673 28 19,248 90.3% 89.8% 90.7% 15.0 14.8 15.2
5MX Heart of Birmingham Teaching PCT 1,051,302 340 3,834 216 234 4,284 16 4,640 89.5% 88.5% 90.4% 4.1 4.0 4.2
5CN Herefordshire PCT 739,725 341 2,998 384 7 3,389 45 3,775 88.5% 87.3% 89.5% 4.6 4.4 4.7
5PH North Staffordshire PCT 878,079 190 3,874 493 6 4,373 14 4,577 88.6% 87.6% 89.5% 5.0 4.8 5.1
5PF Sandwell PCT 1,146,991 343 9,107 589 242 9,938 37 10,318 91.6% 91.1% 92.2% 8.7 8.5 8.8
5M2 Shropshire County PCT 1,197,926 369 4,297 970 12 5,279 86 5,734 81.4% 80.3% 82.4% 4.4 4.3 4.5
5QW Solihull PCT 827,616 147 3,404 166 136 3,706 8 3,861 91.9% 90.9% 92.7% 4.5 4.3 4.6
5M1 South Birmingham PCT 1,381,884 401 10,722 648 1,137 12,507 50 12,958 85.7% 85.1% 86.3% 9.1 8.9 9.2
5PK South Staffordshire PCT 2,486,734 709 15,987 1,694 209 17,890 102 18,701 89.4% 88.9% 89.8% 7.2 7.1 7.3
5PJ Stoke On Trent PCT 1,000,465 262 4,893 634 4 5,531 25 5,818 88.5% 87.6% 89.3% 5.5 5.4 5.7
5MK Telford and Wrekin PCT 643,451 146 2,314 392 6 2,712 20 2,878 85.3% 83.9% 86.6% 4.2 4.1 4.4
5M3 Walsall Teaching PCT 1,011,340 470 6,009 681 64 6,754 68 7,292 89.0% 88.2% 89.7% 6.7 6.5 6.8
5PM Warwickshire PCT 2,180,531 456 14,533 730 30 15,293 49 15,798 95.0% 94.7% 95.4% 7.0 6.9 7.1
5MV Wolverhampton City PCT 959,676 270 5,199 478 4 5,681 47 5,998 91.5% 90.8% 92.2% 5.9 5.8 6.1
5PL Worcestershire PCT 2,273,231 649 16,170 1,206 1,053 18,429 54 19,132 87.7% 87.3% 88.2% 8.1 8.0 8.2
Arden 3,437,071 880 25,545 1,458 50 27,053 87 28,020 94.4% 94.1% 94.7% 7.9 7.8 8.0
Birmingham and Solihull 4,826,227 1,198 25,299 1,466 2,011 28,776 105 30,079 87.9% 87.5% 88.3% 6.0 5.9 6.0
Black Country 4,362,326 1,630 37,169 3,515 362 41,046 180 42,856 90.6% 90.3% 90.8% 9.4 9.3 9.5
Staffordshire 4,365,277 1,161 24,754 2,821 219 27,794 141 29,096 89.1% 88.7% 89.4% 6.4 6.3 6.4
West Mercia 4,854,333 1,505 25,779 2,952 1,078 29,809 205 31,519 86.5% 86.1% 86.9% 6.1 6.1 6.2
Total All West Midlands PCOs 21,845,235 6,374 138,546 12,212 3,720 154,478 718 161,570 89.7% 89.5% 89.8% 7.1 7.0 7.1
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics. Notes:
[1] Based on ONS mid-year population estimates for the years 2007 to 2010, current as of September 2011. Estimates for 2010 are also used as proxies for 2011 as data for this year are yet to be published.
[2] Rates are expressed per 1,000 population years at risk. [3] Based on the Wilson score method.(137)
[4] Based on Byar's approximation to the Poisson distribution(138)
Chronic pain health needs assessment 67
Figure 13. Funnel plot of crude episode rate for elective pain management in-patient procedures for West Midlands residents aged 16+ by PCT and PCT Cluster, FYs 2007/8 to 2011/12.
Figure 14. Funnel plot of day cases as percentage of all episodes for elective pain management in-patient procedures, West Midlands residents aged 16+ by PCT and PCT Cluster, FYs 2007/8 to 2011/12.
0
2
4
6
8
10
12
14
16
0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000
Cru
de
elec
tive
ep
iso
de
rate
p
er 1
,00
0 p
op
ula
tio
n y
ears
at
risk
Population years at risk
West Midlands average
2SD limits
3SD Limits
PCTs
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
75
80
85
90
95
100
0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000
Pe
rcen
tage
of
day
cas
es
Number of elective episodes
West Midlands average 2SD limits 3SD Limits PCTs
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
68 Chronic Pain Health Needs Assessment
6.11 Trends by PCT Cluster.
Table 20 shows how the PCT Cluster level elective activity volumes and crude rates have
changed over the five years. Arden, Birmingham and Solihull and Black Country Clusters
have similar trends to that described above for the West Midlands as a whole, i.e. their
episode counts and rates peaked in 2009/10 and have decreased since. This decrease
has been most marked in Arden where the crude elective episode rate has dropped by a
third over two years. Birmingham and Solihull’s rate has remained consistently above
the regional average over the five years. Both Staffordshire and West Mercia have seen
significant increase in their elective activity in the year 2011/12 (Figure 15).
Table 20. Crude episode rate for elective pain management inpatient procedures for West Midlands residents aged 16+ years by PCT Cluster, FYs 2007/08 to 2011/12
PCT Cluster Financial year Total all
years 2007/08 2008/09 2009/10 2010/11 2011/12
Total elective episodes
Arden 4,925 5,865 6,294 5,753 4,216 27,053
Birmingham and Solihull 5,059 5,950 6,445 6,120 5,202 28,776
Black Country 7,032 8,009 8,813 8,733 8,459 41,046
Staffordshire 4,744 5,518 5,487 5,474 6,571 27,794
West Mercia 4,763 6,024 6,544 6,063 6,415 29,809
Total West Midlands residents
26,523 31,366 33,583 32,143 30,863 154,478
Crude elective episode rate
Arden 7.3 8.6 9.1 8.3 6.1 7.9
Birmingham and Solihull 5.3 6.2 6.7 6.3 5.3 6.0
Black Country 8.1 9.2 10.1 10.0 9.7 9.4
Staffordshire 5.5 6.3 6.3 6.2 7.5 6.4
West Mercia 4.9 6.2 6.7 6.2 6.6 6.1
Total West Midlands residents
6.1 7.2 7.7 7.3 7.0 7.1
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
Chronic Pain Health Needs Assessment 69
Figure 15. Crude episode rate for elective pain management in-patient procedures, West Midlands residents aged 16+ by PCT Cluster, FYs 2007/8 to 2011/12.
TRENDS IN SPECIFIC PROCEDURES IN PAIN MANAGEMENT
6.12 There are a large number of specific procedures used in pain management. Using the 3-
digit OPCS4 codes there are 17 broad categories of operation. Data on the number of
each of these procedures is shown in Table 21. The figures include all activity, i.e. for all
methods of admission and all patient classifications. The vast majority of these episodes
are elective activity (over 95%). The three most common procedures alone account for
80% of the activity undertaken (Figure 16). The most common procedure was a puncture
of a joint with over 70,000 episodes or 43% of the activity. This includes aspiration and
injection of a therapeutic substance into the joint. The second most frequent procedure
was other operations on spine – specifically these are all injections around spinal facet of
spine – with over 31,000 episodes (19%). Over 28,000 (17%) of episodes had a
therapeutic epidural injection performed. The next most frequent procedures were
operations on spinal nerve root (5.6%), neurostimulation of peripheral nerve (4.9%) and
therapeutic spinal puncture (3.0%).
6.13 The trend in the 6 most common procedures over the 5 years is shown in Figure 17. The
most notable feature is the steady increase in the frequency of puncture of the joint.
Not only is it the most frequent procedure but it has increased from just under 12,000
episodes in 2007/8 to in excess of 15,000 in 2011/12, a rise of 29%.
0
2
4
6
8
10
12
2007/08 2008/09 2009/10 2010/11 2011/12
Cru
de
rate
p
er 1
,00
0 p
op
ula
tio
n y
ears
at
risk
Financial year
Arden Birmingham and Solihull Black Country
Staffordshire West Mercia West Midlands average
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
70 Chronic Pain Health Needs Assessment
Table 21. Pain management inpatient procedure episodes for West Midlands residents aged 16+ years by 3-digit OPCS4 procedure code and year, FYs 2007/08 to 2011/12
OPCS4 Procedure code (3-digit) [1]
Financial year Total all years
2007-08
2008-09
2009-10
2010-11
2011-12
Count %
W90
Puncture of joint 11,946 13,499 15,088 14,327 15,391 70,251 43.4%
V54 Other operations on spine 5,086 6,333 7,433 6,820 5,456 31,128 19.2%
A52 Therapeutic epidural injection 5,470 6,056 6,235 5,472 4,848 28,081 17.4%
A57 Operations on spinal nerve root 1,348 1,942 1,422 1,638 2,758 9,108 5.6%
A70 Neurostimulation of peripheral nerve
1,142 1,690 2,194 2,328 531 7,885 4.9%
A54 Therapeutic spinal puncture 847 900 1,027 1,045 1,017 4,836 3.0%
V48 Denervation of spinal facet joint of vertebra
494 649 536 643 823 3,145 1.9%
V25 Primary decompression operations on lumbar spine
504 710 470 576 674 2,934 1.8%
V33 Primary excision of lumbar intervertebral disc
462 472 335 360 465 2,094 1.3%
V52 Other operations on intervertebral disc
80 80 99 115 91 465 0.3%
A48 Other operations on spinal cord 78 93 101 96 97 465 0.3%
V29 Primary excision of cervical intervertebral disc
98 70 55 84 121 428 0.3%
V38 Primary fusion of other joint of spine 71 94 47 92 87 391 0.2%
V26 Revisional decompression operations on lumbar spine
45 57 45 43 65 255 0.2%
V34 Revisional excision of lumbar intervertebral disc
41 39 27 38 56 201 0.1%
A09 Neurostimulation of brain 20 17 24 19 9 89 0.1%
V35 Excision of unspecified intervertebral disc
6 5 3 9 3 26 0.0%
Total all procedures 27,738 32,706 35,141 33,705 32,492 161,782 100.0%
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services; Mid-year population estimates, Office for National Statistics.
Notes:
[1] Recorded as the primary procedure within the episode.
Chronic Pain Health Needs Assessment 71
Figure 16. Most widely used pain management procedures (using 3-digit OPCS4 procedure code), West Midlands residents aged 16+, FYs 2007/8 to 2011/12.
Figure 17. Trends in the most frequently used procedures, West Midlands residents aged 16+, FYs 2007/8 to 2011/12.
Puncture of joint (W90) 70251 43%
Other operations on spine (V54)
31128 19%
Therapeutic epidural injection
(A52) 28081 17%
Operations on spinal nerve root
(A57) 9108 6% Neurostimulation
of peripheral nerve (A70)
7885 5%
Therapeutic spinal puncture (A54)
4836 3%
Other pain management procedures
10,493 7%
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning
0
2
4
6
8
10
12
14
16
18
2007/08 2008/09 2009/10 2010/11 2011/12
Co
un
t o
f e
pis
od
es (
tho
usa
nd
s)
Financial year
W90 Puncture of joint
V54 Other operations on spine
A52 Therapeutic epidural injection
A57 Operations on spinal nerve root
A70 Neurostimulation of peripheral nerve
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
72 Chronic Pain Health Needs Assessment
ANALYSIS BY PROVIDER TRUSTS
6.14 Table 22 shows the pain management inpatient procedure episodes for each of the
West Midlands Provider Trusts. It includes all patients treated at the Trusts, including
those resident outside of the West Midlands region and excludes episodes classified as
maternity and delivery episodes (as described in Methods above). There was a total of
153,891episodes to West Midlands providers of which 145,542 were elective episodes.
This is nearly 9,000 fewer elective episodes than reported for West Midlands residents.
This suggests a net flow of patients being treated as elective cases by providers outside
the region.
6.15 Three Trusts undertook significantly larger volumes of elective activity: The Dudley
Group NHS Foundation Trust (21,684), The Royal Orthopaedic Hospital NHS Trust in
south Birmingham (21,921), University Hospitals Coventry and Warwickshire NHS Trust
(20,811). 85.8% of elective activity across the region was done as day cases; this is
slightly lower than the day case percentage for the West Midlands resident patients
(89.7%). Day case percentage varied from a low of 41.5% at the University Hospitals
Birmingham NHS Trust to 99.0% at South Warwickshire NHS Foundation Trust.
Birmingham Women’s NHS Foundation Trust had a rate of 5.3% but this was based on
just 18 cases over 5 years. The distribution of the percentage of first attendances by
provider trust displays over-dispersion when compared to the control limits around the
regional average (Figure 14).
Figure 18. Funnel plot of day cases as a percentage of all elective episodes for West Midlands provider trust patients aged 16+, FYs 2007/8 to 2011/12.
0
10
20
30
40
50
60
70
80
90
100
0 5,000 10,000 15,000 20,000 25,000
Pe
rcen
tage
of
day
cas
es
Number of elective episodes
West Midlands average 2SD limits 3SD Limits Provider Trusts
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services.
Chronic pain health needs assessment 73
Table 22: Pain management inpatient procedure episodes for West Midlands Provider patients aged 16+ years by Provider Trust by admission method and patient classification, FYs 2007/08 to 2011/12
Provider Trust Emergency episodes
Elective episodes Other and unspecif’d episodes
Total episodes
Day case as % of elective
Day cases Ordinary admissions
Regular attenders
Total Percent 95% CI limits [1]
Lower Upper
RNA THE DUDLEY GROUP NHS FOUNDATION TRUST 659 19,574 2,110 0 21,684 25 22,368 90.3% 89.9% 90.7%
RRJ THE ROYAL ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST 175 19,839 2,082 0 21,921 69 22,165 90.5% 90.1% 90.9%
RKB UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 1,027 16,953 3,845 13 20,811 153 21,991 81.5% 80.9% 82.0%
RRK UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 731 4,559 3,813 2,626 10,998 555 12,284 41.5% 40.5% 42.4%
RXK SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST 574 8,574 281 179 9,034 37 9,645 94.9% 94.4% 95.3%
RWP WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 519 8,175 175 13 8,363 18 8,900 97.8% 97.4% 98.0%
RJE UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST 553 6,102 1,593 2 7,697 48 8,298 79.3% 78.4% 80.2%
RL4 THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST 311 6,390 597 0 6,987 56 7,354 91.5% 90.8% 92.1%
RJD MID STAFFORDSHIRE NHS FOUNDATION TRUST 291 6,393 349 102 6,844 26 7,161 93.4% 92.8% 94.0%
RR1 HEART OF ENGLAND NHS FOUNDATION TRUST 431 5,923 210 0 6,133 16 6,580 96.6% 96.1% 97.0%
RJC SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 193 5,948 63 0 6,011 11 6,215 99.0% 98.7% 99.2%
RBK WALSALL HEALTHCARE NHS TRUST 487 4,724 618 0 5,342 57 5,886 88.4% 87.5% 89.3%
RXW SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 507 3,680 306 1 3,987 40 4,534 92.3% 91.4% 93.1%
RL1 THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST
49 2,730 1,264 8 4,002 87 4,138 68.2% 66.8% 69.6%
RLT GEORGE ELIOT HOSPITAL NHS TRUST 79 2,877 79 0 2,956 7 3,042 97.3% 96.7% 97.9%
RLQ WYE VALLEY NHS TRUST 359 2,129 206 0 2,335 43 2,737 91.2% 90.0% 92.3%
RJF BURTON HOSPITALS NHS FOUNDATION TRUST 146 207 66 0 273 7 426 75.8% 70.4% 80.5%
RQ3 BIRMINGHAM CHILDREN'S HOSPITAL NHS FOUNDATION TRUST 2 140 5 0 145 0 147 96.6% 92.2% 98.5%
RLU BIRMINGHAM WOMEN'S NHS FOUNDATION TRUST 0 1 18 0 19 1 20 5.3% 0.9% 24.6%
Total All West Midlands PCOs 7,093 124,918 17,680 2,944 145,542 1,256 153,891 85.8% 85.6% 86.0%
Source: Admitted Patient Commissioning Data Set, Healthcare Commissioning Services. Notes:
[1] Based on the Wilson score method(137).
74 Chronic Pain Health Needs Assessment
7 STAKEHOLDER AND CORPORATE NEEDS ASSESSMENT
CHRONIC PAIN – STAKEHOLDERS
The development of services for people affected by Chronic Pain is advocated by several
professional, third sector and patient representative groups.
7.1 Chronic Pain Policy Coalition.
Policy Connect host the Chronic Pain Policy Coalition (CPPC), a collaboration
formed in 2006 with an aim to ‘unite patients, professionals and
parliamentarians in a mission to develop an improved strategy for the
prevention, treatment and management of chronic pain and its associated
conditions’. The coalition currently lists the following organisations as its
collaborators;
7.2 Medical & Nursing Colleges, and Other Societies
The Royal College of Anaesthetists
The Royal College of General Practitioners
The Royal College of Nursing
Royal College of Obstetricians and Gynaecologists
The Royal College of Physicians
British Society for Rheumatology
The Faculty of Occupational Medicine
The British Pain Society
The British Medical Acupuncture Society
7.3 Patient Support and Representative Groups.
These organisations have variable membership and scale. To assist in reviewing
the likely impact of these groups, where a charitable income could be identified
for 2010/11 or 2011/12, this has been indicated. (Note that this will not include
income for any associated non-charitable companies).
Action for ME - £689,333
Action on Pain - £26,929
BackCare (National Back Pain Association) - £496,521
The British Polio Fellowship - £874,232
Derbyshire Chronic Pain Support Group (COPING) – Not identified
Empower – Not identified
Endometriosis SHE Trust - £7,953
FibroAction - £30,512
Fibromyalgia Association UK - £45,697
The Migraine Trust - £497,752
National Lichen Sclerosus Support Group – Not identified
Pain Association Scotland - £241,580 (Scottish Charitable Commission)
Pain Concern - £34,917 (Scottish Charitable Commission)
Pain Relief Foundation - £318,458
Chronic Pain Health Needs Assessment 75
Pelvic Pain Support Network - £12,966
Poole Endometriosis Support Group – Not identified
Scleroderma Society - £194,337
Shingles Support Society - £100,941
Spinal Injuries Association - £2,164,274
Vulval Pain Society - £5,003
The coalition is funded from a variety of sources, including sponsorship from
medical corporate sponsors, named as Astellas, Grunenthal, Lilly, Medtronic,
Napp, Pfizer and Sanofi Pasteur MSD.
The coalition campaigns against a five point manifesto which it established in
2007. It suggests that the effective approach to the management of chronic
pain requires;
1. Education – integrating management of chronic pain in all professional training 2. Empowerment – to support people making decisions about their condition 3. Collaboration – to bring stakeholders together to deliver joined up patient strategy 4. Early Access – to prevent acute pain becoming chronic pain 5. Measurement – to see pain measured as a basic vital sign in patient management
CPPC hosted the first English ‘Pain Summit’ in November 2011, and published
recommendations for future development of chronic pain services in July
2012(140). It made four overarching recommendations;
A. Clear standards and criteria must be agreed and implemented nationally for the identification, assessment and initial management of problematic pain.
B. An awareness campaign should be run to explain the nature, extent, impact, prevention and treatment of chronic pain to the wider general and NHS community.
C. Nationally-agreed commissioning guidance must be developed and agreed, describing best value care in chronic pain to reduce unwarranted variation
D. A data strategy for chronic pain should be agreed through creation of an epidemiology of chronic pain working group.
The coalition identifies that, despite progress on information gathering, through
the Health Survey for England and the National Pain Audit, commissioning
practice varied widely, and suggested that although examples of best practice in
areas from needs assessment to service delivery could be identified, there was
a lack of consistency across England in the delivery of chronic pain services.
7.4 Other Organisations
76 Chronic Pain Health Needs Assessment
Many of the organisations within the CPPC also advocate independently for
developments in services for patients with chronic pain;
7.5 British Pain Society
The British Pain Society (BPS), a charitable professional organisation, represents
a multidisciplinary body of doctors, nurses, physiotherapists, psychologists,
occupational therapists and other healthcare and related research professionals
involved in the treatment and management of pain. It delivers its charitable
purposes through education and training, professional publications including
treatment guidance, patient literature and participation and membership of
chronic pain stakeholder groups, including those hosted by the National
Institute for Health and Clinical Excellence.
The BPS has undertaken significant work on the development of pain
management pathways, and has recently had two pathways published on the
Map of Medicine
Initial assessment and early management of pain(141)
Spinal Pain(142) The society has also independently published draft pathways covering several
other areas, and has a stated intention to progress these towards publication
through Map of Medicine*. These cover neuropathic pain, chronic widespread
pain and low back pain. The BPS publishes its own Pain Rating Scale, available in
17 languages, which assesses pain against intensity and distress at time of
assessment and during the previous week on an 11 point scale, alongside the
interference with normal everyday activities caused by pain (subjective single
point assessment).
7.6 Royal College of Anaesthetists
Many pain management services are led or supported by anaesthetists, and the
professional college delivers the majority of its professional function to chronic
pain services through the Faculty of Pain Medicine, which covers both the care
of patients with acute pain and chronic pain. The Faculty publishes guidance on
professional competencies for the Pain Management Specialist(143), and is
supported by the college in publishing recommendations on the provision of
services for Chronic Pain Management(144). The college guidance recommends
that a good pain management service will offer;
Ready access for patients to a local, first class chronic pain service
A seamless service between primary and secondary care
A specialised chronic pain management services in each region for adult patients with complex pain problems
* When accessed on 25
th October 2012, it was noted that the project deadline for this had elapsed. No
information was identified on the future timeline for final publication of these additional pathways.
Chronic Pain Health Needs Assessment 77
Specialised chronic pain management services in each region for children and young people with complex pain problems with a requirement to work with children and their families
Established links between acute and chronic pain management services within each hospital to enable patients with pain who present acutely and whose symptoms do not resolve to be managed appropriately as an outpatient
Co-operation between chronic pain management and palliative care services within hospitals and the community
Provision of appropriate time for direct clinical care for consultants in pain medicine, allied health professionals, managers and support staff
Appropriate accommodation, facilities and equipment in accordance with best practice recommendations
Formal links between hospitals on a regional basis so that a comprehensive range of treatments can be offered to all patients who need them
Provision of pain management programmes (PMP) that promote restoration of physical and psychological function, encourage self care and decrease use of healthcare resources
A robust 24/7 on-call system with support from other disciplines (e.g. spinal/ neurosurgery, radiology, microbiology) if neuro-modulation techniques are used
Sufficient funding to enable the service to achieve required targets and quality standards
Continuing professional development of all staff
Equity of access and service provision for all patients
The Royal College of Anaesthetists also includes Chronic Pain services within its
audit criteria(145). These offer specific and substantial audit criteria against
which Chronic Pain Services can be assessed. Standards include;
Management of patients with repeat admissions for chronic pain
Availability and resourcing of core chronic pain services
Long term use of opioid analgesia in chronic non-malignant pain
Each standard is accompanied by specific audit criteria and suggested data
collection sources. For example, in the assessment of management of patients
with repeat admissions, the college propose five standards;
Reduce re-admission rates for non surgical pain.
Develop resources to manage non acute pain effectively.
Reduce length of stay related to acute exacerbations of chronic pain.
Development of shared care amongst specialties.
Reduction of medication-related adverse events.
Standards and targets for best practice are also proposed.
78 Chronic Pain Health Needs Assessment
The priority focus of the college is in delivering training for anaesthetists in the
techniques of managing chronic pain, including best practice guidance on
specific procedures. Outside of its participation on policy and steering groups,
and the above references, no further documents were identified on specific
advocacy for future developments in chronic pain services.
7.7 Spinal Injuries Association
The Spinal Injuries Association is, by charitable income, a major stakeholder.
However, review of the online document archive did not demonstrate any
relevant, contemporary publications outside of the association's contribution to
the Chronic Pain Policy Coalition.
7.8 International Association for the Study of Pain (IASP)
The IASP is one of the international bodies connected with chronic pain, that
significantly contributes to UK practice and treatment. Three outputs are
particularly relevant in the commissioning and delivery of chronic pain services;
1. The 'Desirable Characteristics of National Pain Strategies'(146). These are recommendations by the IASP to assist in the construction of overarching strategy documents linked to Chronic Pain. The critical recommendations are;
Access to pain education for health professionals and the general population Coordination of the care system to ensure timely access to the right support A quality improvement program to address access and standards of care A reasonable proportion of direct and dedicated funding for pain research.
The same guidance also identifies critical success factors around effective epidemiology, clear and available service descriptions, cross-stakeholder working, and strong timescales for delivery.
2. IASP also make 'Recommendations on Pain Treatment Services(147) ', which superseded specific guidance for pain treatment facilities(148) in 2009. This guidance provides broad behaviours for chronic pain services, including the need for interdisciplinary communication, co-ordinated and programmed care delivery, and a commitment to advancing and improving services.
3. Finally, IASP produces a detailed taxonomy(149) for the classification of pain by type and location. This taxonomy is not currently linked to the ICD-10 or NHS classification systems.
7.9 Patient Support Groups
No standardised networks or central co-ordination of support groups for
chronic pain services were identified. Specific subgroups of patients, such as
those with Arthritis, Back pain or Fibromyalgia are served by established disease
specific support networks, but chronic pain per se has no similar national
coverage.
Chronic Pain Health Needs Assessment 79
Organisations such as Action for Pain, Action on Pain and Pain Concern maintain
websites and discussion groups, but do not identify with a specific local
footprint. There is no evidence of systematic professional support on these
websites, with the dominant focus being on peer advice and information
sharing. Pain Concern are identified as PPE representatives on the development
of several national guidelines and strategies connected with pain services, but
do not have clear advocacy aims listed within their charitable objectives.
Neil Betteridge, an independent policy analyst and consultant, and previous
chief executive of Arthritis Care, provides the patient and public representative
on the CPPC executive committee. The CPPC does not include a clear single
patient representative body within its membership.
The West Midlands NHS Local website does not list any support groups
provided outside the context of direct NHS care, and the West Midlands
Commissioning Support Unit was not made aware of any local groups during
the conduct on the needs assessment.
Website and document review of the other organisations within the CPPC did
not identify further relevant substantiated policy documents relevant to the
advocacy and development of Chronic Pain services.
The Patient Association, not directly connected with the CPPC, has also
contributed to the chronic pain policy debate through the 2010 ‘Public
Attitudes to Pain’ report(150). This patient focussed survey concluded with the
Patient Association calling on the Government and healthcare professionals to
take action to -
Establish a clear care pathway for pain services in the NHS and recognise pain as a disease in its own right
Ensure that patients have access to all the information they require to make informed and complete decisions about the care pathway
Provide further education for healthcare professionals on pain services
Ensure that NICE guidelines on Medicines Adherence are followed by healthcare professionals
CHRONIC PAIN – SERVICE DELIVERY
7.10 A survey of NHS provider units in the West Midlands region was conducted by
the West Midlands Commissioning Support Unit as part of the healthcare needs
assessment. This included a standardised set of questions (shown in the
Appendix), and was followed by an electronic reminder where no response was
received. Nine sufficient responses were received, and these results can be seen
summarised in Table 23. An original copy of the questionnaire is included within
the appendices.
80 Chronic Pain Health Needs Assessment
7.11 All providers that responded offered a formal chronic pain management service,
led by the department of Anaesthetics, and delivering a multi-disciplinary clinic.
Some services have dedicated staff working full time for the chronic pain service,
whilst others shared team members with the in-hospital acute pain service, or
with wider multidisciplinary teams, particularly physiotherapy, psychology and
occupational health. Some services used referral to other departments to
complete the multi-disciplinary team
The number of clinical sessions varied widely, as did the number of doctors and
senior specialist nurses supporting the service. Where patient numbers were
stated, these again showed substantial variation, and were not directly
correlated with the number of clinical sessions held.
An array of interventions were offered. Commonly offered interventions
reported through the survey included;
TENS
Anticonvulsants (Gabapentin, Carbamazepine)
Antidepressants
Analgesic, Steroid and Anaesthetic Injections
Back Injections
Intra-articular injections
Nerve Ablation
Psychotherapy
Cognitive Behavioural Therapy
Interventions mentioned infrequently included;
Ultrasound
Low Level Laser Therapy
Facet Denervations
Trigger Injections
Percutaneous chordotomy
Visco-supplementations
Acupuncture
Pain Management Programmes
Spinal Cord Stimulation
Sacral Nerve Stimulation
Capsaicin Patch Therapy
Intrathecal Drug Delivery and Injections
Botulinum A Injections
Note that these were free text responses, and organisations may only have
reported certain therapies, such as those seen as advanced, controversial, or
essential to the delivery of a service. Individual Funding Requests were reported
by four of the nine responders, and included applications for funding to out of
region complex pain services.
Chronic Pain Health Needs Assessment 81
7.12 Summary of Service Design & Delivery by Trust
Table 23: Summary of Questionnaire responses by trust
Trust HoE ROH SWBH S Warks UHCW DGOH RJAH Burton UHNS
Formalised Service Yes Yes Yes Yes Yes Yes Yes Yes Yes
Service Specification Yes Some Yes No Yes Yes No Yes Some
Clinical Sessions
(approximate number) 10 9 20 4.5 12 22 9 9 9
Consultants 2 1 4 2 3 5 2 1 3
Other Doctors 0 1 0 0 0 2 0 0 0
Nurses 2 2-3 5* 1 1 2 1 Unknown Unknown
Psychology Support Dedicated Dedicated Dedicated By Referral None Stated Dedicated None Stated Dedicated None Stated
Physiotherapy Support Dedicated Cross Cover Cross Cover Through
Main Dept None Stated Dedicated None Stated Dedicated Dedicated*
Referrals (Approximate) 3500 2075 2500 Unknown 1500 Unknown 600 Unknown Unknown
NPA Contributor Yes Yes Yes Yes Yes Yes No No No
Notes
Nurses also
cover acute
pain service
Supra-
Regional 3o
IFRs
New Service *0.1 WTE
only
82 Chronic Pain Health Needs Assessment
COMMISSIONING CHRONIC PAIN SERVICES
7.13 Chronic pain services have previously been commissioned through Primary Care
Trusts, with some particular services commissioned through the West Midlands
Specialised Commissioning Team. The implementation of the Health and Social
Care Bill means that the majority of commissioning responsibility for these
services is being transferred to Clinical Commissioning Groups, with specialist
services now becoming the responsibility of the National Commissioning Board.
The West Midlands Commissioning Support Unit has encountered difficulties in
identifying leads in either sender or receiver organisations, at both local and
regional level, who have operational knowledge of the commissioning of these
services, or with sufficient resource to support the unit in identifying the scope
of the existing commissioned service.
It is therefore only possible to present ‘cameos’ of the current chronic pain
commissioning structure;
Service specifications, with varying degrees of detail, do exist for the majority of services. However, these largely focus on necessary targets, such as waiting times and routes of access, and do not provide precise descriptions of the scope of a chronic pain service.
Chronic pain services are largely accessed through General Practice services, although where community pain teams exist, there may be routes of direct referral to an acute provider service
Few commissioners or providers were aware of specific commissioned pathways. Where these were referenced, they were direct transcriptions or copies of national Map of Medicine pathways. No alternative pathways covering other chronic pain conditions were identified.
As well as routinely commissioned services, commissioners made reference to Individual Funding Requests, particularly around complex therapeutic interventions such as neurostimulators.
There was evidence that many commissioners currently included certain procedures used for the relief of pain within lists of procedures of limited clinical value, or for which specific eligibility criteria had to be met. This was most consistently applied in relation to certain joint injection procedures.
An example was identified within a public health pharmacy team of clear guidance on prescribing for chronic pain relief. However, work to connect this to referral pathways, and non-pharmacological interventions had been suspended whilst the new commissioning responsibilities were established.
Worcestershire was the only West Midlands area identified to have a localised pathway listed on Map of Medicine. This addressed both musculoskeletal and neuropathic pain, focussing on management prior to referral to the specialist pain clinic.
Providers reported varying qualifying criteria for access to their chronic pain service. Some reported pre-screening by primary care trusts, some used timeframe criteria (for example, at least three months of pain), and others triaged referrals on a case by case basis, either undertaken by medical or senior nursing staff.
Two Clinical Commissioning Groups (CCGs) stated that they were developing more community focussed pathways, particularly around low back pain, but
Chronic Pain Health Needs Assessment 83
this work was at draft stage, and further detail was not yet available. Four other CCGs contacted were as yet unable to provide a contact for commissioning of these services and referred back to their respective Primary Care Trusts.
7.14 The West Midlands Primary Care Trusts have also previously commissioned
some complex services through the West Midlands Specialised Commissioning
Team. These were defined by the Specialised Services National Definitions Set
(SSNDS), specifically SSNDS 31(151) which established the scope of specialised
services for Chronic Pain. These specifically relate to the commissioning of
certain denervation and chordotomy procedures, both surgical and
radiofrequency, and implantable neuro-stimulation techniques.
7.15 From April 1st, 2013, the responsibility for commissioning of these procedures
will become the responsibility of the National Commissioning Board. Clinical
Reference Groups (CRGs) have been established to construct and assure service
specifications for identified services, including some chronic pain services.
However, these service specifications have not yet been released into the public
domain. The full list of CRGs can be viewed at
http://specialisedcommissioning.com/clinical-reference-groups/
Key CRGs for the development of chronic pain services include;
Specialised Pain CRG
Complex Spinal Surgery CRG
Adult Neurosurgery CRG
Final outputs from these CRGs are expected by April 2013, and will inform the
commissioning pathways for more specialised interventions for patients with
chronic pain. Draft consultation versions of the central service specifications,
which will be used both within the National Commissioning Board and the NHS
standard contract, are expected by December 2012.
7.16 The Specialised Pain CRG is still at an early stage of development, but the clinical
panel has been established. It is chaired by Dr Andrew Baranowski, a pain
specialist working at University College London Hospitals, with commissioning
support led by Joan Ward from NHS South Central and public health input from
John Harris, a public health practitioner in London. The group also has Regional
Representatives from the four England 'old-SHA' sectors, and PPE Members
from Pain Concern and the Chronic Pain Policy Coalition. Invited Members also
attend the group, representing Psychology, Physiotherapy, Cancer Services,
Academic Interests, British Pain Society, Faculty of Pain Medicine, the RCGP and
the Chronic Pain Coalition.
84 Chronic Pain Health Needs Assessment
No information was available on the scope or timeline of potential products of
this CRG(152).
The WMCSU has however been able to review an early draft of the chronic pain
service specification. This proposes the following commissioning model for
chronic pain services. No detailed pathways have yet been proposed.
The proposed pathway identifies that referrals will only be made from
secondary or tertiary care services into very specialised interventions and
conditions, of which the service specification identifies between six and ten that
may already meet criteria to be considered very specialised. It was noted that
the draft service specification did not yet provide detail on how tertiary
activities would be identified in data streams from non-specialised activity
delivered in a concurrent setting.
The early draft specification proposes that minimum standards will be defined
by the British Pain Society, Faculty of Pain Medicine, Royal College of
Anaesthetists and International Association for the Study of Pain, with
pathways parallel to those proposed by British Pain Society, and already
discussed above.
MEASURING OUTCOMES
7.17 Prior discussions with local providers identified an array of assessment tools in
use, including Visual Analogue Scores (Usually 0-10 range), Hospital Anxiety and
Depression Scores, McGill questionnaire, 5th Vital Sign, and the Rowland Morris
Scoring Systems. The draft service specification highlights a series of proposed
GPCommunity
CareSecondary Tertiary
Contracted by CCGs
Non-SpecialisedActivity referred
into the tertiary
setting but not
specifically specialised
Specialised ActivityIdentified by using:
•Specific clinic ID
•OPD diagnostic code
•Patient Register
•Inpatients using OPCS/ICD
10. If not sensitive enough
see following model
Contracted by CCGs Contracted by NHS
Chronic Pain Health Needs Assessment 85
metric for monitoring clinical progress and assessing clinical outcomes; again,
these are unconfirmed and subject to further substantial consultation;
Brief Pain Inventory (short form)
SF-12 Quality of Life Score
PHQ-9 Depression Assessment
Monitoring of employment/education/training status
Patient Global Impression of Change
Service monitoring metrics proposed include;
Percentage of patients assessed within 3 months from referral
Percentage of patients entering multi-disciplinary treatment pathways within 6 weeks following assessment
Percentage of patients discharge to primary care within 12 months from referral.
It should be noted that these proposed measures are not representative of
those used in research methodologies. In particular, the Cochrane Collaboration
Pain, Palliative and Supportive Care (PaPaS) review group have considered
potential outcome measures for use in the evaluation of evidence for
systematic review(153,154,155) and support the adoption of the IMMPACT
assessments in this context.
The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
(IMMPACT) provide a set of outcomes which it deems meaningful in research,
and to patients. They also recommend certain scales for use in the assessment
of pain.
RECOMMENDED CORE OUTCOME MEASURES IN RESEARCH
Pain o 11 point (0-10) numerical rating scale of pain intensity o Usage of rescue analgesics o Categorical rating of pain intensity (none/mild/moderate/severe) where
numerical ratings may be problematic
Physical Functioning o Multidimensional Pain Inventory Interference Scale o Brief Pain Inventory interference items
Emotional Functioning o Beck Depression Inventory o Profile of Mood States
Participant ratings of global improvement and satisfaction with treatment o Patient Global Impression of Change
Symptoms and adverse events - passive capture of spontaneously reported adverse events and symptoms and use of open-ended prompts
Participant Disposition (in line with CONSORT guidance)
86 Chronic Pain Health Needs Assessment
The IMMPACT group identify that the following responses to pain interventions are
significant within trial groups for Pain;
At least 50% pain reduction* or At least 30% pain reduction
Absolute score of 30/100 or less (no worse than mild pain)
Patient Global Impression of very much improved
*In the latest update to IMMPACT it is suggested growing evidence favours an
outcome of a 50% reduction in pain.
No minimum level for improvements in function are set by the IMMPACT group.
TAXONOMY OF CHRONIC PAIN SERVICES
7.18 Based on the information that was received, and through the treatments
identified in the epidemiological and literature reviews, taxonomy for the
delivery of Chronic Pain services has been constructed.
This hierarchy demonstrates that the majority of care is delivered through self
care, and primary care services, but with increasingly complex investigations and
interventions deployed through secondary care, and ultimately highly
specialised tertiary or quarternary care, limited to a few specialist centres.
Chronic Pain Health Needs Assessment 87
88 Chronic Pain Health Needs Assessment
7.19 Prior to the current NHS reconfiguration, the SSNDS defined the specialist pain
interventions using the following ICD-10 and OPCS-4 codes;
OPCS OPCS-4.5 Category OPCS-4.5 Sub-category Yes Maybe Comments
A365 Other operation on
cranial nerve
Denervation of trigeminal nerve (v) x
A472 Other destruction of
spinal cord
Radiofrequency controlled thermal
destruction of spinothalamic tract
x only in conjunction with a
pain ICD code
A473 Other destruction of
spinal cord
Percutaneous chordotomy of spinal
cord
x only in conjunction with a
pain ICD code
A483 Other operations on
spinal cord
Insertion of neurostimulator adjacent
to spinal cord
x for tertiary treatment of
neuropathic pain
A484 Other operations on
spinal cord
Attention to neurostimulator adjacent
to spinal cord NEC
x for tertiary treatment of
neuropathic pain
A543 Therapeutic spinal
puncture
Implantation of intrathecal drug
delivery device adjacent to spinal cord
x only in conjunction with a
pain ICD code
A544 Therapeutic spinal
puncture
Attention to intrathecal drug delivery
device adjacent to spinal cord
x only in conjunction with a
pain ICD code
A545 Therapeutic spinal
puncture
Removal of intrathecal drug delivery
device adjacent to spinal cord
x only in conjunction with a
pain ICD code
A701 Neurostimulation of
peripheral nerve
Implantation of neurostimulator into
peripheral nerve
x only in conjunction with a
pain ICD code
A702 Neurostimulation of
peripheral nerve
Maintenance of neurostimulator in
peripheral nerve
x only in conjunction with a
pain ICD code
A703 Neurostimulation of
peripheral nerve
Removal of neurostimulator from
peripheral nerve
x only in conjunction with a
pain ICD code
A708 Neurostimulation of
peripheral nerve
Other specified neurostimulation of
peripheral nerve
x only in conjunction with a
pain ICD code
V481 Denervation of
spinal facet joint of
vertebra
Radiofrequency controlled thermal
denervation of spinal facet joint of
cervical vertebra
x for tertiary treatment of
spinal pain
Chronic Pain Health Needs Assessment 89
V482 Denervation of
spinal facet joint of
vertebra
Denervation of spinal facet joint of
cervical vertebra NEC
x for tertiary treatment of
spinal pain
X662 Cognitive
behavioural therapy
Cognitive behavioural therapy by
multidisciplinary team
x requires ICD 10 code : where
CBT given as part of an
intensive in-patient
rehabilitation programme
ICD ICD Category ICD Sub Category Yes Maybe
G441 Other headache syndromes Vascular headache NOC x
G521 Disorders of other cranial nerves Disorders of glossopharyngeal nerve x
G564 Mononeuropathies of upper limb Causalgia x
G570 Mononeuropathies of lower limb Lesion of sciatic nerve x
G572 Mononeuropathies of lower limb Lesion of femoral nerve x
G574 Mononeuropathies of lower limb Lesion of medial popliteal nerve x
G579 Mononeuropathies of lower limb
Mononeuropathy of lower limb,
unspecified x
G580 Other mononeuropathies Intercostal neuropathy x
G601 Hereditary and idiopathic neuropathy Refsum's disease x
G602 Hereditary and idiopathic neuropathy
Neuropathy in association with
hereditary ataxia x
G603 Hereditary and idiopathic neuropathy Idiopathic progressive neuropathy x
G608 Hereditary and idiopathic neuropathy
Other hereditary and idiopathic
neuropathies x
G609 Hereditary and idiopathic neuropathy
Hereditary and idiopathic
neuropathy, unspecified x
G611 Inflammatory polyneuropathy Serum neuropathy x
G619 Inflammatory polyneuropathy
Inflammatory polyneuropathy,
unspecified x
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G620 Other polyneuropathies Drug-induced polyneuropathy x
G622 Other polyneuropathies
Polyneuropathy due to other toxic
agents x
G64X
Other disorders of peripheral nervous
system
Other disorders of peripheral
nervous system x
R201 Disturbances of skin sensation Hypoaesthesia of skin x
R203 Disturbances of skin sensation Hyperaesthesia x
It should be noted that this classification system is known to have flaws. Specialised Services
specifically note that;
“As with other specialised services there are difficulties with the current ICD-10
classification system because it does not identify severity or extent of disability and
hence cannot distinguish between complex cases of pain treated by specialist pain
management centres services and those treated by local hospitals.
The OPCS codes for pain management were extensively reviewed during 2003- 2005
and have continued to be refined since then. The use of flags and co-morbidity data
has produced more refined HRGs which better distinguish between local non-
specialised and specialised services for ostensibly similar procedures. If new
treatments for pain arise then new OPCS codes are sought.”
PATHWAYS FOR CHRONIC PAIN PATIENTS
7.20 This taxonomy, alongside the service information that could be derived locally,
and from the evidence reviews, was then used to construct patient pathways to
describe the potential patient journeys for those with chronic pain. Note that it
is possible to travel through the pathway several times, taking different routes
at different times, and also that not all services may be available or
commissioned in all areas.
The following pages show the pathways of care;
1. All potential pathways 2. Those managed through primary care 3. Those managed through a community chronic pain service 4. Those managed through a hospital chronic pain service 5. Those managed through a disease specific pathway
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8 RAPID EVIDENCE REVIEW OF THE EFFECTIVENESS OF INTERVENTIONS FOR
CHRONIC PAIN.
OBJECTIVE
8.1 To conduct a rapid review of the evidence for the effects and effectiveness of
interventions for chronic pain, including chronic low back pain.
8.2 Two key clinical practice guidelines on the diagnostic assessment and management of
low back pain have been published, one by NICE(156) the other jointly by the American
College of Physicians and American Pain Society(157). Both guidelines are supported by
systematic reviews of the evidence. Where relevant, some of the findings of the
guidelines have been appraised and included in this rapid evidence review. A more
comprehensive overview of their main recommendations are presented in Appendix ??
METHODS
8.3 Criteria for considering studies.
Types of studies
Systematic reviews and evidence based guidelines published in English from 2007 onwards.
Types of participants.
Adults from ages 18 to 70 years with chronic pain persisting for three months or longer, including chronic low back pain. Papers which included participants with cancer pain, post-operative pain or pain associated with acute trauma were excluded.
Types of interventions
Any intervention.
Types of outcomes
Primary outcome: Pain, with at least 50% pain reduction on the visual analogue scale and better management of pain.
Secondary outcome: Adverse events.
SEARCH METHODS FOR IDENTIFICATION OF STUDIES
Bibliographic database searches: a systematic literature search were undertaken in the Cochrane Library (all databases) 2011 Issue 4 (chronic pain); 2012 Issue 2 (back pain), MEDLINE (OVID) 1948 – Nov week 3 2011 (chronic pain); 1948 – May 2012 (back pain), EMBASE (OVID) 1980 – 2011 week 48 (chronic pain); 1980 – May 2012 (back pain), TRIP Database and the ARIF Database of Systematic Reviews. Where appropriate a filter for systematic reviews was applied to the searches.
PROSPERO was searched to identify ongoing systematic reviews.
Chronic Pain Health Needs Assessment 97
The searches were limited to papers written in English and those published from 2007 onwards. Retrieved publications were entered into a Reference Manager database. Full details of the search strategies can be found in Appendix ??
DATA COLLECTION AND ANALYSIS
8.4 Selection of studies.
Titles and abstracts of references were screened by one reviewer. Any uncertainties
were resolved with a second reviewer. The full text of the articles was retrieved where
it was unclear whether or not the review was to be included.
8.5 Data extraction and management.
A data extraction table was devised jointly by two reviewers which included author of
the paper, year of publication, type of study, population, intervention, comparator,
outcome, follow-up and results. Data were extracted by one reviewer and put into
Summary of Findings tables. Uncertainties were resolved with the second reviewer.
8.6 Methodological quality assessment.
The methodological quality of the included references for systematic reviews was
independently assessed by two reviewers, using the PRISMA checklist for reporting bias
and AMSTAR for critical appraisal. The quality of guidelines was assessed using GRADE
and completeness of reporting using the AGREE checklist.
The Oxford Centre for Evidence Based Medicine grading system was used to rate the
level of evidence for each included systematic review:
```
98 Chronic Pain Health Needs Assessment
RESULTS
MANUAL THERAPY
8.7 This category of interventions comprises manipulation and mobilisation in chronic neck
pain, and patellar taping and bracing for chronic knee pain.
Two good quality systematic reviews were identified(158,159) and the findings are
summarised in Appendix 1
The first review is a Cochrane Review and as such is an authoritative summary of the
present state of the evidence. The review evaluated manipulation or mobilisation
techniques in acute, sub-acute or chronic neck pain.
The second review evaluated manual therapy combined with exercise in neck pain with
or without radicular symptoms or cervicogenic headache.
8.7.1 Conclusions.
While the estimated effects of manipulation or mobilisation techniques in neck pain
look impressive the quality of evidence is poor.
Moderate quality evidence supports this treatment combination for pain reduction
and improved quality of life over manual therapy alone for chronic neck pain; and
suggests greater short-term pain reduction when compared to traditional care for
acute whiplash. Evidence regarding radiculopathy was sparse.
8.7.2 Implications for practice.
Manipulation or mobilisation techniques in neck pain should be available for those
patients who chose to have it.
Manual therapy combined with exercise in neck pain could be made available to
patients.
PHARMACOLOGICAL PROCEDURES
8.8 Pharmacological procedures include antipsychotics, antidepressants, NSAIDs, opioids,
anti-epileptic drugs, capsicum pain plasters, anaesthetics, and cannabinoids.
Fifteen systematic reviews were identified which looked at a range of pharmacological
interventions(160,161,162,163,164,165,166,167,168,169,170,171,172,173,174) and the
findings are summarised in Appendix 2
Antipsychotics.
One medium to good quality review (160) evaluated antipsychotics for chronic pain. The
authors concluded that data was limited, most trials only studied small patient samples
and further research was required.
Anti-depressants.
Chronic Pain Health Needs Assessment 99
Three recent good quality reviews evaluated anti-depressants (161,162,163). Overall,
the reviews showed that there is strong evidence for the use of antidepressants in
chronic pain management.
Topical treatments.
A Cochrane Review (164) looked at topical rubefacients containing salicylates or
nicotinamides and found that the evidence was limited by the quality and size of the
available studies.
Opioids.
The effectiveness of opioids was investigated in three reviews which were assessed as
either medium or good quality (165,166,167). The evidence for the use of opioids for
short-term treatment was reasonable for older patients without comorbidity, with
frequent surveillance for adverse effects (165). Overall, however, the results of all three
reviews indicated that the evidence base was poor and results were based on weak,
positive evidence.
Cannabinoids
One good quality review looked at cannabinoids for non-cancer chronic pain (168).
Results showed there is evidence that cannabinoids are safe and modestly effective in
neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid
arthritis. However, further large studies of longer duration examining specific
cannabinoids in homogeneous populations are needed before firm conclusions can be
drawn.
Anticonvulsives
Six good quality reviews investigated anticonvulsive/ antiepileptic drugs
(169,170,171,172,173,174). Three were Cochrane Reviews (169,170,174) . One Cochrane
Review (174) concluded that Gabapentin is effective for neuropathic pain however pain
relief may vary between pain conditions and dose. Another (170) found Carbamazepine
effective but the quality of included studies was poor. A third found that Lamotrigine
was not effective(169).
8.8.1 Conclusions.
Evidence for the use of antipsychotics was weak.
There is strong evidence for the effectiveness of anti-depressants in chronic pain
management.
The evidence for the use of topical treatments (rubefacients) is limited.
The evidence base for opioids was poor and results were based on weak, positive
evidence.
Cannabinoids are modestly effective in neuropathic pain with preliminary evidence of
efficacy in fibromyalgia and rheumatoid arthritis. However, further large studies of
longer duration examining specific cannabinoids in homogeneous populations are
needed before firm conclusions can be drawn.
Antiepeliptic drugs have either indeterminate or limited effect.
100 Chronic Pain Health Needs Assessment
Results from three Cochrane reviews suggest varying effectiveness of anticonvlusives.
One (174) concluded that Gabapentin is effective for neuropathic pain however pain
relief may vary between pain conditions and dose. Another (170) found
Carbamazepine effective but the quality of included studies was poor. A third found
that Lamotrigine was not effective.
8.8.2 Implications for practice.
Lamotrigine does not have a significant place in therapy and should not be
commissioned as treatment for any type of chronic pain.
Carbamazepine treatment should be commissioned but only for selected patients
with neuropathic pain.
Gabapentin should be commissioned for selected patients.
The use of antidepressant ( tricyclic antidepressants –TCAs, and serotonin re-uptake
inhibitors - SSRIs) should be included as part of the pain service.
PATIENT EDUCATION.
8.9 Therapeutic patient education was investigated in one recent, good quality Cochrane
review(175). Patients included those with neck pain associated with whiplash or non-
specific and specific mechanical neck pain with or without radiculopathy or cervicogenic
headache. Summaries of findings are presented in Appendix ??
8.9.1 Conclusion.
Effectiveness for educational interventions for neck pain, including advice to activate,
advice on stress-coping skills, workplace ergonomics and self-care strategies has not
been shown.
8.9.2 Implications for practice.
The evidence available does not support the commissioning of education based
interventions for neck pain.
PHYSICAL TREATMENTS
8.10 This includes laser therapy, therapeutic ultrasound, traction, and transcutaneous
electrical nerve stimulation (TENS). Summaries of findings are in Appendix ??
Seven systematic reviews investigated physical treatments
(176,177,178,179,180,181,182). With two exceptions (177,181), all were of either
medium or good quality. Findings are summarised in Appendix ??
Two reviews investigated low level laser therapy (LLLT) (177,183); one (183) for chronic
neck pain, the other (177) for neck pain and carpal tunnel syndrome. Although the
reviews showed moderate statistical significance for efficacy of LLLT for chronic pain,
treatment should be regarded as experimental due to poor methodological quality and
variability of results and small sample size.
Ultrasound for shoulder pain was investigated in one medium to good quality review
Chronic Pain Health Needs Assessment 101
(Alexander 2010). It showed that ultrasound had an indeterminate effect.
One good quality Cochrane review looked at traction for neck pain (Graham 2008). It
found no evidence from RCTs supported or rejected use of either continuous or
intermittent traction for neck pain.
Patellar taping and bracing was investigated in one good quality review(180) . It found
evidence for medially-directed force on the patella and limited evidence to demonstrate
efficacy of patellar bracing. However, outcomes were limited by the presence of high
heterogeneity between study outcomes and significant publication bias.
H wave electrical stimulation for neuropathic pain and soft tissue inflammation was
reviewed by (181). The review was of poor quality and based on uncontrolled studies
therefore little reliance can be based on the reported beneficial effect of H-wave device.
One good quality review(182) investigated physical rehabilitation interventions for non-
specific low back pain (LBP). Overall evidence from RCTs showed effectiveness of
treatments was low. The clinical effect of back school, LLLT, patient education, massage,
traction, superficial heat/cold, and lumbar supports is not clear due to insufficient data.
Only MDT, exercise and BT have some effect on pain intensity and disability, thus only
these three interventions should be provided as conservative treatments in daily
practice in the treatment of chronic LBP.
The NICE guideline (156) makes the following recommendations for low back pain:
consider offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks; consider offering a structured exercise programme tailored to the person which should comprise up to a maximum of eight sessions over a period of up to 12 weeks; offer a group supervised exercise programme in a group of up to ten people; a one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.
8.10.1 Conclusions
Low level laser treatment for chronic pain should be regarded as experimental due to
poor methodological quality and variability of results and small sample size.
Ultrasound had an indeterminate effect, however, it would be premature to conclude
that this treatment is ineffective. More research is required.
Further well conducted RCTs to determine efficacy of traction for neck pain are
required. Recommendations cannot be made with the available evidence.
Evidence was found for medially-directed force on the patella and limited evidence to
demonstrate efficacy of patellar bracing. However, outcomes were limited by the
presence of high heterogeneity between study outcomes and significant publication
bias.
102 Chronic Pain Health Needs Assessment
Only MDT, exercise and behavioural therapy have some effect on pain intensity and
disability in chronic low back pain, thus only these three interventions should be
provided as conservative treatments in daily practice in the treatment of chronic LBP.
8.10.2 Implications for practice.
Only MDT, exercise and behavioural therapy have some effect on pain intensity and
disability in chronic low back pain, thus only these three interventions should be
provided as conservative treatments in daily practice in the treatment of chronic LBP.
Consideration should be given for commissioning manual therapy (including spinal
manipulation) and structured exercise programmes, either in a group or on a one-to-
one basis for low back pain.
BEHAVIOURAL (BT) AND COGNITIVE BEHAVIOURAL THERAPY (CBT)
8.11 Four good quality systematic reviews(184,185,186,187) and a good quality NICE
guideline(156) (ref to guidance and supporting review) were identified and their findings
are presented in Appendix ??
The review by Eccleston(188) is a Cochrane review which evaluated the effectiveness of
psychological therapies on pain, disability and mood. It found that overall there is lack of
evidence for BT, except for pain immediately following treatment, when compared with
‘treatment as usual’. CBT has some small positive effects for pain, disability and mood.
There is insufficient data on quality or content of treatment to investigate their influence
on outcomes. Overall, CBT and BT may have a positive effect on altering mood outcomes
but the results were not statistically significant.
Another Cochrane review (187) investigated behavioural therapy (respondent, operant
and cognitive, behavioural therapy) plus physiotherapy, behavioural therapy plus
inpatient rehabilitation for chronic back pain. For patients with back pain, there is
moderate quality evidence that in the short-term, operant therapy is more effective
than waiting list and behavioural therapy is more effective than usual care for pain relief,
but no specific type of behavioural therapy is more effective than another. In the
intermediate to long-term, there is little or no difference between behavioural therapy
and group exercises for pain or depressive symptoms.
Macea (185) investigated the effectiveness of web-based behavioural interventions on
chronic pain. Results of this meta-analysis suggest that web-based interventions for
chronic pain effect are associated with small reductions in pain in the intervention group
compared with waiting-list control groups however the effect is weak and uncertain.
The review by Hoffman (186) which looked at psychological therapies for chronic low
back pain found there was a significant reduction in pain intensity and depression in
Chronic Pain Health Needs Assessment 103
favour of CBT. However there were concerns about the poor quality of the included
RCTs.
The NICE guideline (156) focused on CBT compared with self care (information package
or a book on back pain) for low back pain. The evidence for effectiveness was provided
by two RCTS. One found no significant difference between groups in terms of pain or
fear. The other found: a greater reduction in average pain intensity for the self-care
group, but difference was significant only at 6 months; significantly lower fear-
avoidance scale scores in the self-care group at all follow-up times; significantly less
disability in the self-care group at 3 months but not at 6 or 12 months and no more
favourable mental health outcomes in self-care group.
8.11.1 Conclusions.
The Cochrane review (189) found that CBT and BT have weak effects in improving
pain.
Both CBT and BT interventions may be effective in altering mood outcomes and the
effect may be maintained at 6 months.
8.11.2 Implications for practice.
The evidence for behavioural therapies in isolation is weak and is not sufficient to
commission these services as individual interventions, however, there is a role for
CBT as part of a comprehensive multi-disciplinary programme.
In view of the small effect and the likely bias, web-based behavioural therapy should
not be commissioned.
CBT may be considered for chronic low back pain but the quality of RCTs examining
its effectiveness should be borne in mind.
INVASIVE PROCEDURES
8.12 Twenty three systematic reviews were identified which looked at a range of invasive
procedures
(176,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204,205,206,207,208,
209,210,211). Also two NICE Interventional Procedures Guidelines, IPG 300 (212) and
IPG 357(213) and one NICE clinical guideline (156) were identified. The findings are
summarised in Appendix ??
Radiofrequency thermal ablation.
A good quality Cochrane review (206) looked at radiofrequency ablation
sympathectomy for neuropathic pain and complex regional pain syndrome. It concluded
that there is little evidence on sympathectomy (one small RCT met the inclusion criteria
of the review).
Intrathecal drug therapy.
Two medium/good quality reviews investigated intrathecal drug therapy for chronic pain
104 Chronic Pain Health Needs Assessment
(195,201). Hayek (195) found modest improvements in patient reported pain scores
however included studies were poorly reported. The results of the review by Patel (201)
were based on four observational studies of which two showed positive results for short
and long-term pain relief. However, the results should be treated with caution given the
low quality of the studies and the lack of RCTs.
Nerve blocks.
Nerve blocks and local anaesthesia for chronic pain was investigated in a good quality
review by Vlassakov 2011. All reviewed articles were single case reports or case series so
no reliable conclusion could be drawn concerning the effectiveness of nerve blocks with
local anaesthetics in neuralgia.
Cervical epidural injections.
A medium/good quality review by Benyamin 2009 (211) reviewed the evidence for
cervical epidural injections for whiplash related neck pain. A significant effect was
observed in relieving chronic intractable pain of cervical origin and providing long-term
relief.
Local analgesia.
A medium/ good quality review looked at local analgesia for chronic stump pain and PLP
(critical ischaemia of peripheral vascular disease) (209). It would appear that there is no
robust evidence to support the use of pre-emptive analgesia to minimise risk of chronic
pain after amputation for critical ischaemia of peripheral vascular disease.
Facet joint injections.
Two reviews looked at facet joint injections for chronic low back pain. One, a good
quality Cochrane review (205) found insufficient evidence to support use of injection
therapy in subacute and chronic low back pain, but it may be beneficial to a subgroup of
patients who may respond to a specific type of injection therapy. The other review
(192), of medium/good quality, concluded that lumbar facet joint and radiofrequency
neurotomy are effective but lumbar intra-articular injections are likely to be ineffective.
The NICE guideline (156) included patients with chronic back pain. The findings, based
on the one RCT which met the inclusion criteria of the review were that injections are of
little value in treating chronic low back pain.
Botulinum Toxin (BoNT)
Five good quality reviews (196,198,199,204,210) investigated this intervention for
shoulder and neck pain; lateral epicondylitis; and myofascial pain.
One Cochrane review (199) found that the evidence failed to confirm either a clinically
important or a statistically significant benefit of BoNT-A injection for chronic neck pain
associated with or without associated cervicogenic headache. Likewise, there was no
benefit seen for disability and quality of life at four week and six months.
Chronic Pain Health Needs Assessment 105
Another Cochrane review (204) concluded that BoNT -A injections seem to reduce pain
severity and improve shoulder function and range of motion when compared with
placebo in patients with shoulder pain due to spastic hemiplegia or arthritis however the
high risk of bias in the included RCTS demands caution in interpreting these results.
Although Zhang (210) found that BoNT-A had a small to moderate analgesic effect in
chronic musculoskeletal pain conditions, especially in plantar fasciitis, tennis elbow and
back pain (but not in whiplash or shoulder pain), further evidence is required before
definitive conclusions can be drawn.
Kalichman (198) found that the evidence provided moderate support for use of BoNTA -
A injections into fore arm extensor muscles (60 units) for treatment of chronic
treatment-resistant lateral epicondylitis.
Finally, the review (196) which investigated BoNT-A for myofascial pain reported that
current evidence does not support the use of BTA injection in trigger points for
myofascial pain.
Trigger point injections
This intervention for musculoskeletal pain was reviewed in one review (202). In general,
regardless of the drug, injected trigger point injection was no more effective than other
less invasive treatments such as laser and ultrasound.
Opiods.
A recent and good quality Cochrane review (214) examined the effectiveness of any
opioid taken by any route in any dose for at least six months in pain of any cause except
cancer. Its findings suggested that opioids could be useful for those patients who have
no previous history of addiction or abuse, however, the evidence supporting this
conclusion is weak. More, longer term studies are required to identify those patients
who would be likely to benefit from such treatment.
Pulsed radiofrequency(PRF).
Pulsed radiofrequency for Zygapophyseal joint pain, cervical radicular pain, lumbosacral
pain, trigeminal neuralgia, chronic shoulder pain was investigated in one review [Chua
2011]. The review was of medium quality and found that PRF may be of benefit in
treatment of cervical radicular pain and chronic shoulder pain, but less effective for
lumbar zygapophyseal joint pain and trigeminal neuralgia but that further research is
required to warrant its use.
Spinal cord stimulation (SCS).
Two reviews were identified which investigated SCS (193,203). Both were of medium to
good quality.
The most recent review found that SCS for Failed Back Surgery Syndrom and Complex
106 Chronic Pain Health Needs Assessment
Regional Pain Syndrome was effective when compared with conventional treatment.
The other (203) had the same findings. However, for ischaemic pain, there may need to
be selection criteria developed for Critical Limb Ischaemia, and SCS may have clinical
benefit for refractory angina in the short term.
Auriculotherapy.
One good review (190) investigated auriculotherapy for all types of chronic pain.
Although, overall it was found to be an effective intervention, the review concluded that
further large, well-designed trials are required.
Surgery.
Five systematic reviews (176,197,200,207,215) and two NICE Interventional Procedures
Guidelines (212,213) were identified. Summary of findings are presented in Appendix ??.
A Cochrane review of medium /good quality (216) investigated discectomy, micro-
discectomy, chemonucleolysis, automated percutaneous discectomy, nucleoplasty, and
laser discectomy in patients with lumbar prolapsed disc who had indications for surgical
intervention. It concluded that the evidence was weak and there was insufficient data to
draw any conclusions about effectiveness of any of the surgical treatments investigated.
Another good quality Cochrane review (197) looked at the effectiveness of spinal fusion
for chronic low back pain. The results, which were based on three good quality RCTs
showed that surgical fusion may improve pain related disability compared to non-
surgical intervention, but the effect was not statistically significant.
A medium quality review, (176) looked at the effectiveness of surgery for low back pain.
The included studies were assessed as low and high quality, but there were potential
biases in some studies including performance bias, and detection bias. There were high
drop-out rates in one trial and data were missing. Trials for decompressive surgery were
assessed as high quality but a high proportion of patients did not adhere to the
treatment. Overall, there was a lack of long-term studies, so the benefits were not
known.
A medium /good quality review which looked at total disc replacement surgery for back
pain (207) found that there are no long-term studies to test the longevity of the
prostheses which was evaluated. Therefore, current evidence does not support routine
use of surgery for the treatment of chronic low back pain.
Lumbar fusion for chronic back pain was investigated in one medium quality review
(200). It appeared that the intervention may be more effective than non-operative care
for chronic back pain but may not be more effective than structured rehabilitation,
including CBT. However, methodological limitations of RCTs prevent firm conclusions
about lumbar fusion.
Lumbar fusion for chronic back pain was investigated in one medium quality review
Chronic Pain Health Needs Assessment 107
(200). It appeared that the intervention may be more effective than non-operative care
for chronic back pain but may not be more effective than structured rehabilitation,
including CBT. However, methodological limitations of RCTs prevent firm conclusions
about lumbar fusion.
Both of the Interventional Procedures Guidelines were based on good quality reviews of
the research literature.
IPG 300 addressed percutaneous endoscopic laser lumbar discectomy. The evidence
consisted of case series. The guideline states: “ Current evidence on the safety and
efficacy of percutaneous endoscopic laser lumbar discectomy is inadequate in quantity
and quality. Therefore this procedure should only be used with special arrangements for
clinical governance, consent, and audit or research”.
IPG 357 addressed percutaneous intradiscal laser ablation in the lumbar spine. The
evidence consisted of case series and non-randomised comparative studies. The
guideline states: “Current evidence on the safety and efficacy of percutaneous
intradiscal laser ablation in the lumbar spine is adequate to support the use of this
procedure provided that normal arrangements are in place for clinical governance,
consent and audit. Patients selected for the procedure should be limited to those with
severe pain refractory to conservative treatment, in whom imaging studies have shown
bulging of an intact disc, and who do not have neurological deficit requiring surgical
decompression.”
8.12.1 Conclusions.
There is little good evidence of effectiveness of sympathectomy, intrathecal drug
therapy, nerve blocks, local analgesia, opioids, or auriculotherapy for chronic pain.
A significant effect was observed for cervical epidural injections in relieving cervical
neck pain.
Facet joint injections are of little value in treating chronic low back pain.
There is low to moderate support for the use of botulinum toxin injections for
shoulder pain, neck pain, lateral epicondylitis and myofascial pain.
Trigger point injections appear to be no more effective than other less invasive
treatments.
Further research is needed to warrant the use of pulsed radiofreqency for chronic
pain.
Spinal fusion may improve pain related disability but the effect was not significantly
significant.
108 Chronic Pain Health Needs Assessment
Current evidence does not support the use of routine surgery for chronic back pain.
There was insufficient good quality data to draw any conclusion about the
effectiveness of many surgical interventions for low back pain. This included
decompressive surgery, discectomy, micro-discectomy, chemonucleolysis, automated
percutaneous discectomy, nucleoplasty and percutaneous endoscopic laser
lumbardiscectomy.
Percutaneous endoscopic laser lumbar discectomy should only be used with special
arrangements for clinical governance, consent, and audit or research.
Current evidence on the safety and efficacy of percutaneous laser ablation in the
lumbar spine is adequate to support the use of this procedure provided normal
arrangements are in place for clinical governance, consent and audit.
8.12.2 Implications for practice.
SCS should be commissioned for use for those patients who fail to respond to other
treatments.
Spinal fusion can only be recommended cautiously to patients with chronic low back
pain.
Botulinum toxin should not be commissioned for chronic pain.
Surgery should only be commissioned for treatment in highly selected patients who
fail all other treatments and with caution. Patients should be made aware of
implications of surgery.
Surgical discectomy should not be commissioned for routine use, but only in carefully
selected patients with sciatica due to lumbar disc prolapsed.
Current evidence on the safety and efficacy of percutaneous laser ablation in the
lumbar spine is adequate to support the use of this procedure provided normal
arrangements are in place for clinical governance, consent and audit.
MULTI-DISCIPLINARY INTERVENTIONS (MDI)
8.13 Two good quality systematic reviews (217,218) a NICE guideline and guideline from the
American Pain Society / American College of Physicians (157) investigated MDI
programmes.
The reviews identified used different definitions of MDI, therefore, they are not directly
comparable.
Chronic Pain Health Needs Assessment 109
The results of one Cochrane review(218) found that one high quality study showed
effectiveness for low intensive multidisciplinary treatment compared to control, but not
for intensive multidisciplinary treatment for chronic low back pain. The other (low
quality) studies found no effectiveness compared to controls. Three high quality RCTs
found effectiveness for some outcome measures (but not all) for intensive compared to
non-intensive programmes. It concluded that multidisciplinary back training has a
positive impact on work participation of people with chronic low back pain. The
evidence for a positive effect on quality of life is limited. Intensity of treatment is not
associated with treatment effectiveness. It concluded that further research should be
carried out with clearer definitions of chronic low back pain, intensity of treatment and
multidisciplinary back training.
The second review investigated multi-disciplinary pain interventions for adults with
chronic non-specific musculoskeletal pain for example low back pain or back pain and
fibromyalgia. Results showed that evidence was strong for MDI being more effective
than control group treatment in 15 studies, five studies showed no difference. Three
studies that compared in-patient versus out-patient treatment found moderate
evidence for better long term outcomes with intensive in-patient MDI.
All interventions considered in the NICE guideline (156), which was under-pinned by a
good quality systematic review, had to have a psychological component such as CBT,
counselling or coping skills training. Studies were included if the content was broadly
similar to that recommended in the British Pain Society guidelines (BPS 2007) as follows:
“education on pain physiology, pain psychology, healthy function and self-management
of pain problems; and of guided practice on setting goals and working towards them,
identifying and changing unhelpful beliefs and ways of thinking, relaxation, and changing
habits which contribute to disability. Participants practise these skills in their home and
other environments to become expert in their application and integration. “PMPs are
delivered in a group format to normalise pain experience, to maximise possibilities of
learning from other group members, and for economy.”
The guideline recommends to consider referral for a combined physical and
psychological treatment programme, comprising around 100 hours over a maximum of
eight weeks, for people who have received at least one less intensive treatment and
have high disability and/or significant psychological distress. Combined physical and
psychological treatment programmes should include a cognitive behavioural approach
and exercise.
The APS/ACP guidelines (157) findings were as follows:
Intensive (>100 hours), daily interdisciplinary rehabilitation was moderately superior to non-
interdisciplinary rehabilitation or usual care for short-and long-term functional status, and
for pain outcomes (at three to four months in two trials). Long-term pain and return to work
outcomes were inconsistent;
110 Chronic Pain Health Needs Assessment
Less intensive interdisciplinary rehabilitation was no better than non-interdisciplinary
rehabilitation or usual care;
Functional restoration with a CBT component was more effective than usual care, normal
activities or standard exercise therapy for reducing time lost from work. There was little
evidence that functional restoration without a CBT component is effective;
In conclusion, interdisciplinary rehabilitation was more effective than usual care for sub-
acute back pain.
8.13.1 Conclusions.
There is considerable heterogeneity between reviews and between the included
RCTs. Effectiveness of the intervention is likely to vary depending on the comparator,
in particular whether it is an active comparator (which may incorporate some of the
elements or similar elements of the multidisciplinary intervention), or a wait list
control. Comparisons across studies (and across reviews) are therefore difficult due
to variability in the definition of multidisciplinary treatment (type and number of
elements), the comparators, the outcome measures/instruments used and follow-up
times (e.g. short-term, intermediate or long-term). The ‘treatment as usual’ often
used as the comparator is likely to vary between studies. Due to the heterogeneity,
there are often few studies that make a direct head-to-head comparison between
particular combinations of treatments.
Overall, there seems be some moderately strong evidence, based on RCTs of variable
quality, that multidisciplinary programmes/more intensive programmes are
significantly better than usual care/less intensive programmes for some outcomes
relating to pain and function. This was the case mainly for shorter-term outcomes,
with less evidence for longer-term outcomes. No evidence was identified for
residential programmes specifically. Several reviews highlight that it is not known
which treatment components are most effective and which patients would benefit
most.
8.13.2 Implications for practice.
Bearing in mind the caveats above, multi-disciplinary pain management programmes
should be commissioned.
Chronic pain health needs assessment 111
APPENDIX I – ADMITTED PATIENT COMMISSIONING DATA SET (CDS) DATA REQUEST SPECIFICATIONS
Request 1: Admitted patient episodes by Provider Trust, admission method, patient classification, gender and financial year
Dataset
Setting: Admitted Patient episodes
Source dataset: Admitted Patient Care - General Episode Commissioning Data Set
Unit: Finished Consultant Episodes (FCEs)
Inclusion criteria:
Coverage: Patients admitted to a West Midlands provider
Ages: 16 years and over
Gender: Persons
Time period: Financial years: 2007/8, 2008/9, 2009/10, 2010/11, 2011/12
Other: Where primary procedure is in the attached OPCS4 Code list (Appendix II)
Output table
Statistic column: Count of FCEs
Row variables: Financial year, Provider Trust, admission method, patient classification, gender
Column variable: n/a
FY Provider Trust Code
Provider Trust Name
Gender Admission Method
Patient Classification
Count of FCEs
Request 2: Admitted patient episodes by Provider Trust, primary procedure, gender and financial year
Dataset
Setting: Admitted Patient episodes
Source dataset: Admitted Patient Care - General Episode Commissioning Data Set
Unit: Finished Consultant Episodes (FCEs)
Inclusion criteria:
Coverage: Patients admitted to a West Midlands provider
Ages: 16 years and over
Gender: Persons
Time period: Financial years: 2007/8, 2008/9, 2009/10, 2010/11, 2011/12
112 Chronic Pain Health Needs Assessment
Other: Where primary procedure is in the attached OPCS4 Code list (Appendix II)
Output table
Statistic column: Count of FCEs
Row variables: Financial year, Provider Trust, primary procedure, gender
Column variable: n/a
FY Provider
Trust Code
Provider Trust
Name
Gender Primary procedure
OPCS4 Code (4-digit)
Count of
FCEs
Request 3: Admitted patient episodes by Primary Care Trust, admission method, patient classification, gender and financial year
Dataset
Setting: Admitted Patient episodes
Source dataset: Admitted Patient Care - General Episode Commissioning Data Set
Unit: Finished Consultant Episodes (FCEs)
Inclusion criteria:
Coverage: Patients resident in West Midlands Primary Care Trusts
Ages: 16 years and over
Gender: Persons
Time period: Financial years: 2007/8, 2008/9, 2009/10, 2010/11, 2011/12
Other: Where primary procedure is in the attached OPCS4 Code list (Appendix II)
Output table
Statistic column: Count of FCEs
Row variables: Financial year, Primary Care Trust, admission method, patient classification, gender
Column variable: n/a
FY ONS
Area
Code
PCT
Code
PCT Name Gender Admission
Method
Patient
Classification
Count of
FCEs
Chronic Pain Health Needs Assessment 113
Request 4: Admitted patient episodes by Primary Care Trust, primary procedure, gender and financial year
Dataset
Setting: Admitted Patient episodes
Source dataset: Admitted Patient Care - General Episode Commissioning Data Set
Unit: Finished Consultant Episodes (FCEs)
Inclusion criteria:
Coverage: Patients resident in West Midlands Primary Care Trusts
Ages: 16 years and over
Gender: Persons
Time period: Financial years: 2007/8, 2008/9, 2009/10, 2010/11, 2011/12
Other: Where primary procedure is in the attached OPCS4 Code list (Appendix II)
Output table
Statistic column: Count of FCEs
Row variables: Financial year, Primary Care Trust, primary procedure, gender
Column variable: n/a
FY Provider
Trust Code
Provider Trust
Name
Gender Primary procedure
OPCS4 Code (4-digit)
Count of
FCEs
Chronic pain health needs assessment 114
APPENDIX II – PAIN MANAGEMENT PROCEDURE CODES
OPCS4 Code
Procedure
A48.3 Insertion of neurostimulator adjacent to spinal cord
A48.4 Attention to neurostimulator adjacent to spinal cord NEC
A48.5 Reprogramming of neurostimulator adjacent to spinal cord
A48.6 Removal of neurostimulator adjacent to spinal cord
A48.7 Insertion of neurostimulator electrodes into the spinal cord
A48.8 Other specified other operations on spinal cord
A09.1 Implantation of neurostimulator into brain
A09.2 Maintenance of neurostimulator in brain
A09.3 Removal of neurostimulator from brain
A09.4 Operation on neurostimulator in brain NEC
A09.5 Insertion of neurostimulator electrodes into the brain
A09.8 Other specified neurostimulation of brain
A09.9 Unspecified neurostimulation of brain
A70.1 Implantation of neurostimulator into peripheral nerve
A70.2 Maintenance of neurostimulator in peripheral nerve
A70.3 Removal of neurostimulator from peripheral nerve
A70.4 Insertion of neurostimulator electrodes into peripheral nerve
A70.5 Electroacupuncture
A70.6 Acupuncture NEC
A70.7 Application of transcutaneous electrical nerve stimulator
A70.8 Other specified neurostimulation of peripheral nerve
A70.9 Unspecified neurostimulation of peripheral nerve
A48.3 Insertion of neurostimulator adjacent to spinal cord
A48.4 Attention to neurostimulator adjacent to spinal cord NEC
A48.5 Reprogramming of neurostimulator adjacent to spinal cord
A48.6 Removal of neurostimulator adjacent to spinal cord
A48.7 Insertion of neurostimulator electrodes into the spinal cord
A48.8 Other specified other operations on spinal cord
A52.1 Therapeutic lumbar epidural injection
A52.2 Therapeutic sacral epidural injection
A52.3 Epidural blood patch
A52.8 Other specified therapeutic epidural injection
A52.9 Unspecified therapeutic epidural injection
A54.1 Injection of destructive substance into cerebrospinal fluid
A54.2 Injection of therapeutic substance into cerebrospinal fluid
A54.3 Implantation of intrathecal drug delivery device adjacent to spinal cord
A54.4 Attention to intrathecal drug delivery device adjacent to spinal cord
A54.5 Removal of intrathecal drug delivery device adjacent to spinal cord
A54.8 Other specified therapeutic spinal puncture
A54.9 Unspecified therapeutic spinal puncture
A57.1 Extirpation of lesion of spinal nerve root
Chronic Pain Health Needs Assessment 115
OPCS4 Code
Procedure
A57.2 Rhizotomy of spinal nerve root
A57.3 Radiofrequency controlled thermal destruction of spinal nerve root
A57.4 Injection of destructive substance into spinal nerve root
A57.5 Destruction of spinal nerve root NEC
A57.6 Reimplantation of spinal nerves into spinal cord
A57.7 Injection of therapeutic substance around spinal nerve root
A57.8 Other specified operations on spinal nerve root
A57.9 Unspecified operations on spinal nerve root
V29.1 Primary laminectomy excision of cervical intervertebral disc
V29.2 Primary hemilaminectomy excision of cervical intervertebral disc
V29.3 Primary fenestration excision of cervical intervertebral disc
V29.4 Primary anterior excision of cervical intervertebral disc and interbody fusion of joint of cervical spine
V29.5 Primary anterior excision of cervical intervertebral disc NEC
V29.6 Primary microdiscectomy of cervical intervertebral disc
V29.8 Other specified primary excision of cervical intervertebral disc
V29.9 Unspecified primary excision of cervical intervertebral disc
V33.1 Primary laminectomy excision of lumbar intervertebral disc
V33.2 Primary fenestration excision of lumbar intervertebral disc
V33.3 Primary anterior excision of lumbar intervertebral disc and interbody fusion of joint of lumbar spine
V33.4 Primary anterior excision of lumbar intervertebral disc NEC
V33.5 Primary anterior excision of lumbar intervertebral disc and posterior graft fusion of joint of lumbar spine
V33.6 Primary anterior excision of lumbar intervertebral disc and posterior instrumentation of lumbar spine
V33.7 Primary microdiscectomy of lumbar intervertebral disc
V33.8 Other specified primary excision of lumbar intervertebral disc
V33.9 Unspecified primary excision of lumbar intervertebral disc
V34.1 Revisional laminectomy excision of lumbar intervertebral disc
V34.2 Revisional fenestration excision of lumbar intervertebral disc
V34.3 Revisional anterior excision of lumbar intervertebral disc and interbody fusion of joint of lumbar spine
V34.4 Revisional anterior excision of lumbar intervertebral disc NEC
V34.5 Revisional anterior excision of lumbar intervertebral disc and posterior graft fusion of joint of lumbar spine
V34.6 Revisional anterior excision of lumbar intervertebral disc and posterior instrumentation of lumbar spine
V34.7 Revisional microdiscectomy of lumbar intervertebral disc
V34.8 Other specified revisional excision of lumbar intervertebral disc
V34.9 Unspecified revisional excision of lumbar intervertebral disc
V35.1 Primary excision of intervertebral disc NEC
V35.2 Revisional excision of intervertebral disc NEC
V35.8 Other specified excision of unspecified intervertebral disc
116 Chronic Pain Health Needs Assessment
OPCS4 Code
Procedure
V35.9 Unspecified excision of unspecified intervertebral disc
V25.1 Primary extended decompression of lumbar spinal cord and intertransverse fusion of joint of lumbar spine
V25.2 Primary extended decompression of lumbar spinal cord NEC
V25.3 Primary posterior decompression of lumbar spinal cord and intertransverse fusion of joint of lumbar spine
V25.4 Primary posterior laminectomy decompression of lumbar spinal cord
V25.5 Primary posterior decompression of lumbar spinal cord NEC
V25.6 Primary lateral foraminotomy of lumbar spine
V25.7 Primary anterior corpectomy of lumbar spine and reconstruction HFQ
V25.8 Other specified primary decompression operations on lumbar spine
V25.9 Unspecified primary decompression operations on lumbar spine
V26.1 Revisional extended decompression of lumbar spinal cord and intertransverse fusion of joint of lumbar spine
V26.2 Revisional extended decompression of lumbar spinal cord NEC
V26.3 Revisional posterior decompression of lumbar spinal cord and intertransverse fusion of joint of lumbar spine
V26.4 Revisional posterior laminectomy decompression of lumbar spinal cord
V26.5 Revisional posterior decompression of lumbar spinal cord NEC
V26.6 Revisional lateral foraminotomy of lumbar spine
V26.7 Revisional anterior corpectomy of lumbar spine and reconstruction HFQ
V26.8 Other specified revisional decompression operations on lumbar spine
V26.9 Unspecified revisional decompression operations on lumbar spine
V38.1 Primary fusion of joint of thoracic spine
V38.2 Primary posterior interlaminar fusion of joint of lumbar spine
V38.3 Primary posterior fusion of joint of lumbar spine NEC
V38.4 Primary intertransverse fusion of joint of lumbar spine NEC
V38.5 Primary posterior interbody fusion of joint of lumbar spine
V38.6 Primary transforaminal interbody fusion of joint of lumbar spine
V38.8 Other specified primary fusion of other joint of spine
V38.9 Unspecified primary fusion of other joint of spine
V48.1 Radiofrequency controlled thermal denervation of spinal facet joint of cervical vertebra
V48.2 Denervation of spinal facet joint of cervical vertebra NEC
V48.3 Radiofrequency controlled thermal denervation of spinal facet joint of thoracic vertebra
V48.4 Denervation of spinal facet joint of thoracic vertebra NEC
V48.5 Radiofrequency controlled thermal denervation of spinal facet joint of lumbar vertebra
V48.6 Denervation of spinal facet joint of lumbar vertebra NEC
V48.7 Radiofrequency controlled thermal denervation of spinal facet joint of vertebra NEC
V48.8 Other specified denervation of spinal facet joint of vertebra
V48.9 Unspecified denervation of spinal facet joint of vertebra
V52.1 Enzyme destruction of intervertebral disc
V52.2 Destruction of intervertebral disc NEC
V52.3 Discography of intervertebral disc
V52.4 Biopsy of lesion of intervertebral disc NEC
Chronic Pain Health Needs Assessment 117
OPCS4 Code
Procedure
V52.5 Aspiration of intervertebral disc NEC
V52.8 Other specified other operations on intervertebral disc
V52.9 Unspecified other operations on intervertebral disc
V54.4 Injection around spinal facet of spine
W90.1 Aspiration of joint
W90.2 Arthrography
W90.3 Injection of therapeutic substance into joint
W90.4 Injection into joint NEC
W90.8 Other specified puncture of joint
W90.9 Unspecified puncture of joint
Chronic pain health needs assessment 118
APPENDIX NN
Key recommendations of the NICE CG 88 and the American College of Physicians / American Pain
Society Guidelines on low back pain.
National Institute for Health and Clinical Excellence. Low back pain. Early management of
persistent non-specific low back pain. CG 88; 2009.
Key recommendations:
Information, education and patient preferences:
Provide people with advice and information to promote self-management of their low back pain.
Offer one of the following treatment options, taking into account patient preference: an
exercise programme, a course of manual therapy or a course of acupuncture. Consider
offering another of these options if the chosen treatment does not result in satisfactory
improvement
Physical activity and exercise
Consider offering a structured exercise programme tailored to the person: this should
comprise up to a maximum of eight sessions over a period of up to 12 weeks.
Offer a group supervised exercise programme, in a group of up to 10 people.
A one-to-one supervised exercise programme may be offered if a group programme is not
suitable for a particular person.
Manual therapy
Consider offering a course of manual therapy, including spinal manipulation, comprising up
to a maximum of nine sessions over a period of up to 12 weeks
Invasive procedures
Consider offering a course of acupuncture needling comprising up to a maximum of 10
sessions over a period of up to 12 weeks.
Do not offer injections of therapeutic substances into the back for non-specific low back
pain.
Combined physical and psychological treatment programme
Consider referral for a combined physical and psychological treatment programme, comprising
around 100 hours over a maximum of 8 weeks, for people who:
− have received at least one less intensive treatment and
− have high disability and/or significant psychological distress
Assessment and imaging
Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
Only offer an MRI scan for non-specific low back pain within the context of a referral for an
opinion on spinal fusion.
Chronic Pain Health Needs Assessment 119
Referral for surgery
Consider referral for an opinion on spinal fusion for people who:
− have completed an optimal package of care, including a combined physical and psychological
treatment programme (section 1.7) and
− still have severe non-specific low back pain for which they would consider surgery.
Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American
College of Physicians and the American Pain Society. Ann Int Med 2007; 147 (7): 478-91.
Key recommendations:
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence- based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or non-steroidal anti-inflammatory drugs.
Recommendation 7: For patients who do not improve with self-care options, clinicians should
consider the addition of non-pharmacologic therapy with proven benefits-for acute low back pain,
spinal manipulation; for chronic or sub-acute low back pain, intensive interdisciplinary rehabilitation,
exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioural
therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
120 Chronic Pain Health Needs Assessment
APPENDIX NN
Search strategies for evidence of effectiveness of interventions in chronic pain
Database Search strategy
Cochrane Library 2011 Issue 4 1. “chronic pain” 2. MeSH descriptor Pain explode all trees 3. MeSH descriptor Chronic Disease explode all
trees 4. (2 AND 3) 5. (1 OR 4)
ARIF (Aggressive Research Intelligence Facility)
Chronic pain (selected abstracts)
MEDLINE (OVID MEDLINE (R) 1948 to November week 3 2011
1. Chronic pain.ab, ti. 2. Pain.sh. 3. Chronic disease.sh. 4. 2 AND 3 5. 1 OR 4 6. Limit 5 to “reviews (maximises specificity)”
EMBASE 1974 to 2011 week 48 1. Chronic pain. ti, ab. 2. Exp pain/ 3. Exp chronic disease/ 4. 2 AND 3 5. 1 OR 4 6. Limit 5 to “reviews (maximises specificity)”
TRIP database 1. “Chronic pain”
PROSPERO (International prospective register of systematic reviews that are ongoing)
Chronic pain Pain
Chronic Pain Health Needs Assessment 121
Search strategies to identify evidence of effectiveness for chronic back pain
Database Search strategy
Cochrane library 2012 Issue 2
#1 ("low back pain") OR ("back pain") #2 "chronic" #3 (#1 AND #2) #4 ("cognitive behavioural therapy") OR ("cognitive behaviour therapy") OR ("cognitive therapy") OR ("behaviour therapy") OR ("behavioural therapy") OR ("CBT") #5 (#3 AND #4) #6 ("discectomy") OR ("lumbar discectomy") #7 (#3 AND #6) #8 ("microdiscectomy") OR ("microdecompression") OR ("lumbar microdecompression") #9 (#3 AND #8) #10 ("facet joint injection") #11 (#3 AND #10) #12 ("pain management programme") OR ("pain management programmes") #13 (#3 AND #12)
MEDLINE (OVID MEDLINE (R) 1948 to May 2012)
1. back pain.tw. 2. Back Pain/ 3. low back pain.tw. 4. Low Back Pain/ 5. chronic low back pain.tw. 6. dorsalgia.tw. 7. 1 or 2 or 3 or 4 or 5 or 6 8. microdiscectomy.tw. 9. microdecompression.tw. 10. Decompression, Surgical/ 11. 8 or 9 or 10 12. facet joint injection.tw. 13. pain management program*.tw. 14. Pain Management/ 15. 13 or 14 16. discectomy.tw. 17. Diskectomy/ 18. diskectomy.tw. 19. 16 or 17 or 18 20. cognitive behavioural therapy.tw. 21. Cognitive Therapy/ 22. behaviour therapy.tw.
23. cognitive psychotherap*.tw. 24. cbt.tw. 25. 20 or 21 or 22 or 23 or 24 26. 7 and 11 27. 7 and 12 28. 7 and 15 29. 7 and 19 30. 7 and 25
122 Chronic Pain Health Needs Assessment
EMBASE (1974 to May 2012)
1. back pain.tw. 2. backache/ 3. backache.tw. 4. low back pain.tw. 5. low back pain/ 6. chronic low back pain.tw. 7. dorsalgia.tw. 8. 1 or 2 or 3 or 4 or 5 or 6 or 7 9. microdiscectomy.tw. 10. intervertebral diskectomy/ 11. intervertebral diskectomy.tw. 12. microdecompression.tw. 13. decompression surgery/ 14. 9 or 10 or 11 or 12 or 13 15. facet joint injection.tw. 16. methylprednisolone acetate/ or corticosteroid/ or bupivacaine/ or methylprednisolone/ or lidocaine/ or local anesthetic agent/ or betamethasone/ 17. 15 or 16 18. pain management program*.tw. 19. discectomy.tw. 20. 10 or 11 or 19 27. cbt.tw. 28. 21 or 22 or 23 or 24 or 25 or 26 or 27
21. cognitive behavioural therap*.tw. 22. cognitive therapy/ 23. behaviour therapy.tw. 24. behavior therapy/ 25. cognitive psychotherap*.tw. 26. psychological aspect/ 29. 8 and 17 30. 8 and 18 31. 8 and 20 32. 8 and 14 33. 8 and 28
Chronic pain health needs assessment 123
Appendix 1 Link to main document
Summary of findings: Manual therapy (manipulation and mobilisation)
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Gross (2010) (219) Manipulation or mobilisation for neck pain
27 RCTs (1522 participants)
With meta-analysis
Neck pain without radicular findings, including neck pain without specific cause, whiplash associated disorder, myofascial pain syndrome, neck disorders associated with degenerative diseases
Manipulation or mobilisation
Placebo (sham/mock mobilisation or other sham treatment), adjunct treatment, wait list or no treatment, another treatment (manipulation or mobilisation versus another treatment, one technique of manipulation or
Pain relief, disability, function, patient satisfaction, global perceived effect, QoL
Cervical manipulation for sub-acute/chronic neck pain: moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term-follow-up. Low quality evidence that manipulation alone compared to a control may provide short term relief following one to four sessions (SMD pooled=-0.90; 95%CI:-1.78, -0.02). Thoracic manipulation
Cervical manipulation and mobilisation produced similar changes Either may provide immediate or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function Optimal techniques and
Cochrane review PRISMA:2 items missing AMSTAR: Good
Level 1 As a Cochrane review, this is an authoritative summary of the present state of evidence. While the estimated effects look impressive the quality of evidence is poor. Hence these treatments should be available for those
124 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
mobilisation versus another, one dose of manipulation or mobilisation versus another dose
for acute/chronic neck pain: Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5; 29% treatment advantage). Mobilisation for sub-acute/chronic neck pain: in addition to the evidence noted above, low quality evidence for sub-acute and chronic neck pain
dose are unresolved Further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate
patients who choose to have it
Chronic Pain Health Needs Assessment 125
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
indicated that 1) Combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) There was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; 3) Neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisations were superior Side effects: 3 of 8 studies that looked at side effects reported
126 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
none. The other 5 reported only minor and temporary effects
Miller (2010) (159) Manual therapy and exercise for neck pain: a systematic review
17 RCTs With meta-analysis
Neck pain with or without radicular symptoms or cervicogenic headache
Manual therapy including manipulation or mobilisation techniques, combined with exercise
Placebo, wait list/no treatment group, an adjunct treatment (e.g., mobilisation and exercise plus ultrasound versus ultrasound), or another treatment
Pain function/disability, QOL, global perceived effect, patient satisfaction for short-term ((closest to 4 weeks) to long-term (closest to 12 weeks) follow-up
Of 17 RCTs included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (SMD= -0.50 (95%CI:-0.76, -0.24) than exercise alone, but no long-term differences across multiple outcomes for (sub) acute/chronic neck pain with or without cervicogenic headache.
Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain. Evidence suggests that there is greater short-term pain reduction when compared to traditional care for acute whiplash Evidence regarding radiculopathy was sparse
Not Cochrane review PRISMA:5 items missing AMSTAR: Good
Level 1
Chronic Pain Health Needs Assessment 127
Appendix 2 Link to main document
Summary of findings: Pharmacological procedures
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Siedel (2010) (160) Antipsychotics for acute and chronic pain in adults
11 studies, randomised controlled trials (770 participants)
Without meta-analysis
Patients of either gender, with acute or chronic pain
Any form of antipsychotic treatment (at any dose)
No treatment, placebo, or other pain-relieving treatments (e.g., non-steroidal, anti-inflammatory drugs, anti-depressants, anticonvulsants, opioids)
Reduction in pain intensity, as measured by the visual analogue scale, self-reported pain relief
Adverse effects, attrition, measures of satisfaction or patient preference, assessment of quality of life
Of 11 RCTs, 5 studies showed beneficial effects of antipsychotics in treatment of acute and chronic pain Results regarding treatment of neuropathic pain were contradictory; there was no significant effect for post herpetic neuralgia with fluphenazine, but there was significant pain reduction in trigeminal neuralgia
Positive effects on painful conditions in 6 trials, whereas 5 trials failed to report any analgesic effect.
Not Cochrane review PRISMA:8 items missing AMSTAR:Good/medium
Level 1 Data was limited, most trials only studied small patient samples. Further research is required
128 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
with pimozide treatment Most frequently reported adverse effects were involuntary movements, parkinsonism, akathisia and sedating effects
Hauser (2009) (161) Treatment of fibromyalgia syndrome with antidepressants
18 randomised controlled trials (1427 participants)
With meta-analysis
Fibromyalgia Tricyclic and tetracyclic antidepressants [TCAs], selective serotonin reuptake inhibitors [SSRIs], serotonin and noradrenaline reuptake inhibitors [SNRIs], or monoamine oxidase
Pharmacological placebo
Pain, fatigue, sleep, and depressed mood
Health-related quality of life
Strong evidence for association of antidepressants with pain reduction (SMD -0.43; 95%CI: -0.55, -0.30), fatigue (SMD: -0.13; 95%CI:-0.26, -0.01), depressed mood (SMD: -0.26; 95%CI:-0.39, -0.12), sleep disturbances (SMD: -0.32; 95%CI: -0.46, -0.18) Strong evidence for
Short-term usage of amytriptyline and duloxetine can be considered for treatment of pain and sleep disturbances in fibromyalgia.
Not Cochrane review PRISMA:2 items missing AMSTAR:Good
Level 1 Internal and external validity of RCTs was limited, short duration, long-term treatment evidence is lacking. Lack of information on whether antidepressant reduce fibromyalgia
Chronic Pain Health Needs Assessment 129
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
inhibitors [MAOIs]
association of antidepressants with improved health-related QOL (SMD: -0.31; 95%CI: -0.42, -0.20) Effect sizes for pain reduction were large for TCAs (SMD: -1.64; 95%CI: -2.47, -0.71), medium for MAOIs (SMD: -0.54; 95%CI: -1.02, -0.07) and small for SSRIs (SMD: -0.36; 95%CI: -0.77, -0.01) and SNRIs (SMD: -0.36; 95%CI: -0.46, -0.25)
related costs
Saarto (2010) (162) Antidepressants for neuropathic pain
61 randomised controlled trials, included 3293 participants
Adult male and female patients with any neuropathic pain
TCAs, MAOIs, SSRIs, SNRIs, RIMAs, newer antidepressant (nefazodone,mirtazepine, venlafaxine), other
Placebo, active control drug, another antidepressant, any other intervention
Patient reported global improvement or pain relief or both, measured
Quality of life, adverse effects, sleep parameters, depression measures
TCAs are effective and have an NNT of 3.6 (95% CI 3 to 4.5) RR 2.1 (95% CI 1.8 to 2.5) for the achievement of at least moderate pain relief
There is some, limited evidence for the role of SSRIs Both TCAs and venlafaxine have NNTs of
Cochrane review PRISMA:4 items missing AMSTAR: Good
Level 1 The use of antidepressant (TCAs and SSRIs) should be included as part of the pain service
130 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
(bupropion, etoperidone, flupenthixol, fluphenazine, hypericum (St John’sWort), mirtazepine, nefazodone, reboxetine, tianeptine, and tryptophan
on any scale
Limited evidence for the effectiveness of the newer SSRIs but no studies of SNRIs were found Insufficient data to assess effectiveness for other antidepressants such as St John’s Wort and L-tryptophan. For diabetic neuropathy the NNT for effectiveness was 1.3 (95% CI 1.2 to 1.5) RR 12.4 (95% CI 5.2 to 29.2) (five studies); for post herpetic neuralgia 2.7 (95% CI 2 to 4.1), RR 2.2 (95% CI 1.6 to 3.1) (four studies) evidence that TCAs
approximately 3 for moderate pain relief. There is evidence to suggest that other antidepressants may be effective but numbers of participants are insufficient to calculate robust NNTs. SSRIs are generally better tolerated by patients but more high quality studies are required
Chronic Pain Health Needs Assessment 131
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
are not effective in HIV-related neuropathies. The number needed to harm (NNH) for major adverse effects defined as an event leading to withdrawal from a study was 28 (95% CI 17.6 to 68.9) for amitriptyline and 16.2 (95% CI 8 to 436) for venlafaxine The NNH for minor adverse effects was 6 (95% CI 4.2 to 10.7) for amitriptyline and 9.6 (95% CI 3.5 to 13) for venlafaxine
Lunn (2011) (163) Duloxetine for treatming painful
6 randomised or quasi-randomised controlled trials, 2220
With meta-analysis
Any form of painful peripheral neuropathy or chronic
All formulations and doses of duloxetine
Placebo or other controls
Improvement of pain (up to 12 weeks) using
Long-term (more than 12 weeks) improvement of pain,
Duloxetine at 60 mg daily is effective in treating painful diabetic peripheral neuropathy in the
Moderately strong evidence that duloxetine 60 mg and 120 mg daily is
Cochrane review PRISMA: no items missing
Level 1 Duloxetine is effective and should be part of the pain service
132 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
neuropathy or chronic pain
participants pain validated scales of pain intensity or pain relief
improvement in short-term and long term pain of at least 30%, improvement in any validated QOL score of more than 30%
short-term to 12 weeks with a risk ratio (RR) for 50% pain reduction at 12 weeks of 1.65 (95% confidence interval (CI) 1.34 to 2.03); NNT 6 (95%CI: 5 to 10) Duloxetine at 60 mg daily is also effective in fibromyalgia over 12 weeks (RR for 50% reduction in pain 1.57, 95%CI 1.20 to 2.06; NNT 8, 95%CI: 5 to 17) and 28 weeks (RR 1.58, 95%CI: 1.10 to 2.27) Adverse events were common in both treatment and placebo arms but more common in the treatment arm with a dose
efficacious for treating pain in diabetic peripheral neuropathy and fibromyalgia Minor side effects are common at therapeutic doses but serious side
effects are rare. Direct comparisons needed of duloxetine with other antidepressants and with other drugs already shown to be efficacious in neuropathic pain with
AMSTAR:Good
that is commissioned
Chronic Pain Health Needs Assessment 133
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
dependent effect. Most side effects were minor, but 16% of participants stopped the drug due to side effects. Serious adverse events were rare
unbiased economic analyse
Matthews (2009) (164) Topical rubefacients for acute and chronic pain in adults
7 randomised controlled trials included
With meta-analysis
Acute and chronic pain
Topical rubefacients containing salicylates or nicotinamides
Topical placebo
“clinical success”, defined as a 50% reduction in pain, or equivalent measure such as a “very good” or “excellent” global assessment of treatment, or “none” or “slight”
numbers of participants with adverse events: local and systemic, and cough numbers of withdrawals: all cause, lack of efficacy, adverse events
In chronic pain the NNT for effective pain relief was 6.2 (95% CI: 4.0 to 13) when compared to topical placebo). There were insufficient data to draw conclusions against active controls
The evidence was limited by the quality and size of the available studies. The evidence of effectiveness was more robust in chronic pain with rubefacients providing effective relief to 1 in 6 patients who use them over
Cochrane review PRISMA:1 item missing AMSTAR:Good
Level 1
134 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
pain on rest or movement measured on a categorical scale patient-reported reduction in pain of at least 50% patient-reported global assessment of treatment; pain on movement pain on rest, or spontaneous pain
and above background improvement with a placebo
Chronic Pain Health Needs Assessment 135
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
undefined “improvement”
Papaleontiou (2010) (165) Outcomes associated with opioid use in the treatment of chronic non-cancer pain in older adults: a systematic review and meta-analysis
31 RCTs, 8 open-label observational studies, one retrospective cohort study 8690 participants
With meta-analysis
Chronic non-cancer pain in older adults
Tramadol, opioids
Placebo, or add on to existing therapy, or another active treatment
Pain intensity, physical quality of life, mental quality of life, sleep
Weighted mean subject age was 64.1 years (mean age range:60-73) Mean duration of treatment studies was 4 weeks and only 5 studies lasted longer than 12 weeks. In meta-analysis, effect size for pain reduction was -0.557 (P<0.001), -0.432 (P<0.001) for physical disability reduction, and 0.859 (P=0.309) for improved sleep Common adverse
Among older adults with chronic pain, there was no significant comorbidity, and short term use of opioids was associated with reductions in pain intensity, improved physical functioning but decreased mental health functioning
Not Cochrane review PRISMA: 4 items missing AMSTAR:Good/medium
Level 1 (majority of studies were RCTs)
Limitations in the available evidence require further research, however, use of opioids for short-term treatment is reasonable for older patients without comorbidity and either nociceptive or neuropathic pain with frequent surveillance for adverse
136 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
effects included constipation, nausea, dizziness, and prompted opioid discontinuation in 25% of cases
effects
Riemsma (2011) (166) Systematic review of tapentadol in chronic severe pain
10 RCTs involving severe pain, and 42 for moderate and severe pain
With meta-analysis
Nociceptive or neuropathic, malignant or non-malignant, severe pain, or moderate/severe pain
Tapentadol Oxycodone and placebo
Pain intensity, pain relief (30% and 50%, patient global impression of change, quality of life, quality of sleep, discontinuations, as well as serious adverse events and selected
For moderate to severe pain, 42 relevant trials were identified for comparisons with transdermal buprenorphine,transdermal fentanyl, hydromorphone, morphine, and oxymorphone were made Treatment with tapentadol was statistically significant over oxycodone for pain intensity, 30% and
Benefit to risk ration of tapentadol appears to be improved compared to strong opioids
Cochrane review PRISMA:4 items missing AMSTAR: Good
Level 1
Chronic Pain Health Needs Assessment 137
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
adverse events
50% pain relief, patient global impression of change, and quality of life Adverse effects of opioid treatment were significantly less frequent with tapentadol compared to oxycodone. Discontinuation was significantly reduced wit tapentadol treatment Fentanyl and oxymorphone showed trends similar to tapentadol
Manchikanti (2011) (167) A systematic review of
23 RCTs were included
With meta-analysis
Adults aged at least 18 years with pain due to
Any opioid administered either orally or topically, any
Placebo treatment
Minimum of 12 weeks of follow-up,
Fair evidence for the use of tramadol in management of osteoarthritis. For
Evidence for all drugs assessed, including tramadol, for all
Not Cochrane review PRISMA: 7
Level 1 The evidence base for the use of opioid or topical
138 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
randomised controlled trials of long-term opioid management for chronic non-cancer pain
any cause other than cancer lasting for at least 3 months prior to trial enrolment, and previously failed non-opioid pharmacotherapy treatment
dose for at least 12 weeks
pain relief (average change in pain scores, proportion of patients with at least 50% pain relief, health related QOL and function)
all drugs assessed, including tramadol, for all other conditions, the evidence was poor
other conditions was poor and based on weak positive evidence, indeterminate evidence or negative evidence
items missing AMSTAR:Good
opioids is generally poor. If these agents are used at all in chronic pain then patient reported outcomes and evaluation of benefit must guide the decision whether to continue to use them
Wiffen (2011) (169) Lamotrigine for acute and chronic pain
12 RCTs, 1511 participants
With meta-analysis
Central post stroke pain, chemotherapy induced neuropathic pain, diabetic neuropathy, HIV related neuropathy, mixed neuropathic
Lamotrigine Placebo or active control
Patient reported pain relief of 50% or greater, patient reported global impression of clinical change,
No study evaluated lamotrigine in acute pain There is no convincing evidence that lamotrigine is effective in treating chronic pain at doses of about 200-400 mg daily.
This update confirmed with further evidence from a larger pool of studies and subjects the earlier conclusion that lamotrigine is not effective in
Cochrane review PRISMA:No items missing AMSTAR:Good
Level1 Lamotrigine does not have a significant place in therapy and should not be commissioned as treatment for any type of chronic pain
Chronic Pain Health Needs Assessment 139
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
pain, spinal cord injury,related pain, trigeminal neuralgia
pain on movement, pain on light touch , pain on rest, any other pain related measure, adverse effects within a subgroup analysis of the elderly if data were available
Almost 10% of participants taking lamotrigine reported a skin rash
treating chronic pain
Wiffen (2011) (170) Carbamazepine for acute and chronic pain in adults
15 RCTs (12 cross-over and 3 parallel group studies), 629 participants
With meta-analysis
Trigeminal neuralgia, post herpetic neuralgia, diabetic neuropathy, HIV related neuropathy, central post
Carbamazepine Placebo or active control
Patient reported pain relief of 50% or greater, patient reported global impression
Five studies with 298 participants showed carbamazepine to be better than placebo. Using any grade of improvement the response was 70%
Carbamazepine is effective in chronic neuropathic pain but with caveats Quality of trials, duration of
Cochrane review PRISMA:3 items missing AMSTAR: Good
Level 1 Carbamazepine treatment should be commissioned but only for neuropathic pain and then only for selected
140 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
stroke pain, irritable bowel, and temporomandibular joint dysfunction pain
of clinical change, pain on movement, pain on rest or spontaneous pain, any other pain related outcomes, adverse events
with carbamazepine v. 12% with placebo (event rate ratio or relative benefit 6.1 (95% CI 3.9 to 9.7), NNT 1.7 (95% CI: 1.5 to 2.0). Four studies (188 participants) reporting outcomes equivalent to 50% pain reduction or more over baseline had a similar NNT Side-effects were frequent. 66% of participants on carbamazeoine experienced at least one adverse event, vs 27% with placebo; relative risk 2.4 (95% CI 1.9 to 3.1); NNH 2.6 (95% CI: 2.1 to 3.5). Adverse event
follow up and reporting of outcomes were all poor therefore, caution is needed in interpretation, and meaningful comparison with other interventions is not possible
patients
Chronic Pain Health Needs Assessment 141
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
withdrawals occurred in 12 of 323 participants (4%) with carbamazepine and 0 of 310 with placebo. Five deaths occurred in patients on carbamazepine, with no obvious drug association
Lynch (2011) (168) Cannabinoids for treatment of chronic non-cancer pain: a systematic review of randomised controlled trials
18 RCTs Without meta-analysis
Chronic non-cancer pain
Cannabinoids Placebo or active control group
Pain reduction (VAS),Neuropathiy pain scale, McGill pain scale
A significant analgesic effect of cannabinoid as compared with placebo was reported by 15 of the 18 trials, and several reported significant improvements in sleep. There were no serious adverse
There is evidence that cannabinoids are safe and modestly effective in neuropathic pain with preliminary evidence of efficacy in fibromyalgia and rheumatoid arthritis
Not Cochrane review PRISMA:11 items missing AMSTAR: Good
Level 1 Further large studies of longer duration examining specific cannabinoids in homogeneous populations are needed before firm conclusions can be drawn
142 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
effects. Adverse effects most commonly reported were generally well tolerated, mild to moderate in severity and led to withdrawal from the studies in only a few cases
Plested (2010) (171) Pregabalin, the lidocaine plaster and duloxetine in patients with refractory neuropathic pain: a systematic review
17 trials Without meta-analysis
Refractory neuropathic pain due to any cause, lower back pain with a neuropathic component
Pregabalin, lidocaine plaster, and duloxetine
Pain intensity (VAS)
Sensory and affective scores (McGill pain questionnaire), function interference, sleep interference, pain associated distress
9/17 studies were for pregabalin, 7/17 were for lidocaine plaster, and one study for duloxetine. Only 6 studies included treatments within UK licensed indications and dose ranges Reported efficacy outcomes were
Indeterminate or of limited effect
Not Cochrane review PRISMA: 10 items missing AMSTAR:Good
Level 2? Included studies had heterogeneous patient populations and study designs. Studies were of poor quality, were small, and enrolled a variety of different refractory
Chronic Pain Health Needs Assessment 143
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
inconsistent between studies. Significant improvements in total, sensory and affective Short-form McGill pain questionnaire in all studies, and in function interference, sleep interference, and pain associated distress with pregabalin treatment. Only one of three studies for lidocaine plaster reported statistical significance for reduction of pain intensity. One study for
neuropathic conditions Further research required
144 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
duloxetine showed that pain severity (VAS) was statistically reduced at endpoint compared to baseline Limited or no QOL data available for lidocaine plaster or duloxetine Pregabalin showed efficacy benefits in patients with neuropathic pain inadequately controlled by gabapentin Adverse events were poorly reported 6 studies reported withdrawals for pregabalin and 4
Chronic Pain Health Needs Assessment 145
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
studies for lidocaine plaster. No data was available for duloxetine
Tzellos (2010) (172) Gabapentin and pregabalin in the treatment of fibromyalgia: a systematic review and a meta-analysis
4 RCTs (2040 participants)
With meta-analysis
Adults aged 18 and over with Fibromyalgia
Gabapentin and pregabalin
placebo >30% pain reduction, percentage of dropouts due to lack of efficacy
Pregabalin at a dose of 600, 450 and 300 mg per day is effective in FBM compared to placebo (NNT: 7, upper 95% CI: 12, 450 mg). A number of adverse events (AE), such as dizziness, somnolence, dry mouth, weight gain, peripheral oedema, is consistently associated with treatment at any dose and could lead one out of four patients to quit
Pregabalin at a dose of 450mg per day is effective in treatment of fibromyalgia
Not Cochrane review PRISMA:2 items missing AMSTAR:Good
Level 1
Although effective, adverse effects are associated with treatment. Further analysis of evidence is required
146 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
treatment (NNH: 6, lower 95% CI: 4, 600 mg). Indirect comparison meta-analysis suggests that PB at a dose of 450 mg per day could result in more responders than at 300 mg, but this result needs to be interpreted with caution as there were no significant differences between 600 and 300 mg or between 600 and 450 mg. Data on GP is limited
Siler (2011) (173) Systematic review of the comparative effectiveness of
8 studies (7 for pregabalin, 1 for gabapentin)
With meta-analysis
Fibromyalgia Any anti-epileptic drug
Placebo Impact on pain (the proportion of patients with response,
Both drugs reduced mean pain scores more than placebo at a modest rate (pregabalin, 38% to 50%;
Moderate benefit in short-term
Not Cochrane review PRISMA:6 items missing
Level 1 Pregabalin and gabapentin can be used for treatment of
Chronic Pain Health Needs Assessment 147
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
antiepileptic drugs for fibromyalgia
change in pain score from baseline, functional status, or sleep quality) and adverse events
gabapentin, 51%). In a 6-month trial of pregabalin responders, 32% continued to have response at 6 months, with a mean time to loss of response of 34 days. Compared to placebo, the drugs had similarly high rates of adverse events and withdrawals
AMSTAR:Good/medium
fibromyalgia in the short-term, but studies are required to assess long term benefits of pregabalin and gabapentin
Moore (2011) (174) Gabapentin for chronic neuropathic pain and fibromyalgia in adults
29 RCTs (3571 participants)
With meta-analysis
Painful diabetic neuropathy, post herpetic neuralgia, trigeminal neuralgia, phantom limb pain, postoperative or traumatic neuropathic
Gabapentin in any dose, by any route
Placebo, no intervention, or any other active comparator
Patient reported pain intensity reduction of 30% or greater. Patient reported pain intensity
Any pain-related outcome indicating some improvement. Withdrawals due to lack of efficacy. Participants
Twenty-nine studies (3571 participants), studied gabapentin at daily doses of 1200 mg or more in 12 chronic pain conditions; 78% of participants were in studies of post herpetic neuralgia, painful diabetic neuropathy or
Gabapentin is effective treatment for painful neuropathic pain
Cochrane review PRISMA: No items missing AMSTAR: Good
Level 1 Results of pain relief may vary between neuropathic pain conditions, as well as dose of gabapentin Gabapentin should be
148 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
pain, complex regional pain syndrome, cancer-related neuropathy, HIV-neuropathy, spinal cord injury, fibromyalgia
reduction of 50% or greater. Patient reported global impression of clinical change (PGIC) much or very much improved. Patient reported global impression of clinical change (PGIC) very much improved
experiencing any adverse event. Participants experiencing any serious adverse event. Withdrawals due to adverse events. Specific adverse events, particularly somnolence and dizziness
mixed neuropathic pain. Using the IMMPACT definition of at least moderate benefit, gabapentin was superior to placebo in 14 studies with 2831 participants, 43% improving with gabapentin and 26% with placebo; the NNT was 5.8 (4.8 to 7.2). Using the IMMPACT definition of substantial benefit, gabapentin was superior to placebo in 13 studies with 2627 participants, 31% improving with gabapentin and 17% with placebo; the NNT was 6.8 (5.6 to 8.7) Adverse events
commissioned but for selected patients
Chronic Pain Health Needs Assessment 149
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
occurred significantly more often with gabapentin. Persons taking gabapentin can expect to have at least one adverse event (66%), withdraw because of an adverse event (12%), suffer dizziness (21%), somnolence (16%), peripheral oedema (8%), and gait disturbance (9%). Serious adverse events (4%) were no more common than with placebo
Derry (2009) (220)Topical capsaicin for chronic neuropathic
9 RCTs (1600 participants)
With meta-analysis
Adults with neuropathic pain of at least moderate
Topical capsaicin (low dose formulation <0.1%)
Placebo or other active treatment
Clinical improvement of at least 50% reduction
Numbers of participants with adverse events: local, systemic and
Six studies (389 participants in total) compared regular application of low dose (0.075%)
Effective Cochrane review PRISMA: one item missing
Level 1 Capsaicin seems to be effective in providing clinically
150 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
pain in adults intensity resulting from any cause, with a duration of at least three months
in pain, patient reported global assessment of treatment, pain on movement, pain on rest or spontaneous pain, undefined improvement
cough Numbers of withdrawals: all cause, lack of efficacy and adverse effects
capsaicin cream with placebo cream; the NNT for any pain relief over six to eight weeks was 6.6 (4.1 to 17). Two studies (709 participants in total) compared a single application of high dose (8%) capsaicin patch with placebo patch; the NNT for _ 30% pain relief over twelve weeks was 12 (6.4 to 70). Local skin reactions were more common with capsaicin, usually tolerable, and attenuated with time; the NNH for repeated low dose application was 2.5 (2.1 to 3.1). There were
AMSTAR: Good
useful relief (but at the expense of local skin irritation) from various neuropathic pain conditions alone or in combination with other treatment in patients who fail to respond to or cannot tolerate other available therapies
Chronic Pain Health Needs Assessment 151
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
insufficient data to analyse either data set by condition or outcome definition. All studies satisfied minimum criteria for quality and validity, but maintenance of blinding remains a potential problem.
Noble (2010) (214) Long-term opioid management for chronic non-cancer pain (update of 2008)
One RCT and 26 pre-post case studies (27 treatment groups, 4893 participants)
With meta-analysis
Adults with pain due to any cause other than cancer lasting from at least three months prior to enrolment. Previous non-opioid pharmacotherapy must have failed before beginning
Any opioid taken by any route in any dose for at least six months
No comparator
Adverse effects, discontinuation from study due to adverse effects, discontinuation due to insufficient pain relief, average change in pain score, proportion of patients
Many participants discontinued due to adverse effects (oral: 22.9% [95% confidence interval (CI): 15.3% to 32.8%]; transdermal:12.1% [95% CI: 4.9% to 27.0%]; intrathecal: 8.9% [95% CI: 4.0% to 26.1%]); or insufficient pain relief (oral: 10.3% [95% CI: 7.6% to 13.9%]; intrathecal:
Some long-term benefit
Cochrane review PRISMA: two items missing AMSTAR: Medium
Level 4 Weak evidence suggests that patients able to continue opioids long-term experience clinically significant pain relief Inconclusive evidence for quality of life and /
152 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
opioids with at least 50% pain relief, health-related QoL
7.6% [95%CI: 3.7% to 14.8%]; transdermal: 5.8%[95% CI: 4.2% to 7.9%]) Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity
functional improvement Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare Long term opioids should be commissioned but their use should be restricted to selected patients in view of the
Chronic Pain Health Needs Assessment 153
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies
lack of conclusive evidence of benefit
Gill (2011) (221) Valproic acid and sodium valproate for neuropathic pain and fibromyalgia in adults
3 RCTs (2 were in diabetic neuropathy (total 84 subjects with 42 on placebo and 42 on valproate; one study was in post-herpetic neuralgia (23 active and 22 placebo)
Without meta-analysis
Adults with one or more of the following chronic neuropathic conditions: painful diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia, phantom limb pain, postoperative or traumatic
Valproic acid or sodium valproate in any dose, by any route, administered for the relief of neuropathic pain or fibromyalgia
Placebo, no intervention, or any other active comparator
Patient-reported pain relief of 30% or greater Patient-reported pain relief of 50% or greater Patient-reported PGIC much or very much improved
Any pain-related outcome indicating some improvement Withdrawals due to lack of efficacy. Participants experiencing any adverse event Participants experiencing
The primary outcome – 50% or more pain relief was reported only in 1 study, while all 3 reported group means for pain reduction from baseline to end-point. 1 study in diabetic neuropathy and the study in post-herpetic neuralgia reported significant differences in favour of valproic acid. Pooled analysis not
Likely to be ineffective
Cochrane review PRISMA: three items missing AMSTAR: Medium
Level 1 These results hint at a beneficial effect of valproic acid. The effect may have been overestimated because the studies did not analyse the data on an intention to treat basis. Evidence does not
154 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
neuropathic pain, complex regional pain syndrome, cancer-related neuropathy, Guillain Barré, HIV-neuropathy spinal cord injury, fibromyalgia
Patient-reported PGIC very much improved
any serious adverse event Withdrawals due to adverse events Specific adverse events, particularly somnolence and dizziness
possible due to insufficient data. Adverse events (nausea, drowsiness and abnormal liver function tests were reported more often in active treatment group
justify the use of valproic acid or sodium valproate in neuropathic pain
Straube (2011) (222) Interference with work in fibromyalgia: effect of treatment with pregabalin and relation to pain response
4 RCTs Meta-analysis
Adults with fibromyalgia
Pregabalin Placebo Pain improvement (0-10 numerical pain rating scale score at beginning of trial and end of trial pain state (VAS 100mm
All patients improved but those on pregabalin saw greater reduction in days lost. Days of work lost in placebo group fell from a mean of 2.2 (SD 2.3) days to 1.9 (SD 2.1) days at trial end (p < 0.01). Patients on 600 mg pregabalin saw a reduction
Effective Not Cochrane review PRISMA: 13 items missing AMSTAR: Low (some questions not applicable)
Level 1 This meta-analysis shows that effective pain relief translates into other benefits – in this case a return to work A reduction
Chronic Pain Health Needs Assessment 155
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
pain scale) from 2.1 (SD 2.2) days to 1.6 (SD 2.0) days (p < 0.001) Patients with a good pain response saw the best improvement in days lost from work: from 2.0 (SD 2.2) days to 0.97 (SD 1.6) days (p < 0.0001) for those experiencing >/= 50% pain improvement and from 1.9 (SD 2.2) days to 0.73 (SD 1.4) days (p < 0.0001) for those achieving a low level of pain at trial end (<30 mm on the VAS) Patients achieving both >/= 50% pain improvement and a pain score <30 mm
of more than a day a week in time off work can be achieved in patients with good pain responses
156 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
on the VAS had the largest improvement, from 2.0 (SD 2.2) days to 0.60 (SD 1.3) days (p < 0.0001)
Chronic Pain Health Needs Assessment 157
Appendix 3 Link to main document
Summary of findings: Patient education
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Gross (2012) (175) Patient education for neck pain
15 RCTs With meta-analysis
Neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache
Therapeutic patient education
Placebo (sham/mock education strategy), other treatment added to both arms of trial, wait list or no treatment, another treatment
Pain intensity, function, disability, knowledge transfer, behaviour change
QOL, global perceived effect, patient satisfaction. Adverse effects, follow-up
Moderate quality evidence (one trial, 348 participants) than an educational video of advice focussing on activation was more beneficial for acute whiplash related pain vs no treatment at intermediate-term (RR=0.79; 95%CI:0.59, 1.06) but not long-term follow-up (0.89; 95%CI: 0.65, 1.21) Low quality evidence (one trial, 102 participants) that whiplash pamphlet on advice focusing on activation is less beneficial for pain
With exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies
Cochrane review PRISMA: one item missing AMSTAR: Good
Level 1 The evidence available does not support the commissioning of education based interventions for neck pain
158 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short or intermediate term follow-up
Haines (2009) (223) Patient education for neck pain with or without radiculopathy
10 RCTs with meta-analysis
Adults with neck pain with or without radiculopathy
Patient education
Placebo (sham/mock education strategy) or other treatment (eg sham TENS), other treatment added to both arms of the trial (eg education and ultrasound versus ultrasound), waiting list control or no
Pain relief, function/disability, global perceived effect, QoL, patient satisfaction, follow up
Of the 10 trials, two trials were of high quality, 8 trials focussed on activation compared to no treatment or to various active treatments, including therapeutic exercise, manual therapy, and CBT, showed inferiority or no difference for pain, spanning a full range of follow-up periods and disorder types. Two trials showed no benefit for chronic neck pain and stress
Limited effect Cochrane review PRISMA: one item missing AMSTAR: Medium
Level 1 The review has not shown effectiveness for educational interventions in various disorder types and follow-up periods, including advice to activate, advice on stress coping skills, and 'neck school'. In future research, further
Chronic Pain Health Needs Assessment 159
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
treatment, or another treatment (eg education versus another intervention, one technique of education versus another, or one dose of education versus another dose)
coping skills at intermediate/long-term follow-up. One trial compared effects of traditional neck school to no treatment, yielding limited evidence of no benefit for pain at intermediate-term follow-up in mixed acute/subacute/ chronic neck pain
attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of the specific educational components
160 Chronic Pain Health Needs Assessment
Appendix 4 Link to main document
Summary of findings: Physical treatments
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Chow (2009) (183) Efficacy of low level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials
16 RCTs included
With meta-analysis
Acute neck pain Chronic neck pain
Low level laser therapy
Placebo or active treatment
Reduction in pain intensity (VAS)
Acute neck pain: results of two trials showed RR of 1.69 (95% CI: 1.22-2.33) for pain improvement of LLLT vs placebo Chronic neck pain: 11trials reported changes in VAS and pain intensity reduced by 19.86mm (95% CI:10.04-29.68) 5 trials reported RR for pain improvement of 4.05 (95% CI: 2.74-5.98) of LLLT
Moderate statistical significance for efficacy of LLLT for acute/chronic neck pain in short and medium term For chronic neck pain, average reduction of VAS of 19.86mm
Not Cochrane review PRISMA: 4 missing items AMSTAR: Good
Level 1 These results must be seen as preliminary evidence. Further trials are required
Chronic Pain Health Needs Assessment 161
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
across all studies was considered clinically relevant Clinical benefits of LLLT occur both when LLLT is used as monotherapy and in the context of regular exercise and stretching programme
Mark (2010) (177) Low level laser therapy for carpal tunnel syndrome and chronic neck pain
6 randomised controlled trials included 4 studies included
Without meta-analysis
Chronic neck pain, carpal tunnel syndrome
Low level laser therapy
Sham treatment
Pain relief on VAS, McGill pain questionnaire, neck pain and disability score, functionality
Chronic neck pain: studies showed variable results. Two studies showed statistically significant findings for primary outcome of change in VAS score. Two studies showed changes in VAS
Treatment should be regarded as experimental due to poor methodological quality and variability of
Not Cochrane review PRISMA:11 items missing AMSTAR: Low
Level 1 Further larger trials required to confirm clinical benefit, LLLT cannot be recommended
162 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
but not statistically significant. Two studies showed no difference between treatments
results and small sample size
Alexander (2010) (178) Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review
8 RCTs included
Without meta-analysis
Shoulder pain Ultrasound Control treatment
Pain reduction Quality of life, functionality
Three studies produced significantly better outcomes compared to control groups Two studies reported significantly reduced pain and significant improvements in function
Indeterminate, optimal ultrasound energy not known
Not Cochrane review PRISMA:8 items missing AMSTAR:Good/medium
Level 1 Optimal parameters for effectiveness of ultrasound is not known, it would be premature to conclude that this treatment is ineffective. More research is required
Graham (2008) (179) Mechanical traction for neck pain with
7 RCTs included
With meta-analysis
Neck pain with or without radiculopathy
Mechanical traction alone or in combination with other
Placebo or another treatment
Pain relief using the VAS score, NRS.
Functional or disability measures including work-related
No evidence from RCTs that supports or rejects use of either continuous or intermittent traction for neck pain
Indeterminate Cochrane review PRISMA:6 items missing
Level 1 Requires further well conducted RCTs to determine
Chronic Pain Health Needs Assessment 163
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
or without radiculopathy
treatments disability, return to work, patient satisfaction, global perceived effect and quality of life
AMSTAR:Good
efficacy of traction. Recommendations cannot be made with the available evidence
Warden (2008) (180) Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis
7 RCTS included 9 randomised cross-over studies
With meta-analysis
Chronic knee pain
Patellar taping and/or bracing
No taping or bracing
Pain relief using 100 mm VAS score
On 100mm scale, pain decreased with tape application (95%CI:22.2 to 10;P<0.001) compared to no tape and sham tape by 10.9mm (95%CI:-18.4 to -3.4; P<0.001) Anterior knee pain and OA, pain decreased with medially-directed tape compared with no tape by 14.7mm (95%CI:-22/8 to -6.9; P<0.001) and 20.1 mm (95%CI:-26.0 to 14.3; P<0.001) respectively
Evidence for medially-directed force on patella Limited evidence to demonstrate efficacy of patellar bracing
Not Cochrane review PRISMA:2 items missing AMSTAR:Good
Level 1 Outcomes limited by presence of high heterogeneity between study outcomes and significant publication bias
164 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Blum (2008) The H-wave
5 studies included but not clear what type of studies included 2 studies included disproportionately large populations; one study had 1291 participants and the other had 5132 participants
With meta-analysis
Neuropathic pain and soft tissue inflammation
H-wave electrical stimulation
No treatment Pain reduction and reduction in use of pain medication
For chronic soft tissue inflammation and neuropathic pain: Decreased pain ratings, mean weighted effect size=0.59, estimated effect size=0.00003 (95%CI:0.580, 0.600) Decreased intake of pain medication, mean weighted effect size=0.56, estimated effect size variance=0.000013(95%CI:0.553, 0.567) Improved patient functionality, mean weighted effect size=0.70, estimated effect size variance=0.00002 (95%CI:0.691, 0.709) Chi2 test for homogeneous effect sizes
Strong to moderate effect in providing pain relief, reducing medication requirement and increasing functionality. May facilitate quicker return to work and other related daily activities
Not Cochrane review PRISMA:5 items missing AMSTAR:Low/medium
Not clear Systematic review is of poor quality, based on uncontrolled studies and little reliance can be based on the reported beneficial effect of H-wave device
Chronic Pain Health Needs Assessment 165
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
highly significant variability (P<0.00001), indicating a robust significant effect size for increased functionality relative to both pain relief and reductions in pain medication. Little to no evidence of any adverse effects
Van Middelkoop (2011) (182) A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain
83 RCTs (8816 participants)
With meta-analysis
Adults older than 18 years with non-specific chronic LBP that persisted for 12 weeks or more
Physical and rehabilitation intervenetions
No treatment, waiting list controls, other interventions
Pain and physical functional status (pain intensity (VAS, McGill pain questionnaire), back specific disability (ODI), perceived recovery, return to work, side effects)
Exercise therapy versus usual care: exercise treatment improved post-treatement pain intensity and disability and long-term function BT versus no treatment/waiting list: BT was more effective in reducing pain intensity at short-term follow-up compared to no
Overall evidence from RCTs, effectiveness of treatments was low. Exercise versus usual care, quality of evidence was low
Not Cochrane review PRISMA:6 items missing AMSTAR: Good to medium
Level 1 The clinical effect of back school, LLLT, patient education, massage, traction, superficial heat/cold, and lumbar supports is not clear due to insufficient
166 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
treatment/waiting list controls MDT versus no treatment/waiting list controls: MDT reduced pain intensity and disability at short-term follow-up compared to no treatment/ waiting list control
BT versus no treatment/waiting list control, quality of evidence was low MDT versus no treatment/waiting list control, evidence of effectiveness was moderate at short-term at reducing pain in cLBP
data. Only MDT, exercise and BT have some effect on pain intensity and disability, thus only these three interventions should be provided as conservative treatments in daily practice in the treatment of cLBP
Chronic Pain Health Needs Assessment 167
Appendix 5 Link to main document
Summary of findings: Behavioural and cognitive behavioural therapy
Summary of findings for systematic reviews
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Eccleston (2009) (224) Psychological therapies for the management of chronic pain (excluding headache) in adults
40 RCTs (4781 participants)
With meta-analysis
Adults reporting non-cancer pain of at least three months duration in any body site, with neck facial or dental pain
Cognitive behavioural therapy, behavioural therapy
Placebo other active treatment, treatment as usual, or waiting list control
Pain experience, negative mood, disability
Overall lack of evidence for BT, except for pain immediately following treatment, when compared to TAU CBT has some small effects for pain, disability and mood
Insufficient data on quality or content of treatment to investigate their influence on outcomes CBT and BT may have a positive effect on altering mood outcomes but results are not statistically
Cochrane review PRISMA: 2 items missing AMSTAR: good
Level1 CBT and BT have weak effects in improving pain Both interventions may be effective in altering mood outcomes and the effect may be maintained at 6 months The evidence for
168 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
significant behavioural therapies in isolation is weak and is not sufficient to commission these services as individual interventions There is a role for CBT as part of a comprehensive multi-disciplinary programme
Macea (2010) (185) The efficacy of web-based cognitive behavioural interventions for chronic pain: a systematic review and
11 randomised trial studies, 2953 participants
With meta-analysis
Adults with chronic pain
Internet-based cognitive behavioural programmes, with or without minimal therapist contact for patients in treatment of
Waiting list group
Pain improvement
Results of this meta-analysis suggest that web-based interventions for chronic pain effect are associated with small reductions in pain in the interventions group compared with waiting-list control groups
The effect of web-based psychological interventions is weak and uncertain
Not Cochrane review PRISMA- 6 items missing AMSTAR: Good
Level 2 In view of the small effect and the likely bias, web-based behavioural therapy should not be commissioned
Chronic Pain Health Needs Assessment 169
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
meta-analysis chronic pain The 11 studies showed wide variability in the type of assessments that were used, the study population, the aetiology of chronic pain, and time of intervention Drop-out rate from the study was 26%
Hoffman (2007) (186) Meta-analysis of psychological interventions for chronic low back pain
34 RCTs, Meta-analysis
Adults with non-cancerous cLBP
Psychological interventions
Waiting list control or treatment as usual
Pain intensity, QOL, physical and emotional functioning
3 or 4 RCTs (depending on outcome) for CBT versus waiting list controls: There was significant reduction in pain intensity at post-treatment in favour of CBT but not at follow-up (time not specified). No significant differences for HRQOL or depression (post –treatment only stated). 3 or 4 RCTs (depending on outcome) for CBT
Effective for CBT Although the review methodologywas generally good, it was unclear which studies were contributing to the meta-analyses and whether there was
Not Cochrane review PRISMA: 5 items missing AMSTAR: Good
Level 1 Results provide support for efficacy of psychological interventions in reducing self-reported pain, pain-related interference, depression, disability, and increasing HRQOL in
170 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
versus self-regulatory treatment: there was a significant reduction in pain intensity and depression in favour of CBT at follow-up (time not specified) but not at post-treatment
clinical heterogeneity. RCTs of variable quality; authors comment on lack of reporting on treatment fidelity and concurrent treatments
patients with CLBP. Psychological interventions could be commissioned for the treatment of CLBP
Henschke (2010) (187) Behavioural treatment for chronic low-back pain
30 RCTs (3438 participants)
Without meta-analysis
Adults with non-specific chronic low back pain that had persisted for 12 weeks or more
Combined behavioural treatment (respondent, operant and cognitive, behavioural therapy) + physiotherapy, behavioural therapy+ inpatient rehabilitation
Waiting list controls, usual care, group exercise, other treatment
Self-reported or observed overall improvement, back-pain specific functional status (Rowland Morris questionnaire or ODI), generic functional status, return
For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined
Only CBT showed significant difference between waiting list control for short-term pain control Other comparisons : likely to be ineffective
Cochrane review PRISMA: 2 items missing AMSTAR: Good
Level 1 For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is
Chronic Pain Health Needs Assessment 171
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
to work, pain intensity (VAS or NRS)
behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone
more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. CBT should
172 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
be commissioned as part of a multidisciplinary programme
Chronic pain health needs assessment 173
Summary of Findings: Guidelines
Citation
Low back pain. Early management of persistent non-specific low back pain. CG 88; 2009(156)
Guideline: Care pathway domain and topic
Treatment: BT and CBT: CBT
PICOT summary
Pop: People aged 18 or older with symptoms of non-specific low back pain (LBP) which has not resolved within 6weeks of initial onset, consultation or exacerbation up to a period of 12 months. Int: CBT Comp: Usual care in general practice, pamphlet, information package Out: Pain
Guideline evidence: Study design Searching and study selection Validity
Study designs: RCTs Searching: Comprehensive search strategy. Studies were selected which matched the inclusion/exclusion criteria. Validity: Each paper was assessed for quality and critically appraised using the Institute’s criteria for quality assessment.
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
1 RCT: No significant differences between groups in terms of pain or fear avoidance (follow-up time not stated). 1 RCT: Greater reduction in average pain intensity for the self care group but difference significant only at 6 mths.Significantly lower fear avoidance scale scores in the self care group at all follow-up times. Significantly less disability in self care group at 3 mths but not 6 or 12 mths.No more favourable mental health outcomes in self care group.
GRADE assessment
High
Did evidence justify recommendations
Yes
Chronic pain health needs assessment 174
Appendix 6. Link to main document
Summary of findings: Invasive procedures
Summary of findings: systematic reviews
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Straube (2010) (206) Cervico-thoracic or lumbar sympathectomy for neuropathic pain
1 study satisfied inclusion criteria, 4 others were excluded
No Adults with peripheral or central neuropathic pain syndromes and complex regional pain syndrome.
Radiofrequency thermal ablation Sympathectomy (Cx-thoracic or lumbar)
Chemical sympathectomy using Phenol injection
Subjective Pain scores, no binary outcomes reported
% patients with <30% or mild pain relief, pain relief of <4 weeks duration, adverse events, occurrence of persistent new or expanded pain
1 RCT included. 20 patients, 10 in each arm, Both groups sign reductions in pain scores (from 8-9/10 to 4/10 and remained at 3-5 out of 10 over 4 months.
Both types of sympathectomy seem equally efficacious but comparisons with sham procedure is lacking. Small sample size. Soreness at injection site lasted 5-7 days. Paresthesia in 2 patients in Rf group and 1 in phenol group. Number with serious adverse events not
Cochrane review PRISMA: 5 items missing AMSTAR:Good
Level 2 Sympathectomy is based on little high quality evidence. Other evidence suggests that it can work at least in some cases. Should be used with caution if at all, outside a research context.
Chronic Pain Health Needs Assessment 175
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
reported.
Hayek (2011) (195) Intrathecal therapy for cancer and non-cancer pain
15 studies for non- non cancer pain. Of the manuscript reviewed 5 were cancer pain related and 39 were excluded
No Adults with various forms of chronic non-cancer pain
Intrathecal drug delivery
Does not apply since all 15 studies were observational in nature
Pain relief defined as a 2 point drop in 11 point pain scale, or a decrease of 30% on baseline pain intensity
Function improvement, reduction in oral medication, QoL changes, decrease in side effects from oral drugs
The included non-cancer studies were generally poorly reported. Most reported modest improvements in patient reported pain scores as measured by a visual analogue score Adverse events ranged from no cases in some studies to 23/136 in one study with some studies reporting substantial rates of removal. Rare but serious complications include infection and granuloma
Intrathecal infusion of drugs using in implantable programmable system is supported by level 2c grade of evidence (lowest of 6 possible grades used by Guyatt), and is suggested that other alternative treatments may be equally reasonable
Not Cochrane review PRISMA:11 items missing AMSTAR:Good/medium
Level 3 The available evidence base does not justify the commissioning of this treatment in any but the most exceptional circumstances.
Vlassakov (2011) (208) Local
12 included studies: single case
Not applicable
Neuralgias, radicular pain syndromes
Nerve blocks with local anaesthetics
No comparator Pain relief There were no controlled studies. Nine reports
All reviewed articles were single case
Not Cochrane review
Level 4 More research efforts are warranted.
176 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
anaesthetic blockade of peripheral nerves for treatment of neuralgias: systematic analysis
reports or case series
associated with chronic pain or more than a 3-month duration
assessed a single block outcome. All reported pain relief beyond the duration of conduction blockade. The nine studies represented a total of 69 patients, 30 of whom had complete pain relief and 10 had at least 50% relief. Seven reports assessing continuous pain for more than 1 week after single block reported complete or profound pain relief in 11 of 17 patients. All 3 reports assessing series of blocks in a large number of patients (270) reported overall positive results
reports or case series, no reliable conclusion could be drawn concerning the effectiveness of nerve blocks with local anaesthetics in neuralgia. However, two features of the analysed reports-the large magnitude of the effect and the high consistency of the reported outcome
PRISMA:13 items missing AMSTAR:Good/medium
Cannot justify commissioning on the basis of evidence provided in the study
Benyamin 3 RCTs and Without Chronic mechanical Cervical epidural Comparator not Pain relief Psychological Studies were at level A significant Not Cochrane Level 2
Chronic Pain Health Needs Assessment 177
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
(2009) (211) Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain
17 observational studies
meta-analysis
or whiplash-related neck pain with or without radiculopathy for at least 3 months
injections with or without steroids
indicated functionality
improvement, return to work, change in opioid intake
2 (evidence obtained from well designed controlled trials without randomisation) in managing chronic neck and upper extremity pain with 1C (strong recommendation, low quality or very low quality evidence)
effect was observed in relieving chronic intractable pain of cervical origin and providing long-term relief with an indicated evidence level of II-1 on the AHRQ
review PRISMA:7 items missing AMSTAR:good/medium
Ypsilantis (2010) (209) Pre-emptive analgaesia for chronic limb pain after amputation for peripheral vascular disease: a
11 studies (7 RCTs, 2 case-control studies, 2 prospective observational cohort studies)
Without meta-analysis
Chronic stump pain and PLP (critical ischaemia of peripheral vascular disease)
Pre-emptive analgaesia (local) anaesthetics, opiates, N-methyl-D- aspartate receptor agonists, a2-agonists, gamma-aminobutyric acid analogues administered separately or in
Comparator not indicated in review
Pain relief 11 studies, five different types of analgesic drugs evaluated. Beneficial effect of combined bupivacaine, diamorphine, and clonidine in reducing the risk of phantom limb pain was supported by only one study (level 3
There is no robust evidence to support the use of pre-emptive analgesia to minimise risk of chronic pain after amputation for critical ischaemia of peripheral
Not Cochrane review PRISMA:14 items missing AMSTAR:Good/medium
Level 1 (7/11 studies were RCTs)
Not recommended for commissioning
178 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
systematic review
combinations, through the oral, invtravenous, epidural, or regional route
evidence), epidural and perineural infusions containing local anaesthetic +/- opiates are effective in treating acute perioperative pain, although not without potentially serious complications Most studies characterised by high dropout rates because of disease-related mortality
vascular disease. The methods used are effective in treating acute post operative pain
Staal (2008) (205) Injection therapy for subacute and chronic low back pain
18 RCTs (1179 participants)
Meta-analysis not possible
Patients with low back pain with symptoms persisting for at least 1 month, Subacute low back pain lasting for 4 weeks or longer and chronic pain as lasting for 12 weeks or longer
Epidural injections, facet joint injections (intra-articular, peri-articular, and nerve blocks), tender and trigger point injections using drugs consisting of
Placebo Pain relief or improvement
Global measure of improvement, back-specific disability, generic health status or well-being, disability for work, patient satisfaction
Facet joint injections with corticosteroid vs placebo: One RCT (Carette 1991) showed no significant difference at 3 months. Differences at 6 months described as statistically significant (self-rated
Statistical pooling was not possible because of clinical heterogeneity in the trials. Results indicate that there is no strong evidence for or against
Cochrane review PRISMA:4 items missing AMSTAR:Good
Level 1 There is insufficient evidence to support use of injection therapy in subacute and chronic low back pain, but may be beneficial to a
Chronic Pain Health Needs Assessment 179
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
corticosteroids, local anaesthetics, and a variety of other drugs
improvement, pain, and functional status in favour of active treatment) One RCT(Lilius 1990) showed no statistical differences between groups for pain, disability or work attendance at 1 hour, 2 weeks, 6 weeks and 3 months (corticosteroid injected intra-articularly, corticosteroids injected peri-capsularly and placebo injections) Facet joint injections with corticosteroids vs other treatments: 4RCTs: Manchikanti (2001) showed no significant
the use of any type of injection therapy Adverse events were either not reported or there were no complications reported. Only 3 RCTs were of high quality
subgroup of patients who may respond to a specific type of injection therapy
180 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
differences for pain relief, overall health, physical, functional and psychological status and return to work throughout a 2.5 yr follow-up period (facet joint injections with corticosteroids, local anaesthetics, and Sarapin vs similar injections with local anaesthetics and Sarapin) Mayer (2004) showed no significant post-treatment differences for pain or disability (facet joint injections with mixtures of local anaesthetics and corticosteroids) with a home stretching exercise programme vs exercise
Chronic Pain Health Needs Assessment 181
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
programme only Marks (1992) showed significant difference in favour of facet joint injections (compared to facte nerve blocks) at 1 month, but not at post-treatment, 2 weeks or 3 months, for pain relief. No difference for disability scores or work attendance Fuchs (2005) Showed no significant difference for pain relief, disability or QOL over a 180-day period (facet joint injections with sodium hyaluronate vs injections with corticosteroids)
182 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Facet joint injections with local anaesthetics vs other treatments: 1 RCT, Ravel (1999) showed significantly higher pain relief post treatment with facet joint injections with lidocaine compared to injections with saline. In both groups these injections were followed with an injection of corticosteroids. Other outcomes were not measured
Datta (2009) (192) Systematic assessment of diagnostic
7 studies included, consecutive or non-consecutive allocation and
Without meta-analysis
Chronic low back pain
Lumbar facet joint interventions
Placebo or comparative local anaesthesic block under fluoroscopy
For diagnostic interventions: Pain relief was categorised as at
For diagnostic interventions: measures of improvement in functional status, psychological
Diagnostic lumbar facet joint nerve blocks: Study 1: 500 patients evaluated for facet joint pain, 397 were evaluated for low
Lumbar facet joint and radiofrequency neurotomy are effective Lumbar intra-
Not Cochrane review PRISMA:5 items missing AMSTAR:Mediu
Level 5 Strong recommendations for lumbar facet joint injections and radiofrequency neurotomy
Chronic Pain Health Needs Assessment 183
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
accuracy and therapeutic utility of lumbar facet joint interventions
observational studies
least 80% pain relief from baseline pain and ability to perform previously painful movement For therapeutic interventions: short-term pain relief (lasting 6 months or less) and long-term relief (lasting longer than 6 months)
statusm return to work, reduction in opioid intake
back pain (prevalence 31%; 95%CI: 27%, 36%; false positive rate with single blocks with lidocaine: 95%CI: 22%, 32%)) Study 2: 438 patients evaluated of which 303 patients had lumbar pain (prevalence 27%; 95%CI: 22%, 33%) with a false-postive rate of single blocks in the lumbar region of 45% (95%CI: 36%, 53%) Study 3: zygapophysial joint pain in 20 patients (32%; 95%CI: 20% to 44%) obtained ≥50% pain relief after saline treatment.
articular injections likely to be ineffective
m/good Very weak recommendation for lumbar intra-articular injections
184 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
23/57 patients who completed the study failed to obtain pain relief after saline injection but obtained relief with one or more intra-articular local anaesthetic Study 4: 120 patients with low back pain were evaluated for facet nerve blocks, provocative discography, and sacroiliac joint injections. Facet joint
Zhang (2011) (210) The efficacy of botulinum toxin type A in managing
14 RCTs and 1 crossover study
With meta-analysis
Shoulder pain, whiplash, plantar fasciitis, tennis elbow, myofascial pain
Intra-muscular or subcutaneous botulinum toxin A (single or complementary therapy)
Placebo, non-active injection or other treatments in reducing chronic musculoskeletal pain (e.g. exercise)
Duration of pain severity, disease of interest, dosing regimen, length of
Small to moderate pain reduction among BoNTA patients when compared to control (SMD= -0.27; 95%CI: -0.44, -0.11)
BoNTA had a small to moderate analgesic effect in chronic musculoskeletal pain conditions, especially in
Not Cochrane review PRISMA:4 items missing AMSTAR:Good
Level 1 (majority of studies were RCTs)
Further evidence is required before definitive conclusions can be drawn The evidence
Chronic Pain Health Needs Assessment 185
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
chronic musculoskeletal pain: a systematic review and meta-analysis
follow-up Subgroups, only tennis elbow (SMD= -0.44; 95%CI: 0.86, -0.01) and plantar fasciitis (SMD= -1.04; 95% CI: -1.68, -0.40) demonstrated significant pain relief One back pain study also demonstrated positive results for BoNTA
plantar fasciitis, tennis elbow and back pain, but not in whiplash or shoulder patients Studies were small with follow-up between 4 to 24 weeks
does not support commissioning of this treatment
Langevin (2011) (199) Botulinum toxin for subacute/chronic neck pain
9 randomised and quasi-randomised trials
With meta-analysis
Sub-acute/chronic non-specific neck pain/mechanical neck pain
Botulinum toxin A intra-muscular injections alone or in addition to another treatment (e.g., exercise)
Placebo or another active treatment (ultrasound)
Patient reported pain, function, disability, QOL, global perceived effect and satisfaction
High quality evidence for little or no difference in pain between BoNTA and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for
Likely to be ineffective at 4 weeks and 6 months for chronic pain
Cochrane review PRISMA: 1 item missing AMSTAR:Good
Level 1 This evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated
186 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
chronic neck pain.
Very low quality evidence of little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics compared to saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)).
Very low quality evidence from one
with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months
Chronic Pain Health Needs Assessment 187
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
trial (32 participants) of little or no difference between BoNT-A and placebo at 4 weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache.
Very low quality evidence from one trial (31 participants), of benefit from BoNT-A in global perceived effect in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)).
Singh (2010)
6 RCTs (164 participant
With meta-
Shoulder pain due to any cause
Botulinum toxin injection by any
Placebo injection or another active
Pain measured
Function or disability, joint
A single injection of BoNT-A (v placebo)
Indeterminate or of limited
Cochrane review
Level 1 High risk of bias demands
188 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
(204) Botulinum toxin for shoulder pain
s) analysis
route, including, but not limited to intramuscular, subcutaneous, intradermal or intra-articular routes
treatment on a VAS or semi-quantitative scale Adverse effects, total and serious; number of withdrawals due to adverse events, and deaths
range of motion, QOL, patient or physician evaluated success of treatment, radiographic progression for patients with shoulder arthritis, stroke patient disability
significantly reduced pain at three to six months post-injection (MD -1.2 points, 95% CI -2.4 to -0.07; 0 to 10 point scale) but not at one month (MD -1.1 points, 95% CI -2.9 to 0.7) in post stroke shoulder pain. Shoulder external rotation was increased at one month (MD 9.8°, 95% CI 0.2 to 19.4) but not at three to six months. Shoulder abduction, external rotation or spasticity did not differ between groups, nor did the number of adverse events (RR 1.46, 95% CI 0.6 to 24.3). One RCT in arthritis-
effect PRISMA:1 item missing AMSTAR:Good
caution. Botulinum toxin A injections seem to reduce pain severity and improve shoulder function and range of motion when compared with placebo in patients with shoulder pain due to spastic hemiplegia or arthritis It is unclear if the benefit of pain relief in post-stroke shoulder pain at three to six months but not at one month is due to limitations of evidence, which
Chronic Pain Health Needs Assessment 189
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
related shoulder pain indicated that botulinum toxin reduced pain severity (MD -2.0, 95% CI -3.7 to -0.3; 10 point scale) and shoulder disability with a reduction in Shoulder Pain and Disability Index score (MD -13.4, 95% CI -24.9 to -1.9; 100 point scale) when compared with placebo. Shoulder abduction was improved (MD 13.8 degrees, 95% CI 3.2 to 44.0). Serious adverse events did not differ between groups (RR 0.35, 95% CI: 0.11, 1.12)
includes small sample sizes with imprecise estimates, or delayed onset of action. More studies with safety data are needed
Kalichman (2011)
4 RCTs With meta-
Lateral epicondylitis
Botulinum toxin injections
Placebo Level of pain
Meta-analysis of 4 RCTs showed a
Indeterminate or of limited
Not Cochrane review
Level 1 Present literature
190 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
(198) Injection of botulinum toxin for treatment of chronic lateral epicondylitis:Systematic review and meta-analysis
analysis reduction, grip strength
moderate effect for pain favoring botulinum toxin (effect size -0.5, 95% CI: -0.9,-0.1) at 3 months and no effect for grip strength Qualitative analysis of studies that could not be pooled also showed improvement in pain, but was limited by potential bias No data presented on safety.
effect PRISMA: 5 items missing AMSTAR:Good
provides support for use of botulinum toxin A injections into fore arm extensor muscles (60 units) for treatment of chronic treatment-resistant lateral epicondylitis
Ho (2007) (196) Botulinum toxin A for myofascial trigger point injection: a qualitative systematic
5 clinical trials
Without meta-analysis
Chronic myofascial pain
Trigger point injections
Placebo Pain intensity, pain pressure threshold
One trial with 14 and 12 patients with a saline control arm concluded that BoNTA was effective, while four other trials (sample sizes ranging from 22 to 66 in both arms) concluded
Indeterminate or of limited effect
Not Cochrane review PRISMA: 12 items missing AMSTAR: Medium/good
Level 1 Current evidence does not support the use of BTA injection in trigger points for myofascial pain. The evidence
Chronic Pain Health Needs Assessment 191
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
review that Botulinum toxin injection was not better than saline injection in improving the pain.
Of the studies excluded from this review many were open label trials that claimed superior efficacy for botulinum toxin. The included studies were all small in size and methodologically
weak.
does not support commissioning this treatment
Scott (2009) (202) Trigger point injections for chronic non-
15 RCTs Without meta-analysis
Chronic non-malignant musculoskeletal pain
Trigger point injections
Placebo or no treatment
Pain reduction, pain pressure, subjective function, medication usage
Detailed results from RCTs presented. 10 of 15 studies had very small sample sizes. Internal validity ranged from good to poor.
Likely to be ineffective
Not Cochrane review PRISMA: 4 items missing AMSTAR:Good
Level 1 Efficacy not proven. Only advantage of including local anaesthetic in the injection appears to be to
192 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
malignant musculoskeletal pain: a systematic review
In general, regardless of the drug injected trigger point injection was no more effective than other less invasive treatments such as laser and ultrasound
reduce the pain of the needling The evidence available does not support commissioning this treatment
Patel (2009) (201) Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain
15 observational studies
Without meta-analysis
Chronic non-cancer pain
Intrathecal infusion devices
? At least 50% pain relief
Improvement of function, reduction amount of oral medication, decrease in side effects from systemic drugs, improvement in QOL
Of 4 observational studies, only two studies showed positive results for short- and long-term relief. The studies included were regarded as strongly recommended by authors, but low quality or very low quality evidence Study showed that benefits of intrathecal infusion devices outweighed
Indeterminate or of limited effect.
Not Cochrane review PRISMA:8 items missing AMSTAR:Medium/good
Level 2 Although this study strongly recommended intrathecal devices for management of chronic non-cancer pain, there were limitations to the study, including paucity of literature, lack of quality of evidence and lack of
Chronic Pain Health Needs Assessment 193
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
risk and burdens randomised controlled trials
Chua (2011) (191) Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications-a review
6 RCTs for PRF
Without meta-analysis
Zygapophyseal joint pain, cervical radicular pain, lumbosacral pain, trigeminal neuralgia, chronic shoulder pain
Pulsed radiofrequency
Corticosteroid injection, sham intervention, conventional radiofrequency thermocoagulation
Global perceived effect (>50%), pain reduction using VAS, disability
Cervical radicular pain: one study showed significant improvement (>50%) of global perceived effect and VAS (NNT=3 in sham group and NNT =1,1 in PRF group). After 6 months, NNT for sham intervention=6, PRF group=1.6 Lumbar zygapophyseal joint pain: One RCT showed PRF against RF denervation to have comparable results at 6 months, reduced pain scores maintained at 1 yeear only for the RF group.
Evidence shows that PRF may be of benefit in treatment of cervical radicular pain and chronic shoulder pain, but less effective for lumbar zygapophyseal joint pain and trigeminal neuralgia
Not Cochrane review PRISMA:13 items missing AMSTAR:Medium
Level 1 Further research is required to warrant use of PRF for the treatment of chronic pain
194 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Another RCT showed no significant difference between RF and PRF groups in improvement of pain scores. Over a three month interval, RF showed significant improvement in VAS score (but potential bias due to lack of blinding, lack of numbers of withdrawals, and patients lost to follow-up) Lumbosacral radicular pain: one RCT showed no significant difference in VAS between PRF only group and PRF+RF group, no significant neurological deficits. Loss of analgesic effect between 2 to
Chronic Pain Health Needs Assessment 195
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
4 months. By month 8, majority of patients returned to baseline pain intensity Trigeminal neuralgia:one RCT showed significant pain reduction in all patients treated with RF, while only 2/20 patients in the PRF group experienced the same level of pain relief. Chronic shoulder pain: one RCT for intra-articular corticosteroid injection vs suprascapular nerve RF showed significant improvements up to three months in
196 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
terms of pain scores, range of motion, and QOL. Patients in the intra-articular corticosteroid injections had improved pain scores and shoulder disability scores compared to suprascapular nerve RF. In another study, suprascapular nerve RF has been shown to be effective up to 6 months
Dretzke (2011) (193) The clinical and cost-effectiveness of neurostimulation for relief of chronic/ne
Two RCTs for SCS
Without meta-analysis
FBSS, CRPS
SCS
Conventional medical treatment
Pain reduction by at least 50%
Functional ability, EQ-5D improvement
FBSS: One trial (PROCESS) reported at least 50% pain reduction at 6 months compared to patients receiving conventional medical management and the effect was
SCS for FBSS: Effective, statistically significant SCS for CRPS I: effective, statistically significant
Not Cochrane review
Level 1 FBSS: Evidence suggests that SCS is more effective than conventional medical management or re-operation in terms of pain relief. SCS may be more
Chronic Pain Health Needs Assessment 197
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
uropathic pain: an evidence based review
sustained at 12 months follow-up and 24 months follow-up. Functional ability was measured by ODI which improved significantly for the SCS group and was sustained at 24 months compared to patients receiving conventional medical management, and between group differences were significant. There was no difference in the use of opiate, other analgesic, or antidepressant between the SCS group and the CMM group. Another trial (North)
effective at improving function and HRQOL. Two RCTs reported device-related complications, but were minor. Incidence of AEs upon removal of the SCS device was low, and number of device related incidences fall after the first year. Other complications included infections, and cerebrospinal fluid leakage. CRPS I: Evidence from a small but
198 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
reported significantly higher positive outcomes in the SCS group, with 39% reporting at least 50% improvement in pain scores alone. The mean follow-up for this trial was 2.9 years. Patient-self reported neurological function was generally worse at long-term follow-up in the re-operation group compared to the SCS group, although differences were not statistically significant. An increase in opiate use in 42 % of patients of the the re-operation group compared to 13% in the SCS group was
well-conducted RCT suggests a significant reduction in pain and significant improvement in global perceived effect at 6 months and two years. The effect on quality of life at any time-point is not known. SCS should be commissioned for use for those patients who fail to respond to other treatments
Chronic Pain Health Needs Assessment 199
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
also reported. CRPS I: patients implanted with SCS reported a significant reduction in pain as measured by VAS at 6 months and 2 years. Similar changes were also observed for global perceived effect, which diminished at the three year time point, and at 5 years there were no longer any significant differences between standard therapy groups and SCS groups. SCS did not appear to influence HRQOL or functional status. Patient satisfaction was high in those patients who received a
200 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
permanent implant.
Simpson (2009) (203) Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin: systematic review and economic evaluation
11 RCTs With meta-analysis
Adults with chronic neuropathic or ischaemic pain who have had inadequate response to medical or surgical treatment other than SCS
Spinal cord stimulator devices
Medical and/or surgical treatment (appropriate to condition) that does not include spinal cord stimulation
Pain, health related QOL, physical and functional abilities, anxiety and depression, medication use, complications and adverse effects (eg, procedural complications and technical failures
Of 11 RCTs (three for neuropathic pain and eight of ischaemic pain), trials were available for FBSS and CRPS type I. SCS was found to be more effective than conventional medical management or re-operation in reducing pain. Evidence failed to show that effectiveness for SCS in critical limb pain relief compared to conventional medical management. SCS was effective in delaying refractory angina pain onsest at short term follow-up but no more than
Evidence suggested that SCS was effective in reducing the chronic neuropathic pain of FBSS and CRPS type I. For ischaemic pain, there may need to be selection criteria developed for CLI, and SCS may have clinical benefit for refractory angina in the short term
Not Cochrane review PRISMA:11 items missing AMSTAR: Medium/good
Level 1 Further studies required for other types of neuropathic pain or subgroups of ischaemic pain
Chronic Pain Health Needs Assessment 201
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
coronary artery bypass grafting. Complications varied from study to study, but were usually minor
Ibrahim (2009) (197) Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials
4 RCTs (634 participants)
Meta-analysis
Chronic low back pain
Spinal fusion with or without instrumentation
Physical therapy with or without cognitive therapy
Pain-related disability( Owestry disability index), daily life and social participation
Patient satisfaction, return to work
3 RCTs compared surgical vs non-surgical treatment for low back pain short-term. All studies were of good methodological quality. Pooled results showed a trend in favour of surgery (mean ODI difference=4.13; P=0.10; 95%CI: -0.48 to 9.17) Heterogeneity in surgical techniques, analysis had limitations due to paucity of studies. The only outcome
Limited benefit Cochrane review PRISMA: 4 items missing AMSTAR:Good
Level 1 Surgical fusion may improve ODI compared to non-surgical intervention at 2 years follow-up, but effect was not statistically significant. Spinal fusion can only be recommended cautiously to patients with chronic low back pain. Further long term follow up of studies is required.
202 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
measure examined was ODI, and other outcomes were not addressed which could limit conclusions. Possible publication bias due to small number of studies
Current evidence does not support routine use of surgery for treatment of chronic low back pain
Van den Eerenbeemt (2010) (207) Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature
19 studies (16 prospective cohort, 3 prospective controlled studies, 3 RCTs)
Without meta-analysis
Chronic low back pain
Total disc replacement surgery
Lumbar fusion
Pain intensity (VAS), functional status, global improvement, return to work
Physiological outcome, radiological outcome, patient satisfaction
Charite trial (artificial disc) was considered to have a low risk of bias for 2 year follow-up and was non-inferior to the BAK interbody fusion system (57.1 vs 46.5% for 2 year follow-up; 57.8 vs 51.2% for 5 year follow-up). There were no statistically significant differences in mean pain and physical function scores. The prodisc artificial disc was found to be
Not of benefit due to low quality evidence
Not Cochrane review PRISMA: 8 items missing AMSTAR:Medium/good
Level 3 (majority of studies were cohort studies)
There are no long-term studies to test the longevity of the prostheses evaluated in this study. Current evidence does not support routine use of surgery for the treatment of chronic low back pain
Chronic Pain Health Needs Assessment 203
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
statistically more effective compared to lumbar circumferential fusion, but risk of bias was high. Flexicore trial: high risk of bias, no clinical relevant There were no statistically significant difference in mean pain and physical function scores.differences on pain and physical function compared to circumferential spinal fusion at 2 year follow-up. No conclusions can be drawn from the study
204 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Asher (2010) (190) Auriculotherapy for pain management:a systematic review and meta-analysis of randomised controlled trials
17 studies (8 perioperative, 4 acute, and 5 chronic pain)
With Meta-analysis
All chronic pain and acute pain types
Auriculotherapy Sham, placebo, or standard care control
Pain reduction, medication use
17 studies met inclusion criteria (8 perioperative, 4 acute, and 5 chronic pain). Auriculotherapy was superior to controls for studies evaluating pain intensity (SMD, 1.56 [95% confidence interval (CI): 0.85, 2.26]; 8 studies). For perioperative pain, auriculotherapy reduced analgesic use (SMD, 0.54 [95% CI: 0.30, 0.77]; 5 studies). For acute pain and chronic pain, auriculotherapy reduced pain intensity (SMD for acute pain, 1.35 [95% CI:
Effective, but significant heterogeneity existed for acute and chronic pain groups analysed except for perioperative subgroup.
Not Cochrane review PRISMA: 1 item missing AMSTAR:Good
Level 1 Auriculotherapy may be effective for treatment of various pain types, further large, well-designed trials are required
Chronic Pain Health Needs Assessment 205
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
0.08, 2.64], 2 studies; SMD for chronic pain, 1.84 [95% CI: 0.60, 3.07], 5 studies)
Mirza (2007) (200) Systematic review of randomised trials comparing lumbar fusion to non-operative care for treatment of chronic back pain
5 RCTs, 4 of which focused on non-specific chronic back pain
Chronic back pain Lumbar fusion surgery
Non-operative care
Pain reduction VAS), disability
All trials enrolled similar subjects. One study suggested greater improvement in back-specific disability for fusion compared to unstructured nonoperative care at 2 years, but the trial did not report data according to intent-to-treat principles. Three trials suggested no substantial difference in disability scores at 1-year and 2-years when fusion
Moderately effective over non-surgical care
Not Cochrane review PRISMA:9 items missing AMSTAR:Medium
Level 1 Lumbar fusion may be more effective for treatment of chronic back pain than non-operative care Lumbar fusion may not be more effective than structured rehabilitation including CBT Methodological limitations of RCTs prevent firm conclusions about lumbar fusion
206 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
was compared to a 3-week cognitive behaviour treatment addressing fears about back injury. However, 2 of these trials were underpowered to identify clinically important differences. The third trial had high rates of cross-over (20% for each treatment) and loss to follow-up (20%)
Gibson (2008) (225) Surgical interventions for lumbar disc prolapse
40 RCTs and two Quasi-RCTs (5197 participants)
Without meta-analysis
Patients with lumbar prolapsed disc who have indications for surgical intervention
Discectomy, micro-discectomy, chemonucleolysis, automated percutaneous discectomy, nucleoplasty, and laser discectomy
Conservative treatment
Self-reported pain relief Resolution or improvement in pain Disability/QOL
Measures of objective physical impairement (spinal flexion, improvement in straight leg raise, alteration in muscle power, change in neurological
Of 40 RCTs, only 4 trials directly compared discectomy with conservative management, but was not conclusive. Other trials showed that discectomy produced better outcomes than chemonucleolysis
Some positive effect
Cochrane review PRISMA:6 items missing AMSTAR:Good/medium
Level 1 Further research is required, weak evidence, insufficient data to draw any conclusions about effectiveness of any of the surgical treatments
Chronic Pain Health Needs Assessment 207
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Return to work Rate of subsequent back surgery
signs) Adverse complications(early: damage to spinal cord, cauda equine, dural lining, nerve root or any combination, infection, vascular injury, allergic reaction to chymopapain, medical complications, death. Late: chronic pain, altered spinal biomechanics, instability or both, adhesive arachoiditis, nerve root dysfunction,
(which was better than placebo) Microdiscectomy gave broadly comparable results to standard discectomy Information on many trials was limited, but included recurrence of symptoms, need for additional surgery, and allergic reactions Many of the trials had design weaknesses that could lead to bias
investigated. Surgical discectomy should not be commissioned for routine use, but only in carefully selected patients with sciatica due to lumbar disc prolapse
208 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
myelocele recurrent disc prolapsed) Cost data
Chou (2009) (176) Surgery for low back pain
84 studies (4 RCTs 2 SRs)
With meta-analysis
Adults 18 years and over with low back pain of any duration, alone or with leg pain
Surgery Non-surgical interventions
Back specific function, generic health status, pain, work disability or patient satisfaction
Fusion versus non-surgical therapy/non-radicular low back pain with common degenerative changes: Swedish lumbar spine study (n=294) statistically significant results in favour of surgery for (i) ‘excellent’ or ‘good’ assessment by independent assessors; (ii) patient ratings (‘better’ or ‘much better’), (iii) pain (VAS score) and (iv) proportion returning
Effective, statistically significant
Not Cochrane review PRISMA: AMSTAR: medium
Level 1 Studies assessed as low and high quality, but potential biases in some studies including performance bias, and detection bias. High drop-out rates in MRC trial, and missing data. Trials for decompressive surgery were assessed as high quality but a high proportion of patients did
Chronic Pain Health Needs Assessment 209
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
to work MRC spine stabilisation trial (n=349) statistically significant improvements in ODI after 24 months but difference not considered clinically significant (NB this trial included 11% of patients with spondylolisthesis and 15% had non-fusion surgical treatment) Two smaller trials (n=60, n=64) found no significant differences on any main outcomes after one year (trend towards slightly improved outcomes with surgery in one
not adhere to treatment. Lack of long-term studies, so benefits not known. Fair evidence exists that is in favour of surgery over non-surgical treatment, but should only be commissioned for treatment in highly selected patients who fail all other treatments and with caution. Patients should be made aware of implications of surgery.
210 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
trial) In the latter three trials, non-surgical treatment consisted of intensive rehabilitation incorporating CBT; in the Swedish study the non-surgical treatment was less intensive and more heterogeneous. There were differences in inclusion criteria between trials One SR (Ibrahim 2008) pooled three of the above trials (one small trial not identified) and found the difference on the ODI to be (just) non-significant (trend towards favouring surgery). Other outcomes
Chronic Pain Health Needs Assessment 211
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
were not pooled. Artificial disc replacement versus fusion. Chronic non-radicular back pain with single level degenerative disc disease: 2 RCTs found that artificial disc was not inferior to anterior lumbar inter body fusion on a composite outcome of ‘clinical success’ at 24 months; no statistically significant differences in mean ODI, VAS, or rates of employment at 24 months. Another study found artificial disc to be superior to circumferential fusion on a
212 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
composite outcome of success after 24 months; no statistically significant differences in mean ODI, pain score or SF-36 scores. NB: trial was designed as a non-inferiority trial, but appears to have been analysed as a superiority trial Discectomy versus non-surgical therapy for radiculopathy with prolapsed lumbar disc: one RCT for open discectomy found that surgery was associated with lower likelihood of poor results (statistically significant) after one year, but not long term. A higher
Chronic Pain Health Needs Assessment 213
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
quality trial found no differences between treatments but there was very poor treatment adherence in on treatment analyses adjusted for confounders, surgery was found to be moderately superior (statistically significant at one to two years) NB, technique left at discretion of surgeons (open or microdiscectomy). Microdiscectomy: two trials found surgery to be moderately superior to non-surgical treatment at 6-8 weeks, but not long term (26 weeks). In
214 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
both trials around 40% of patients in control arms eventually underwent surgery, which could potentially affect results (reduce benefit of surgery) in an intention-to-treat analysis. A further two trials are identified that find surgery to be more effective than more conservative management, at least in the shorter term (up to 18 months in one trial). Decompressive surgery: laminectomy versus non-surgical therapy for symptomatic spinal stenosis (+/-
Chronic Pain Health Needs Assessment 215
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
degenerative spondylolisthesis): two trials found moderate benefits (ODI, pain, good result) in favour of surgery, mainly up to one year. Two larger trials found few differences between surgery and non-surgical therapies over two years, but almost half of patients did not adhere to treatment assignment. Decompressive surgery: interspinous spacer device versus non-surgical therapy for symptomatic spinal stenosis: Two trials found that an
216 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
interspinous spacer device was substantially superior to non-surgical treatment in terms of overall treatment success at two years. One trial found lower rates of subsequent laminectomy with the interspinous spacer device, the other found no difference in rates.
Chronic Pain Health Needs Assessment 217
Chronic pain health needs assessment 218
Summary of Findings: Guidelines
Citation
Low back pain. Early management of persistent non-specific low back pain. CG 88; 2009(156)
Guideline: Care pathway domain and topic
Treatment: Invasive procedures: Facet joint injections
PICOT summary
Pop: People aged 18 or older with symptoms of non-specific low back pain (LBP) which has not resolved within 6 weeks of initial onset, consultation or exacerbation up to a period of 12 months. Int: Facet joint injections of methylprednisolone acetate (isotonic saline). Comp: Usual care in general practice. Out: Pain scores; disability scores; psychological distress; safety; adverse events
Guideline evidence: Study design Searching and study selection Validity
Study designs: Systematic reviews and RCTs Searching: Comprehensive search strategy. Studies were selected which matched the inclusion/exclusion criteria. Validity: Each paper was assessed for quality and critically appraised using the Institute’s criteria for quality assessment.
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
Based on 1 RCT: After 1 month: none of the outcomes evaluating pain, functional status and back flexion differed statistically between the groups. At 6 months: more improvement, less pain (VAS score) and less physical disability in the treatment group 1-6 months: sustained improvement in 22% (active) v 10% (placebo), not stat. sig (p=0.19) Injections are of little value in treating Chronic LBP.
GRADE assessment
High
Did evidence justify recommendations
Yes
Comments
Summary of Findings: Guidelines
Citation
Percutaneous endoscopic laser lumbar discectomy. NICE IPG 300;2009 and Overview document(212,226).
Guideline: Care pathway domain and topic
Treatment: Invasive procedures: Surgery: Percutaneous endoscopic laser lumbar discectomy
PICOT summary
Pop: Symptomatic lumbar disc prolapse Int: Percutaneous endoscopic laser lumbar discectomy Comps: Usual care Out: Success rates (MacNab score); pain; mobility
Guideline evidence:
Chronic Pain Health Needs Assessment 219
Study design Searching and study selection Validity
Study designs: Case series Searching: Comprehensive search strategy Validity: Validity is commented on but no method stated.
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
Efficacy 3 case series a) (n=300). Return to work and increased mobility in 67%, reduced pain medication in 32% (those with central prolapsed, n=279) b) (n=67). VAS leg pain and score on Oswestry Disability Index improved at 18 months (significantly for ODI); 88% with good or excellent results at final follow-up. c) (n=43). 81% of patients with good or excellent outcome (MacNab criteria) Safety a) Reoperation in 2%, psoas haematoma in <1% and sympathetic medicated pain in 5% b) 3% conversion to open procedure, 1% repeat surgery, 1% recurrent herniations, 3% injured thecal sac, 13% transient dysaesthesia in the leg c) Transient dysaesthesia in 5%, 1 patient with further surgery Comments a) outcome measures not well described b) Loss to follow-up not described, no objective outcome measures c) Consecutive sample, radiologist blinded to study Guideline: Current evidence on the safety and efficacy of percutaneous endoscopic
laser lumbar discectomy is inadequate in quantity and quality. Therefore this procedure should only be used with special arrangements for clinical governance, consent, and audit or research
GRADE assessment
Low
Did evidence justify recommendations
Yes
Summary of Findings: Guidelines
Citation
Percutaneous intradiscal laser ablation in the lumbar spine. NICE IPG 357; 2010 and Overview document(213,227).
Guideline: Care pathway domain and topic
Treatment: Invasive procedures: Surgery
PICOT summary
Pop: Lumbar disc herniation Int: Percutaneous intradiscal laser ablation Comps: Microdiscectomy; automated percutaneous lumbar discectomy Out: Success rates (MacNab criteria); pain score
Guideline evidence: Study design Searching and study
Study designs: Case series; non-randomised comparative study Searching: Comprehensive search strategy Validity: Validity is commented on but no method stated.
220 Chronic Pain Health Needs Assessment
selection Validity
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
Laser disc decompression only:
a) One case series (n=518) reported a success rate (based on McNab criteria) of 75%; absolute figures and follow-up not stated. b) One case series (n=576) reported that 61% of patients were satisfied with the outcome of the procedure; absolute figures and follow-up not stated. c) Case series (n=182), safety outcomes only reported d) Case-series (n=10), found no effect on low back pain or sciatica Safety a) 2 patients with aseptic discitis, 2 with septic discitis and 1 patient with a retro-oesophageal abscess b) 4 patients with aseptic discitis c) 4 patients with subchondral osteonecrosis d) leg sensory disturbance and/or muscle weakness in 3 patients Comments a) Results only for 350/518 patients (68%). Unclear when outcome was assessed. b) 67% at last follow-up c) Unclear completeness of follow-up; retrospective safety study d) Retrospective safety study, 100% follow-up Laser disc decompression versus microdiscectomy: Non-randomised comparative study (n=1000) reported similar rates of ‘excellent or good’ MacNab criteria scores in both groups. Safety Appear to be slightly more neurological symptoms, higher reoperation rates and other adverse events in the microdiscectomy group. Comments 100% follow-up. Unclear if retrospective. Laser disc decompression versus automated percutaneous lumbar discectomy Non-randomised comparative study (n=106). No significant differences between success rates (defined as excellent, good, passable or poor) between the groups. Safety 1 patient with infection of intervertebral disc (automated group). Comments No significant differences in study populations in the two groups. 100% follow-up, but timing unclear. Unclear if retrospective. Laser disc decompression using Nd:Yag laser (case series) Laser disc decompression using KTP laser versus automated percutaneous lumbar discectomy Non-randomised comparative study and case series (n=81).Relatively high failure rates (25% and 26%) in KTP laser and automated group meant that these techniques were abandoned early in the initial study (failure=daily back pain or daily use of analgesics). Safety 2 patients with aseptic discitis requiring hospitalisation in laser disc decompression using Nd:Yag group Comments 100% follow-up in both studies. No description of allocation of patients in comparative study Guideline: Current evidence on the safety and efficacy of percutaneous intradiscal laser
ablation in the lumbar spine is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit. Patients selected for the procedure should be limited to those with severe pain refractory to conservative treatment, in whom imaging studies have shown bulging of an intact disc, and who do not have neurological deficit requiring surgical decompression.”
GRADE assessment
Low
Chronic Pain Health Needs Assessment 221
Did evidence justify recommendations
Yes
Chronic pain health needs assessment 222
Appendix 7 Link to main document
Summary of findings: Multidisciplinary interventions
Summary of findings: systematic reviews
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention
Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
Scascighini (2008) (217) Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes
27 RCTs Without meta-analysis
Adults with chronic non-specific musculoskeletal pain for example low back pain or back pain and fibromyalgia
Multidisciplinary treatments
No treatment, standard medical treatment
Pain intensity, QoL, disability, coping, physical capacity, sick leave, drug intake, pain behaviour, use of health care professionals
Inclusion of many studies with diverse interventions meant that meta-analysis was not possible. The quality of included studies varied with only 6 studies being rated as high Evidence was strong for MDI being more effective than control group treatment in 15 studies, 5 studies showed no difference 3 studies that compared in-patient vs out-patient
Multidisciplinary pain management programmes offer safe and effective option for many chronic pain conditions Unclear as to which of the components of MDI are responsible for benefit
Not Cochrane review PRISMA: 9 items missing AMSTAR: Good
Level 1 Multi-disciplinary pain management programmes should be commissioned
Chronic Pain Health Needs Assessment 223
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention
Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
treatment found moderate evidence for better long term outcomes with intensive in-patient MDI
Minimum standard for MDI comprises specific individual exercising, regular training in relaxation techniques, group therapy led by a clinical psychologist, patient education sessions, physiotherapy training sessions and clinician delivered
224 Chronic Pain Health Needs Assessment
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention
Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
information about pain physiology
Van Geen (2007) (218) The long-term effect of multidisciplinary back training: a systematic review
8 RCTs, included; total of 1958 participants
Without meta-analysis
Adults with back pain or chronic low back pain for at least 6 months
Multidisciplinary back training
Standard treatment?
Work participation, experienced pain, functional status, QOL
One high quality study found effectiveness for low intensive multidisciplinary treatment compared to control, but not for intensive multidisciplinary treatment The other (low quality) studies found no effectiveness compared to controls 3 high quality RCTs found effectiveness for some outcome measures (but not all) for intensive compared to non-intensive programmes
4/8 RCTs described as low quality
Cochrane review PRISMA:8 items missing AMSTAR: Good
Level 1 Multidisciplinary back training has a positive impact on work participation of people with CLBP. The evidence for a positive effect on quality of life is limited. Intensity of treatment is not associated with treatment effectiveness Further research should be carried out with clearer definitions of
Chronic Pain Health Needs Assessment 225
Citation Year Title, Authors
Number and type of primary studies Included Excluded
With or without meta-analysis
Population Intervention
Comparator Outcome measures Primary
Outcome measures Secondary
Findings Summary Finding Effective, statistically significant Indeterminate or of limited effect Likely to be ineffective or potentially harmful
Quality ?Cochrane review PRISMA – items not reported Critical Appraisal - bias, heterogeneity, size of effect estimate and precision, generalizability
OCEBM level
Comments
chronic low back pain, intensity of treatment and multidisciplinary back training
Chronic pain health needs assessment 226
Summary of Findings: Guidelines
Citation
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P et al. Diagnosis and treatment of low back pain: a joint clinical practice guidelines from the American College of Physicians and the American Pain Society. Ann Int Med 2007; 147: 478-491.
Guideline: Care pathway domain and topic
Treatment: Multi-disciplinary pain programmes
PICOT summary
Pop: Adults with acute and chronic LBP not associated with major trauma Int: Multi disciplinary pain programmes Comp: Usual care, normal activities, exercise therapy, Out: Pain
Guideline evidence: Study design Searching and study selection Validity
Study designs: Systematic reviews and RCTs Searching: Comprehensive search strategy. Studies were selected which matched the
inclusion/exclusion criteria. Validity: Each paper was assessed for quality and critically appraised.
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
Interdisciplinary rehabilitation more effective than usual care for sub-acute back pain (a) Intensive (>100 hours), daily interdisciplinary rehabilitation moderately superior to non-interdisciplinary rehabilitation or usual care for short-and long-term functional status, and for pain outcomes (at 3-4 months in two trials). Long-term pain and return to work outcomes inconsistent. (b) Less intensive interdisciplinary rehabilitation was no better than non-interdisciplinary rehabilitation or usual care Functional restoration with a CBT component was more effective than usual care, normal activities or standard exercise therapy for reducing time lost from work. Little evidence that functional restoration without a CBT component is effective.
GRADE assessment
High
Did evidence justify recommendations
Yes
Comments
Chronic Pain Health Needs Assessment 227
Summary of Findings: Guidelines
Citation
Low back pain. Early management of persistent non-specific low back pain. CG 88; 2009(156)
Guideline: Care pathway domain and topic
Treatment: Multi-disciplinary pain programmes
PICOT summary
Pop: People aged 18 or older with symptoms of non-specific low back pain (LBP) which has not resolved within 6weeks of initial onset, consultation or exacerbation up to a period of 12 months. Int: Multi disciplinary pain management programmes (education, back school, exercises, plus a psychological component such as CBT, coping skills, problem solving training). Comp: Usual care in general practice, physiotherapy, spinal stabilisation. Out: Pain
Guideline evidence: Study design Searching and study selection Validity
Study designs: RCTs Searching: Comprehensive search strategy. Studies were selected which matched the inclusion/exclusion criteria. Validity: Each paper was assessed for quality and critically appraised using the Institute’s criteria for quality assessment.
Guideline evidence: Outcomes: Benefits Harms Cost effectiveness
Low intensity programme Pain management programme (education, group exercises, CBT, 8 sessions of 90 minutes) versus individual physiotherapy (up to 12 sessions of 30 minutes) versus spinal stabilisation (specific muscle training and group exercise, up to 8 sessions of 90 minutes) All groups had improved on the Roland Morris Disability Questionnaire (RMDQ) at 18 months (not stated if significantly). No significant difference between groups at 18 months. Attrition rate between 17% and 32%. Comments Although also shown to be cost-effective, NICE did not make a recommendation for low intensity combined physical and psychological interventions due to the high attrition rate and the fact that there was no significant difference between groups. Low intensity programme (women only) Back school + usual care (a four day, five session programme, education, coping skills and exercises) versus usual care (medication with paracetamol, NSAIDs or chlordiazepoxide) Statistically significant difference on SF-36 in favour of back school, but results or p-values not presented. High intensity programme (at least one full day of five sessions a wk over at least 3 wks. Functional restoration programmes compared to other interventions/usual care (3 RCTs) or compared to physical training (1 RCT) Three of four RCTs found significant improvements in pain/disability for patients in the FR group compared to less intensive interventions. Follow-up was up to 5 years in one RCT (statistically significant difference in function but not pain at 5 years; difference in function and pain significant at 1 and 2 years). Format of interventions varied widely, but best evidence was considered to be that for programmes of >100 hours of exposure. High intensity programme Multidisciplinary programmes versus physiotherapy or no treatment. No significant differences in pain disability or depression (low risk of bias RCT); significantly better pain and function scores with the multidisciplinary approach in one study; one study did
228 Chronic Pain Health Needs Assessment
not conduct statistical analyses. High intensity programme Exercise and motivational programme versus exercise only. Pain and function statistically significantly improved in intervention group only at 12 months (pain only at 5 years)-NB unclear whether between group difference was statistically significant. High intensity programme Combination of physical training, graded activity and problem solving versus individual treatments No significant differences between groups at 12 months. Guideline: Consider referral for a combined physical and psychological treatment programme, comprising around 100 hours over a maximum of 8 weeks, for people who have received at least one less intensive treatment and have high disability and/or significant psychological distress. Combined physical and psychological treatment programmes should include a cognitive behavioural approach and exercise
GRADE assessment
High
Did evidence justify recommendations
Yes
Chronic pain health needs assessment 229
References
1. Department of Health. Services for patients with pain: Report of a CSAG committee chaired by Professor Alastair Spence [online]. 2003 [cited 2012 Sept. 14]. Available from URL:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007468 .
2. Donaldson L. Pain: Breaking through the barrier. In 150 Years of the Annual Report of the Chief Medical Officer. London: Department of Health; 2008 p.32-39.
3. Anon. Adult Chronic Pain Management Services in Primary care. Research project by Dr Foster [online]. 2004 [cited 2012 July 9]. Available from URL:http://www.drfoster.co.uk/images/pain%20report%20final.pdf.
4. Price C. National Pain Audit. Phase I report: Oragnisational Audit of NHS Chronic Pain Services. [online]. 2011 [cited 2012 July 9]. Available from URL:http://www.hqip.org.uk/assets/NCAPOP-Library/Pain-Audit-Phase-1-National-Report-2011.pdf.
5. Croft P, Blyth FM, van der Windt D. The global occurrence of chronic pain: an introduction. In Croft, P., Blyth, F. M., and van der Windt, D., editors. Chronic pain epidemiology: from aetiology to public health. New York: Oxford University Press; 2010 p.9-18.
6. Tracey I, Bushnell MC. How neuroimaging studies have challenged us to rethink: Is chronic pain a disease? Journal of Pain 2009; 10: 1113-1120.
7. May A. Structural brain imaging: a window into chronic pain. The Neuroscientist 2011; 17: 209-220.
8. International Association for the Study of Chronic Pain. Editorial - The need of a taxonomy. Pain 1979; 6: 247-252.
9. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. report of the Multicenter Criteria Committee. Arthritis and Rheumatology 1990; 33: 160-172.
10. Hunt I, Silman A, Benjamin S, McBeth J, Macfarlane G. The prevalence and associated features of chronic widespread pain in the community using the 'Manchester' definition of chronic widespread pain. Rheumatology (Oxford) 1999; 38: 275-279.
11. McQuay HJ, Smith LA, Moore RA. Chronic Pain. In Health Care Needs Assessment Series 3. Birmingham: University of Birmingham; 2007 p.519-600.
12. Baron R. Mechanisms of disease: neuropathic pain: a clinical 2 perspective. Nat Clin Pract Neurol 2006; 2: 95-106.
13. Freynhagen R, Bennet MI. Diagnosis and management of neuropathic pain. BMJ 2009; 339: 391-395.
14. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well being: A World Health Organization Study in Primary Care. JAMA 1998; 280: 147-152.
230 Chronic Pain Health Needs Assessment
15. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J.Pain 2006; 10: 287-333.
16. Fox PL, Raina P, Jadad AR. Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review. CMAJ 1999; 160: 329-333.
17. Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: studies in differences in age, gender, social class, and pain localization. Clin J.Pain 1993; 9: 174-182.
18. Brattberg G, Thorslund M, Wikman A. The prevalence of pain in a general population. The results of a postal survey in a county of Sweden. Pain 1989; 37: 215-222.
19. Birse TM, Lander J. Prevalence of chronic pain. Can J Public Health 1998; 89: 129-131.
20. Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: a telephone survey of 1037 households. Pain Clin 1991; 4: 223-230.
21. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999; 354: 1248-1252.
22. Parsons, S., Ingram, M., Clarke-Cornwell, A. M., and Symmons, D. P. M. A Heavy burden - the occurrence and impact of musculoskeletal conditions in the United Kingdom today.2011,1-39
23. Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998; 57: 649-655.
24. Office for National Statistics General Household Survey 2007 Report - Table 7.14 Chronic sickness: rate per 1000 reporting selected longstanding conditions, by sex and age.2009,
25. Department of Health Back Pain: Report of a Clinical Standards Advisory Group Committee on back pain.1994,
26. Macfarlane GJ, Jones GT, Hannaford PC. Managing low back pain presenting to primary care: where do we go from here? Pain 2006; 122: 219-222.
27. Croft P, Papageorgious A, McNally R. Low Back Pain. In Stevens, A and Raftery, J., editors. Health Care needs assessment. The epidemiology based needs assessment reviews. Oxford: Radcliffe Medical Press; 1997
28. Walsh K, Cruddas M, Coggon D. Low back pain in eight areas of Britain. J.Epidemiol Community Health 1992; 46: 227-230.
29. Mason, V. and Office of Population Censuses and Surveys, Social Survey Division The prevalence of back pain in Great Britain.1994,1-2http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_4079573
30. Webb R, Brammah T, Lunt M, et al. Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine 2003; 28: 1195-1202.
Chronic Pain Health Needs Assessment 231
31. Hillman M, Wright A, Rajaratnam G, Tennant A, Chamberlain MA. Prevalence of low back pain in the community: implications for service provision in Bradford, UK. J Epidemiol Community Health 1996; 50: 347-352.
32. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4 European Guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 1996; 15: S192-S300.
33. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000; 13: 205-217.
34. Biering-Sorensen F. Low back trouble in a general population of 30-, 40-, 50-, and 60-year-old men and women. Study design, representativeness and basic results. Dan Med Bull 1982; 29: 289-299.
35. Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low back pain and its related medical care in the united states. Spine 1987; 12: 264-268.
36. Heliovaara M, Impivaara O, Sievers K, et al. Lumbar disc syndrome in Finland. J Epidemiol Community Health 1987; 41: 251-258.
37. Svensson HOea. A retrospective study of low back pain in women. Spine 1988; 13: 548-552.
38. Cassidy JD, Carroll LI, Cote P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine 1998; 23: 1860-1866.
39. Papageorgiou AC, Croft PR, Thomas E, et al. Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study. Pain 1996; 66: 181-185.
40. Freynhagen R, Baron R, Gockel U, Tolle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22: 1911-1920.
41. Carbone LD, Cooper C, Michet CJ, et al. Ankylosing spondylitis in Rochester, Minnesota, 1935-1989. Is the epidemiology changing? Arthritis Rheum 1992; 35: 1476-1482.
42. Bakland G, Nossent HC, Gran JT. Incidence and prevalence of ankylosing spondylitis in Northern Norway. Arthritis Rheum 2005; 53: 850-855.
43. Gran JT, Husby G, Hordvik M. Prevalence of ankylosing spondylitis in males and females in a young middle-aged population of Tromsø, northern Norway. Ann Rheum Dis 1985; 44: 359-367.
44. Braun J, Bollow M, Remlinger G, et al. Prevalence of spondylarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum 1998; 41: 58-67.
45. Calin A, Fries JF. Striking prevalence of ankylosing spondylitis in "healthy" w27 positive males and females. N Engl J Med 1975; 293: 835-839.
46. McCormick, A., Fleming, D., and Charlton, J. Morbidity statistics from general practice: fourth national study 1991-1992.1995,
232 Chronic Pain Health Needs Assessment
47. Association of British Insurers. Press Release Ref 32/12 - The UK's pain in the neck culture must end says the ABI. [online]. 2012 [cited 2012 Oct. 29]. Available from URL:
48. Galasko CSB, Murray P, Stephenson W. Incidence of whiplash-associated disorder. BCMJ 2002; 44: 237-240.
49. Crouch R, Whitewick R, Clancy M, Wright P, Thomas P. Whiplash associated disorder: incidence and natural history over the first month for patients presenting to a UK emergency department. Emerg Med J 2006; 23: 114-118.
50. Galasko CSB, Murray PM, Pitcher M. Neck sprains after road traffic accidents: a modern epidemic. Injury 1993; 24: 155-157.
51. Suri P, Morgenroth DC, Hunter DJ. Epidemiology of Osteoarthritis and Associated Comorbidities. PM R 2012; 4: S10-S19.
52. Kopec JA, Rahman MM, Berthelot C, et al. Descriptive epidemiology of osteoarthritis in British Columbia, Canada. J Rheumatol 2007; 34: 386-393.
53. Lawrence JS. Prevalence of Rheumatoid Arthritis. Ann Rheum Dis 1961; 20: 11-17.
54. Wiles N, Symmons DP, Harrison B, et al. Estimating the incidence of rheumatoid arthritis: trying to hit a moving target? Arthritis Rheum 1999; 42: 1339-1346.
55. Symmons D, Turner G, Webb R, et al. The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Rheumatology 2002; 41: 793-800.
56. Harrison BJ, Silman AJ, Barrett EM, Scott DG, Symmons DP. Presence of psoriasis does not influence the presentation or short-term outcome of patients with early inflammatory polyarthritis. J Rheumatol 1997; 41: 1744-1749.
57. Wilson FC, Icen M, Crowson CS, et al. Time trends in epidemiology and characteristics of psoriatic arthritis over 3 decades: a population-based study. J Rheumatol 2009; 36: 361-367.
58. Cimmino MA. Epidemiology of Psoriasis and Psoriatic Arthritis. Reumatismo 2007; 59: 19-24.
59. Wilson FC, Icen M, Crowson CS, et al. Time trends in epidemiology and characteristics of psoriatic arthritis over 3 decades: a population-based study. J Rheumatol 2009; 36: 361-367.
60. Michet CJ, Matteson EL. Polymyalgia rheumatica. BMJ 2008; 336: 765-769.
61. Clauw DJ, Crofford LJ. Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Pract Res Clin Rheumatol 2003; 17: 685-701.
62. Gallagher AM, Thomas JM, Hamilton WT, White PD. Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001. J R Soc Med 2004; 97: 571-575.
Chronic Pain Health Needs Assessment 233
63. Gallagher AM, Thomas JM, Hamilton WT, White PD. Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001. J R Soc Med 2004; 97: 571-575.
64. Peat G, Thomas E, Handy J, et al. The Knee Clinical Assessment Study-CAS(K). A prospective study of knee pain and knee osteoarthritis in the general population:baseline recuitment and retention at 18 months. BMC Musculoskeletal Disorders 2006; 7: 30-30.
65. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2001; 60: 91-97.
66. Verhaak PF, Meijer SA, Visser AP, Wolters G. Persistent presentation of medically unexplained symptoms in general practice. Fam Pract 2006; 23: 414-420.
67. Kerssens JJ, Verhaak PF, Bartelds AI, Sorbi MJ, Bensing JM. Unexplained severe chronic pain in general practice. Eur J Pain 2002; 6: 203-212.
68. Scher AI, Stewart WF, Lipton RB. Migraine and headache: A meta-analytic approach. In Crombie, I. K., editors. Epidemiology of pain. Seattle: IASP Press; 1-1-1999 p.159-170.
69. Hu XH, Markson LE, Lipton RB. Burden of migraine in the United States. Arch Intern Med 1999; 159: 813-818.
70. Torelli P, Castellini P, D.C.Morgenroth, et al. Cluster headache prevalence: methodological considerations. A review of literature. Acta Biomed 2006; 77: 4-9.
71. Katusic S, Beard CM, Bergstralh E, Kurland LT. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol 1990; 27: 89-95.
72. Brewis M, Posanzer DC, Rolland C, Miller H. Neurological disease in an English city. Acta Neurologica Scandinavica 1966; 42: 1-89.
73. Torrance N, Smith BH, Bennett MI, Lee AJ. The epidemiology of chronic pain of predominantly neuropathic origin. Results from a general population study. The Journal of Pain 2006; 7: 281-289.
74. Bouhassira D, Lanteri-Minet M, Attal N, Laurent B, Touboul C. Prevalence of chronic pain with neuropathic chracteristics in the general population. Pain 2008; 136: 380-387.
75. McDermott AM, Toelle TR, Rowbotham DJ, Schaefer CP, Dukes EM. The burden of neuropathic pain: results from a cross-sectional survey. European Journal of Pain 2006; 10: 127
76. Dieleman JP, Kerklaan J, Huygen FJPM, Bouma PAD, Sturkenboom MCJM. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain 2008; 137: 681-688.
77. Abbott CA, Malik RA, van Ross ERE, Kulkarni J, Boulton AJM. Prevalence and characteristics of painful diabetic neuropathy in a large community-based diabetic population in the U.K. Diabetes Care 2011; 34: 2220-2224.
234 Chronic Pain Health Needs Assessment
78. Jensen TS, Backonja MM, Jiménez SH, et al. New perspectives on the management of diabetic peripheral neuropathic pain. Diabetes and Vascular Disease Research 2006; 3: 108-119.
79. Ziegler D. Painful diabetic neuropathy: treatment and future aspects. Diabetes/Metabolism Research and Reviews 2008; 24: S52-S57.
80. Davies M, Brophy S, Williams R, Taylor A. The prevalence, severity, and impact of painful diabetic peripheral neuropathy in type 2 diabetes. Diabetes Care 2006; 29: 1518-1522.
81. NHS Information Centre for health and social care Disease prevalence-Quality and Outcomes Framework (QOF) for April 2010-March 2011, England.2011,http://www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2010-11/qof-2010-11-data-tables/qof-prevalence-data-tables-2010-11
82. Hall GC, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain:the UK primary care perspective. Pain 2006; 122: 156-162.
83. Hall GC, Carroll D, McQuay HJ. Primary care incidence and treatment of four neuropathic pain conditions: a descriptive study, 2002-2005. BMC Family Practice 2008; 9: 1-9.
84. Smith BH, Torrance N. Neuropathic pain. In Croft, P., Blyth, F. M., and Van der Windt, D., editors. Chronic pain epidemiology-from aetiology to public health.Oxford University Press; 9-8-2010 p.219-376.
85. Choo PW, Galil K, Donahue JG, et al. Risk factors for postherpetic neuralgia. Archives of Internal Medicine 1997; 157: 1217-1224.
86. Hall GC, Carroll D, McQuay HJ. Primary care incidence and treatment of four neuropathic pain conditions: a descriptive study, 2002-2005. BMC Family Practice 2008; 9: 1-9.
87. Hall GC, Carroll D, Parry D, McQuay HJ. Epidemiology and treatment of neuropathic pain:the UK primary care perspective. Pain 2006; 122: 156-162.
88. Cockerel OC, Goodridge DMG, Brodie D, Sander JWAS, Shorvon SD. Neurological disease in a defined population: the results of a pilot study in two practices. Neuroepidemiology 2012; 15: 73-82.
89. Alonso A, Susan SJ, Olek MJ, Hernán MA. Incidence of multiple sclerosis in the United Kingdom: findings from a population-based cohort. Journal of Neurology 2007; 254: 1736-1741.
90. Richards RG, Sampson FC, Beard SM, Tappenden P. A review of the natural history and
epidemiology of multiple sclerosis: implications for resource allocation and health economic
models. Health Technology Assessment 2002; 6: 1-79.
91. Rothwell PM, Coull AJ, Silver LE, et al. Population-based study of event-rate, incidence, case fatality, and mortality for all acute vascular events in all arterial territories (Oxford Vascular Study). The Lancet 2005; 366: 1773-1783.
Chronic Pain Health Needs Assessment 235
92. Hippsley-Cox, L., Pringle, M., and Ryan, R. Stroke, prevalence, incidence and care in general practices 2002 to 2004. Final report to the National Stroke Audit Team, Royal College of Physicians.2004,
93. Lee S, Shafe ACE, Cowie MR. UK stroke incidence, mortality and cardiovascular risk management 1999-2008: time-trend analysis from the General Practice Research Database. BMJ Open 2011; 2: 1-8.
94. Scarborough, P., Bhatnagar, P., Wickramasinghe, K, Smolina, K, Mitchell, C, and Rayner, M Coronary heart disease statistics 2010.2010,42-57http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001546
95. ERPHO Modelled estimate of prevalence of stroke in England.6Dec2011,http://www.apho.org.uk/resource/item.aspx?RID=111124
96. Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain 2003; 103: 199-207.
97. de Mos M, Brujin AGJ, Huygen FJPM, Dieleman JP, ricker MCJM. The incidence of complex regional pain syndrome: a population-based study. Pain 2007; 129: 12-20.
98. Fowkes FGR, Housley E, Cawood EHH, et al. Edinburgh artery study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. International Journal of Epidemiology 1991; 20: 384-392.
99. Meijer WT, Hoes AW, Rutgers D, et al. Peripheral arterial disease in the elderly: the Rotterdam study. Journal of the American Heart Association 1998; 18: 185-192.
100. Meijer WT, Cost B, Bernsen RM, Hoes AW. Incidence and management of intermittent claudication in primay care in The Netherlands. Scandinavian Journal of Primary Health Care 2002; 20: 33-34.
101. Murabito J, Evans J, D'Agostino RS, Wilson P, Kannel W. Temporal trends in the incidence of intermittent claudication from 1950 to 1999. American Journal of Epidemiology 2005; 162: 430-437.
102. Suter L, Murabito J, Felson D, Fraenkel L. The incidence and natural history of Raynaud's phenomenon in the community. Arthritis and Rheumatism 2005; 52: 1259-1263.
103. Joint Health Surveys Unit Health Survey for England 2006 Volume 1 - Cardiovascular disease and risk factors in adults.31Jan2008,http://www.ic.nhs.uk/webfiles/publications/HSE06/HSE%2006%20report%20VOL%201%20v2.pdf
104. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet 2006; 367: 13-19.
105. Macrae WA. Chronic post-surgical pain:10 years on. British Journal of Anaesthesia 2008; 101: 77-86.
106. Hall GC, Carroll D, McQuay HJ. Primary care incidence and treatment of four neuropathic pain conditions: a descriptive study, 2002-2005. BMC Family Practice 2008; 9: 1-9.
236 Chronic Pain Health Needs Assessment
107. Jung BF, Ahrendt GM, Oaklander AL. Neuropathic pain following breast cancer surgery: proposed classification and research update. Pain 2003; 104: 1-13.
108. Baron RH, Fey JV, Borgen PI, et al. Eighteen sensations after breast cancer surgery: A 5-year comparison of sentinel lymph node biopsy and axillary lymph node dissection. Annals of Surgical Oncology 2007; 14: 1653-1661.
109. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet 2006; 367: 13-19.
110. Stiff G, Rhodes M, Kelly A, et al. Long-term pain: less common after laparoscopic than open cholecystectomy. British Journal of Surgery 1994; 81: 1368-1370.
111. Wilson RG, Macintyre IM. Symptomatic outcome after laparoscopic cholecystectomy. British Journal of Surgery 1993; 80: 439-441.
112. Poobalan AS, Bruce J, King PM, et al. Chronic pain and quality of life following open inguinal hernia repair. British Journal of Surgery 2001; 88: 1122-1126.
113. Aasvang E, Kehlet H. Chronic postoperative pain: the case of inguinal herniorrhaphy. British Journal of Anaesthesia 2005; 95: 69-76.
114. Remérand F, le Tendre C, Baud A, et al. The early and delayed analgesic effects of ketamine after total hip arthroplasty: a prospective, randomized, controlled, double-blind study . Anesthesia and analgesia 2009; 109: 1963-1971.
115. Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H. Chronic pain following total hip arthroplasty: a nationwide questionnaire study. Acta Anaesthesiologica Scandinavica 2005; 50: 495-500.
116. Puolakka PA, Rorarius MG, Roviola M, et al. Persisten pain following knee arthroplasty. European Journal of Anaesthesiology 2010; 27: 455-460.
117. Belze O, Remerand F, Laulen J, et al. Chronic pain after carpal tunnel surgery: Epidemiology and associated factors. Annales Françaises d'Anesthésie et de Réanimation 2012; S0750-7658
118. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet 2006; 367: 13-19.
119. NHS Quality Improvement Scotland Management of chronic pain in adults.Feb2006,
120. Macrae WA. Chronic post-surgical pain:10 years on. British Journal of Anaesthesia 2008; 101: 77-86.
121. Remérand F, le Tendre C, Baud A, et al. The early and delayed analgesic effects of ketamine after total hip arthroplasty: a prospective, randomized, controlled, double-blind study . Anesthesia and analgesia 2009; 109: 1963-1971.
122. Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H. Chronic pain following total hip arthroplasty: a nationwide questionnaire study. Acta Anaesthesiologica Scandinavica 2005; 50: 495-500.
Chronic Pain Health Needs Assessment 237
123. Puolakka PA, Rorarius MG, Roviola M, et al. Persisten pain following knee arthroplasty. European Journal of Anaesthesiology 2010; 27: 455-460.
124. NHS Information Centre for health and social care Hospital episode statistics for England. Inpatient statistics, 2011-12. Main procedures and interventions:summary.2012,http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=204
125. NHS Information Centre for health and social care Hospital episode statistics for England. Inpatient statistics, 2011-12. Main procedures and interventions:3 character.2012,http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=204
126. Elliott AM, Smith BH, Hannford PC, Smith WC, Chambers WA. The course of chronic pain in the community:results of a 4-year follow-up study. Pain 2002; 99: 299-307.
127. Elliott AM, Smith BH, Penny KI, Cairns Smith W, Chan HN. The epidemiology of chronic pain in the community. Lancet 1999; 354: 1248-1252.
128. Papageorgiou C, Silman AJ, Macfarlane GJ. Chronic widespread pain in the population: a seven year follow up study. Ann Rheum Dis 2002; 61: 1071-1074.
129. Phillips C, Main C, Buck R, et al. Prioritising pain in policy making: the need for a whole systems perspecttive. Health Policy 2008; 88: 166-175.
130. Black C and Frost D. Health at work - an independent review of sickness absence [online]. 2011 [cited 2012 July 9]. Available from URL:http://www.dwp.gov.uk/docs/health-at-work.pdf.
131. Department of Health NHS Manual for Accounts 2011-12 Programme Budgeting guidance for PCTs version 1.0.2012,http://www.dh.gov.uk/health/2012/09/programme-budgeting-guidance/
132. Department of Health Programme-Budgeting-Mappings-Definitions.xls.2012,http://www.dh.gov.uk/health/2012/08/programme-budgeting-methodology/
133. Department of Health NHS Payment by Results 2010-11 National Tariff Information.2012,http://data.gov.uk/dataset/payment-by-results-2010-11-national-tariff-information
134. Department of Health 2010-11 Programme budgeting PCT benchmarking tool.2012,http://www.dh.gov.uk/health/2012/08/programme-budgeting-data/
135. Audit Commission By definition. Improving data definitions and their use by the NHS. A briefing from the Payment by Results data assurance programme.2012,http://www.audit-commission.gov.uk/health/paymentbyresults/Pages/datadefinitions.aspx
136. NHS Information Centre for health and social care Pain Management HRGs.2011,http://www.ic.nhs.uk/webfiles/Services/casemix/Pain_Management_HRGs_v1.1.pdf
238 Chronic Pain Health Needs Assessment
137. Wilson EB. Probable inference, the law of succession, and statistical inference. J Am Stat Assoc 1927; 22: 209-212.
138. Breslow,NE and Day,NE Statistical methods in cancer research, Volume II: The design and analysis of cohort studies.Lyon: IARC, WHO; 1987
139. Flowers, J. APHO technical Briefing 2 - Statistical process control methods in public health intelligence.2007,
140. Chronic Pain Policy Coalition. Putting Pain on the Agenda. The Report of the first English Pain Summit. [online]. 2011 [cited 2012 Nov. 10]. Available from URL:http://www.painsummit.org.uk/.
141. British Pain Society and Map of Medicine Initial assessment and early management of pain. International View.2012,
142. Map of Medicine and British Pain Society Spinal Pain. International View.2012,
143. Faculty of Pain Medicine. The Good Pain Medicine Specialist. Standards for revalidation of specialists in pain medicine. [online]. 2012 [cited 2012 Nov. 16]. Available from URL:http://www.rcoa.ac.uk/document-store/the-good-pain-medicine-specialist.
144. Royal College of Anaesthetists. Guidance on the provision of Chronic Pain Management Services. In Guidelines for the provision of Anaesthetic Services.1-7-2011
145. Vickers A and Grady K. Pain Medicine [online]. 2012 [cited 2012 Nov. 16]. Available from URL:https://www.google.com/url?q=http://www.rcoa.ac.uk/ARB2012&sa=U&ei=YEKmUP7AOs2ShgeB2oDwBg&ved=0CAgQFjAA&client=internal-uds-cse&usg=AFQjCNEai-U4Cuuo2OOSLjaXCr3ezHIkDw.
146. International Association for the Study of Pain. Desirable Characteristics of National Pain Strategies [online]. 2011 [cited 2012 Nov. 2]. Available from URL:http://www.iasp-pain.org/PainSummit/DesirableCharacteristics_Nov2011.pdf.
147. International Association for the Study of Pain. Recommendations for Pain Treatment Services [online]. 2009http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Treatment_Facilities&Template=/CM/HTMLDisplay.cfm&ContentID=9218.
148. International Association for the Study of Pain. Desirable Characteristics for Pain Treatment Facilities [online]. 1990 [cited 2012 Nov. 2]. Available from URL:http://www.iasp-pain.org/AM/Template.cfm?Section=Home&Template=/CM/HTMLDisplay.cfm&ContentID=3011.
149. International Association for the Study of Pain. Classification of Chronic Pain [online]. 2011 [cited 2012 Nov. 2]. Available from URL:http://www.iasp-pain.org/Content/NavigationMenu/Publications/FreeBooks/Classification_of_Chronic_Pain/default.htm.
150. The Patient Association. Public Attitudes to Pain [online]. 2010 [cited 2012 Nov. 2]. Available from URL:http://www.patients-association.com/Portals/0/Public/Files/Research%20Publications/PUBLIC%20ATTITUDES%20TO%20PAIN.pdf.
Chronic Pain Health Needs Assessment 239
151. NHS Specialised Services. Specialised Pain Management Services (adult) - Definition No. 31 [online]. 2012 [cited 2012 Nov. 2]. Available from URL:http://www.specialisedservices.nhs.uk/library/26/Specialised_Pain_Management_Services_adult.pdf.
152. NHS Specialised Services. Specialised Pain Clinical Reference Group [online]. 2012 [cited 2012 Nov. 2]. Available from URL:http://specialisedcommissioning.com/programmes-of-care/traumatic-injury-orthopaedics-head-and-neck-and-rehabilitation/specialised-pain/.
153. Dworkin R, Turk D, Farrar J. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain Med 2005; 113: 9-19.
154. Moore RA, Eccleston C, Derry S. Evidence in chronic pain – establishing best practice in the reporting of systematic reviews. J Pain 2010; 150: 386-389.
155. Dworkin R, Turk D, Wyrwich K. Interpreting the Clinical Important of Treatment outcomes in Chronic Pain Clinical Trials: IMMPACT recommendations. J Pain 2008; 9: 105-121.
156. National Institute for Health and Clinical Excellence. Low back pain: Early management of persistent non-specific low back pain. NICE Clinical guideline 88. [online]. 2009 [cited 2012 June 26]. Available from URL:http://www.nice.org.uk/nicemedia/pdf/CG88NICEGuideline.pdf .
157. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147: 478-491.
158. Gross A, Miller J, D'Sylva J, et al. Manipulation or Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews: Reviews 2010; Issue 1
159. Miller J, Gross A, D'Sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Manual Therapy 2010; 15(4): 334-354.
160. Seidel S, Aigner M, Ossege M, et al. Antipsychotics for acute and chronic pain in adults. [Review] [35 refs]. Journal of Pain & Symptom Management 2010; 39: 768-778.
161. Hauser W, Bernardy K, Uceyler N, et al. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA 2009; 301: 198-209.
162. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain. Cochrane Database of Systematic Reviews: Reviews 2007; Issue 4
163. Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful neuropathy or chronic pain. Cochrane Database Syst.Rev. 2009; Issue 4. Art. No.: CD007115. DOI: 10.1002/14651858.CD007115.pub2.
164. Matthews P, Derry S, Moore RA, et al. Topical rubefacients for acute and chronic pain in adults. Cochrane Database Syst.Rev. 2009; Issue 3. Art. No.: CD007403. DOI: 10.1002/14651858.CD007403.pub2.
165. Papaleontiou M, Henderson CR, Jr., Turner BJ, et al. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. [Review] [79 refs]. Journal of the American Geriatrics Society 2010; 58: 1353-1369.
240 Chronic Pain Health Needs Assessment
166. Riemsma RF. Systematic review of tapentadol in chronic severe pain. Current Medical Research and Opinion 2011; 27: 1907-1930.
167. Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. [Review]. Pain Physician 2011; 14: 91-121.
168. Lynch MEC. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. British Journal of Clinical Pharmacology 2011; 72: 735-744.
169. Wiffen PJ, Derry S, Moore RA. Lamotrigine for acute and chronic pain. Cochrane Database Syst.Rev. 2011; Issue 2. Art. No.: CD006044. DOI: 10.1002/14651858.CD006044.pub3
170. Wiffen PJ, Derry S, Moore RA, McQuay HJ. Carbamazepine for acute and chronic pain in adults. Cochrane Database Syst.Rev. 2011; Issue 1. Art. No.: CD005451. DOI: 10.1002/14651858.CD005451.pub2
171. Plested M, Budhia S, Gabriel Z, et al. Pregabalin, the lidocaine plaster and duloxetine in patients with refractory neuropathic pain: a systematic review. [Review]. BMC neurology 2010; 10: 116
172. Tzellos TG, Toulis KA, Goulis DG, et al. Gabapentin and pregabalin in the treatment of fibromyalgia: a systematic review and a meta-analysis. [Review]. Journal of Clinical Pharmacy & Therapeutics 2010; 35: 639-656.
173. Siler AC, Gardner H, Yanit K, et al. Systematic review of the comparative effectiveness of antiepileptic drugs for fibromyalgia. [Review]. Journal of Pain 2011; 12: 407-415.
174. Moore RA, Wiffen PJ, Derry S, et al. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst.Rev. 2011; Issue 3. Art. No.: CD007938. DOI: 10.1002/14651858.CD007938.pub2.
175. Gross A, Forget M, St GK, et al. Patient education for neck pain. Cochrane Database Syst.Rev. 2012; Issue 3. Art. No.: CD005106. DOI: 10.1002/14651858.CD005106.pub4.
176. Chou R, Baisden J, Carragee EJ, et al. Surgery for low back pain: a review of the evidence for an American pain society clinical practice guideline. Spine 2009; 34: 1094
177. Mark, D. Low-level laser therapy for carpal tunnel syndrome and chronic neck pain.2010,http://www.bcbs.com/blueresources/tec/vols/25/low-level-laser-therapy.html
178. Alexander LDG. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Physical therapy 2010; 90: 14-25.
179. Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews: Reviews 2008; Issue 3
180. Warden SJ, Hinman RS, Watson MA, Jr., et al. Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. [Review] [49 refs]. Arthritis & Rheumatism 2008; 59: 73-83.
Chronic Pain Health Needs Assessment 241
181. Blum K, Chen AL, Chen TJ, et al. The H-Wave device is an effective and safe non-pharmacological analgesic for chronic pain: a meta-analysis. Advances in therapy 2008; 25: 644-657.
182. van Middelkoop M., Rubinstein SM, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011; 20: 19-39.
183. Chow RT, Johnson MI, Lopes-Martins RAB, Bjordal JM. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. The Lancet 2009; 374: 1897-1908.
184. Eccleston C, Williams-Amanda Cd, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst.Rev. 2009;
185. Macea DD, Gajos K, glia Calil YA, et al. The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. [Review]. Journal of Pain 2010; 11: 917-929.
186. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain (Structured abstract). Health Psychology 2007; 26: 1-9.
187. Henschke N, Ostelo-Raymond WJG, van-Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst.Rev. 2010; Issue 7. Art. No.: CD002014. DOI: 10.1002/14651858.CD002014.pub3.
188. Eccleston C, Williams-Amanda Cd, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst.Rev. 2009;
189. Eccleston C, Williams-Amanda Cd, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst.Rev. 2009;
190. Asher GN, Jonas DE, Coeytaux RR, et al. Auriculotherapy for pain management: a systematic review and meta-analysis of randomized controlled trials. [Review]. Journal of Alternative & Complementary Medicine 2010; 16: 1097-1108.
191. Chua NH, Vissers KC, Sluijter M, et al. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications-a review. [Review]. Acta Neurochirurgica 2011; 153: 763-771.
192. Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician 2009; 12: 437-460.
193. Dretzke J, Meadows A, Fry-Smith A, Moore D. The clinical and cost-effectiveness of neurostimulation for relief of chronic/neuropathic pain: an evidence based review [online]. 2011 [cited 2012 July 16]. Available from URL:http://www.birmingham.ac.uk/Documents/college-mds/haps/projects/WMCSU/WorkProgramme/EvidenceReviews/Neurostimulatorsforchronicneuropathicpain.pdf.
242 Chronic Pain Health Needs Assessment
194. Gibson JNA and Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4. [online]. 2008 [cited 2012 Sept. 1]. Available from URL:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001350.pub4/full.
195. Hayek S, Deer TR, Pope JE, Panchal SJ, Patel V. Intrathecal therapy for cancer and non-cancer pain. Pain Physician 2011; 14: 219-248.
196. Ho KY, Tan KH, Ho KY, Tan KH. Botulinum toxin A for myofascial trigger point injection: a qualitative systematic review. [Review] [45 refs]. European Journal of Pain. 2007; 11: 519-527.
197. Ibrahim T, Tleyjeh IM, Gabbar O. Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials. International Orthopaedics 2008; 32: 107-113.
198. Kalichman L, Bannuru RR, Severin M, et al. Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis. [Review]. Seminars in Arthritis & Rheumatism 2011; 40: 532-538.
199. Langevin P, Peloso Paul MJ, Lowcock J, et al. Botulinum toxin for subacute/chronic neck pain. Cochrane Database of Systematic Reviews: Reviews 2011; Issue 7
200. Mirza SK, Deyo RA. Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine 2007; 32: 816-823.
201. Patel VB, Manchikanti L, Singh V, et al. Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain. [Review] [123 refs]. Pain Physician 2009; 12: 345-360.
202. Scott NA, Guo B, Barton PM, et al. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. [Review] [73 refs]. Pain Medicine 2009; 10: 54-69.
203. Simpson EL, Duenas A, Holmes MW, Papaioannou D. Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin. Health Technology Assessment 2009; 13: 1-86.
204. Singh JA and Fitzgerald PM. Botulinum toxin for shoulder pain. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008271. [online]. 2010 [cited 2012 Sept. 21]. Available from URL:http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD008271/frame.html.
205. Staal JB, De BR, De Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low-back pain [online]. 2008 [cited 2012 Sept. 1]. Available from URL:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001824.pub3/full.
206. Straube S, Derry S, Moore R, McQuay H. Cervico-thoracic or lumbar sympathectomy for neuropathic pain. Cochrane Database Syst.Rev. 2010; Issue 7. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.pub2
207. Van Den Eerenbeemt KD, Ostelo RW, Van Royen BJ, Peul WC, van Tulder MW. Total disc replacement surgery for symptomatic degenerative lumbar disc disease: A systematic review of the literature. European Spine Journal. 2010; %2010.: Date
Chronic Pain Health Needs Assessment 243
208. Vlassakov KVN. Local anesthetic blockade of peripheral nerves for treatment of neuralgias: Systematic analysis. Anesthesia and Analgesia 2011; 112: 1487-1493.
209. Ypsilantis E, Tang TY, Ypsilantis E, Tang TY. Pre-emptive analgesia for chronic limb pain after amputation for peripheral vascular disease: a systematic review. [Review]. Annals of Vascular Surgery 2010; 24: 1139-1146.
210. Zhang T, Adatia A, Zarin W, et al. The efficacy of botulinum toxin type A in managing chronic musculoskeletal pain: a systematic review and meta analysis. Inflammopharmacology 2011; 19(1): 21-34.
211. Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician 2009; 12: 137-157.
212. National Institute for Health and Clinical Excellence.Interventional Procedures Programme. IPG 300 Percutaneous endoscopic laser lumbar discectomy [online]. 2009 [cited 2012 July 11]. Available from URL:http://publications.nice.org.uk/percutaneous-endoscopic-laser-lumbar-discectomy-ipg300.
213. National Institute for Health and Clinical Excellence.Interventional Procedures Programme. IPG 357 Percutaneous intradiscal laser ablation in the lumbar spine [online]. 2010 [cited 2012 July 11]. Available from URL:http://publications.nice.org.uk/percutaneous-intradiscal-laser-ablation-in-the-lumbar-spine-ipg357.
214. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst.Rev. 2010; Issue 1. Art. No.: CD006605. DOI: 10.1002/14651858.CD006605.pub2.: CD006605
215. Gibson JNA and Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4. [online]. 2008 [cited 2012 Sept. 1]. Available from URL:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001350.pub4/full.
216. Gibson JNA and Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4. [online]. 2008 [cited 2012 Sept. 1]. Available from URL:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001350.pub4/full.
217. Scascighini L, Toma V, Dober-Spielmann S, et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. [Review] [63 refs]. Rheumatology (Oxford) 2008; 47: 670-678.
218. van Geen JW, Edelaar MJ, Janssen M, van-Eijk JT. The long-term effect of multidisciplinary back training: a systematic review (Structured abstract). Spine 2007; 32: 249-255.
219. Gross A, Miller J, D'Sylva J, et al. Manipulation or Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews: Reviews 2010; Issue 1
220. Derry S, Lloyd R, Moore RA, McQuay HJ. Topical capsaicin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews: Reviews 2009; Issue 4
244 Chronic Pain Health Needs Assessment
221. Gill D, Derry S, Wiffen PJ, et al. Valproic acid and sodium valproate for neuropathic pain and fibromyalgia in adults. [Review]. Cochrane Database Syst.Rev. 2011; CD009183
222. Straube S, Moore RA, Paine J, et al. Interference with work in fibromyalgia: effect of treatment with pregabalin and relation to pain response. BMC Musculoskeletal Disorders 2011; 12: 125
223. Haines T, Gross A, Burnie SJ, Goldsmith CH, Perry L. Patient education for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews: Reviews 2009; Issue 1
224. Eccleston C, Williams-Amanda Cd, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst.Rev. 2009;
225. Gibson JNA and Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001350. DOI: 10.1002/14651858.CD001350.pub4. [online]. 2008 [cited 2012 Sept. 1]. Available from URL:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001350.pub4/full.
226. National Institute for Health and Clinical Excellence.Interventional Procedures Programme. Percutaneous endoscopic laser lumbar discectomy (interventional procedures overview) [online]. 2009 [cited 2012 July 11]. Available from URL:http://www.nice.org.uk/IP733overview.
227. National Institute for Health and Clinical Excellence.Interventional Procedures Programme. Percutaneous intradiscal laser ablation in the lumbar spine - Overview [online]. 2010 [cited 2012 July 11]. Available from URL:http://www.nice.org.uk/IP75aoverview.
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