Pain physician
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Documentation assists health care professionals in providing appropriate services to patients by documenting indications and medical necessity, and reflects the competency and character of the physician. Documentation is considered a cornerstone of the quality of patient care. This is nowhere more true than in interventional pain management. ⋯ Evaluation and management services incorporate 5 levels of service for consultations and visits, with multiple key elements of service including history, physical examination, and medical decision making. Documentation of interventional procedures in general requires a history and physical, indication and medical necessity, intra-operative procedural description, post-operative monitoring and ambulation, discharge, and disposition. With minor variations, these requirements are similar for an in-office setting, hospital out patient department, and ambulatory surgery centers.
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Persistent pain interfering with daily activities is common. Chronic pain has been defined in many ways. Chronic pain syndrome is a separate entity from chronic pain. ⋯ The additional costs of misuse, abuse, and addiction are enormous. Comorbidities including psychological and physical conditions and numerous other risk factors are common in spinal pain and add significant complexities to the interventionalist's clinical task. This section of the American Society of Interventional Pain Physicians (ASIPP)/Evidence-Based Medicine (EBM) guidelines evaluates the epidemiology, scope, and impact of spinal pain and its relevance to health care interventions.
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Calcineurin may be involved in affecting nociceptive processes in multiple circumstances. It is conceivable that interfering with calcineurin's normal role in contributing to glial resting membrane potential, via its effects on the ion channel (TRESK) [tandem-pore-domain weakly inward rectifying potassium channels (TWIK)-related spinal cord potassium channels] may facilitate nociception. Another aspect of calcineurin function may be its role in the pronociceptive signaling of nuclear factor of activated T-cells (NFAT). ⋯ In fact, multiple articles have described the clinical use of calcineurin-inhibitors leading to pain, a phenomenon referred to as calcineurin inhibitor-induced pain syndrome (CIPS). Thus, it appears that calcineurin functions may encompass actions which promote or dampen nociceptive processes. A greater understanding of the physiology of calcineurin, especially as it relates to modulating nociception may lead to the development of novel analgesic targets in attempts to optimally alleviate patient discomfort.
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Practice Guideline
Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain.
Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians. ⋯ The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. Further, these guidelines also do not represent "standard of care."
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Clinical Trial
Intrathecal ziconotide and opioid combination therapy for noncancer pain: an observational study.
Intrathecal ziconotide is used to manage severe chronic pain. Although ziconotide is approved by the US Food and Drug Administration for monotherapy, it is sometimes used in combination with other intrathecal drugs for the management of intractable pain conditions in clinical practice. ⋯ Results from this observational study suggest that combination intrathecal ziconotide and opioid therapy may be a safe and potentially effective treatment option for patients with refractory chronic pain. Controlled, prospective clinical trials to evaluate ziconotide combination therapy are needed.