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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

Must-Have Devices for Your Pain Practice

A review of the most popular electromedical devices, from ease of use to patient satisfaction.
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The use of medical devices is becoming critically important as the healthcare industry stands at a crossroads of change. A renewed focus on chronic pain and how to best treat these costly conditions has brought medical device technology, specifically electromedical therapies, into the discussion. These alternative treatment strategies are further being considered as the paradigm shifts from fee-for-service to risk-sharing and risk-based contracting. This electromedical device review serves as an update of a previously published report that appeared in Practical Pain Management.

As healthcare reform moves forward, there will be an increased tendency to use large data sets, or big data, to gather intelligence from across a diverse set of clinical environments. As the industry shifts from volume to value, organizations will look toward leveraging flexible analytics to help manage population risk across care settings. The point of gathering and analyzing data is to then generate action-driving insights.

As medical device technology evolves, patients will have more non-pharmacologic approaches to help control their pain.

Approach

The approach to the analysis presented herein is to compare the outcomes of patients, within certain diagnostic categories, using a device with the outcomes of similar patients not using a device. For this exercise, the readers should consider these measures as crude indicators of association between the use of a device and a favorable outcome. In the near future, it is hoped that the analytics presented herein will stratify the patient population to help reduce sampling bias. In addition, it may help to identify subgroups who respond optimally to a certain treatment pathway or intervention, including the various elements that comprise an episode of care, such as specific electromedical devices.

As care and reimbursement models change to prioritize value (performance metrics versus service intensiveness), new medical device technology will play a key role in this transformation. Patient experience and throughput, cost, organizational flow, treatment effectiveness and a myriad of critical clinical, operational, financial- and patient-centered data can be made available using machine learning algorithms. The use or non-use of medical devices, such as those described herein can, and will, affect all of these medical economic aspects.

Rating & Selection Criteria

As part of this update, the author has attempted to substantiate the technology selections using the literature, practical experience, and an estimated odds ratio (OR) statistic. The OR has been applied where possible to the devices herein. The OR should be considered a crude measure of effectiveness in correlating the application of a medical device to a final endpoint, or outcome. In other words, the OR is a measure of association between exposure (medical device) and outcome (clinical end-point). The medical device becomes the predictor variable and the clinical end-point is the outcome variable.

The OR is defined herein as the ratio of probabilities [ie, probability of success in achieving selected end-point(s) over the probability of failure to achieve the selected end-point(s)]. The data repository utilized consists of just under 7,000 rehabilitation patients (approximately 140,000 patient visits) treated between the years 2008 and 2017.

The author is uniquely positioned to conduct this type of analysis as his facility conducts clinical research within the context of patient care; the clinic can include or withhold a particular therapy in patients. Beyond simply evaluating the effect of a medical device intervention on a particular patient with a specific target condition, the author understands the greater need to compare the effects of multiple devices and interventions (ie, comparative effectiveness research), which will provide important insights into which devices work best for a specific condition.

The selections herein are not rank-ordered; they represent what is considered best in brand within a certain device category. The rationale behind the choices was influenced by a combination of factors, including the availability of research and of the device for review through formal testing and informal personal experience.

For those reasons, the following products may not necessarily be “the best,” but they do demonstrate safety and clinical effectiveness, as well as high patient satisfaction. Practitioners are encouraged to explore and compare the various technologies to find which may “fit” their practice setting and patient population.

 

1. Extracorporeal Shockwave Therapy

Extracorporeal shockwave therapy (ESWT), also known as acoustic compressions, myotripsy, or shockwave therapy, has rapidly become the gold standard for the treatment of chronic, calcified, internalized, and/or fibrotic tissue stemming from longstanding trauma. The etiology of the traumatic injury can vary from repetitive strain to acute, forceful injury. In fact, the more consolidated the tissue, the greater the therapeutic target for shockwave treatments. For this reason, above-average results are typically obtained in enthesopathic conditions or where fibrotic scarring is confirmed.

Strength & Ease of Treatment

ESWT must be applied by the provider in the delivery of the focused soundwaves emitted from the probe. There is no mistaking when this device is “on”; one merely has to pass over abnormal or disorganized tissue for it to be felt by the patient. For example, application of ESWT along active trigger points or a calcified tendon, such as in calcific supraspinatus tendonitis where the increased stiffness of the lesion causes the mechanical waves to collide with the target lesion, can lead to painful pressure sensations felt by the patient. One particular device, the PiezoWave by Richard Wolf GmbH (Knittlingen, Germany), has a sono-isolation mode that allows the therapist to routinely scan over normal or healthy soft tissue with no sensations felt until an area of dysfunction (disorganization) is encountered, at which point, nociception is described as a deep achy sensation.1

The ESWT units tested and used clinically have been relatively simple to use. Frequency, intensity, and selection of stand-off pads are the primary decision points to be made.

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Obsessive-Compulsive Disorder & Chronic Pain

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