Complex Pain Patients Research Articles

Anorectal and perineal pain

Anorectal and perineal pain Abstract. Anorectal pain is a common clinical challenge in the outpatient office. Anal fissures, anal venous thrombosis, proctitis or neoplasms are frequent etiologies for proctalgia. After exclusion of somatic disorders by diagnostic imaging and endoscopy, functional anorectal pain or pathologies like interstitial cystitits, chronic prostatitis, coccycodynia or pudendal neuralgia should be considered. The Rome IV criteria distinguish proctalgia fugax, a sharp paroxysmal pain lasting for maximum 30minutes, and the levator ani syndrom. Latter is characterized by a tender puborectal muscle on digital rectal examination and pain lasting for more than 30minutes. Treatment consists in reassurance, sitz bathes, topical vasodilators and anal massage. Biofeedback is a further option for levator ani syndrome. Painful palpation of the ox coccygis leads to the diagnosis of coccycodynia, a non-functional disorder. Therapy consists in anti-inflammatory medications, os coccygis mobilisation and infiltration therapy. Urologic chronic pelvic pain (chronic prostatitis and interstitial cystitis) as well as pudendal neuralgia, both neurogenic pelvic pain syndromes, can cause pain radiating into the after and perineum. The diagnosis and discrimination from functional rectal pain is difficult. Patients with neurogenic anorectal pain are best treated with anti-inflammatory medications, pain modulating antidepressives, anticonvulsives or local infiltration therapy. Interdisciplinary management of complex pain patients is mandatory.

Reducing Opioid Overprescribing by Educating, Monitoring and Collaborating with Clinicians: A Quality Improvement Study.

IntroductionMultiple barriers have been described for reducing opioid prescribing by primary care providers. We describe a quality improvement report on the effects of a series of focused interventions on opioid prescribing after the release of the Centers for Disease Control and Prevention (CDC) guidelines while monitoring patient satisfaction.Material and methodsThe study began as an intervention project to inform and educate providers about the CDC’s guidelines and to improve adherence. A convenience sample of 165 providers from 33 outpatient clinics of a healthcare system was utilized. This quality improvement study compared a 20-month preintervention baseline period with a 16-month post-intervention period ending on December 31, 2017, using the health system’s electronic medical record. Interrupted time series analysis was used to assess the effect of the intervention on opioid prescribing. Providers were given quarterly individual reports on their prescribing patterns of schedule II opioids and comparing their prescribing patterns to their peers. Providers had access to educational opportunities for CDC guidelines, various aspects of safe opioid prescribing, and professionally written patient hand-outs about opioid risks and alternatives. Provider collaboration with patients for tapering opioids and collaboration with specialists in managing complex pain patients was encouraged. A total number of schedule II chronic opioid prescriptions per month was measured.ResultsThe total schedule II opioid prescription rate was 19.6% lower than the average of the baseline. Every month after August 2016, there was a significant reduction of total schedule II opiate orders with a risk decrease of 2% [risk ratio (RR) 0.982; 95% confidence interval (CI) 0.976-0.989; p < 0.0001]. The patient satisfaction scores improved from 92.1 % in January 2015 to 95.1% by December 2017.DiscussionWe noticed an initial decrease in opioid prescribing with the release of the CDC guidelines. However, a greater decline in opioid prescribing was noted after distributing data to providers that compared their own opioid prescribing patterns to their peers. This data offered an opportunity for self-analysis to clinicians to justify the clinical reasons for writing more opioid prescriptions. Provider and patient education on the benefits of opioid reduction enabled better collaboration and engagement in shared decision making with a detailed plan of gradual opioid reduction. Our study was limited by the inability to determine the most effective intervention as the interventions were initiated as a bundle in our healthcare system. Indications for opioid therapy such as pain management for cancer pain or palliative care versus chronic non-cancer pain were not available. The major adverse events related to opioid use, such as opioid overdose deaths and opioid use disorder, were not measured in this data source.ConclusionsOpioid overprescribing was reduced by educating providers and patients, monitoring clinicians’ opioid prescribing patterns, and seeking physicians’ collaboration. Future healthcare initiatives can utilize similar methods to evaluate interventions impacting the opioid epidemic.

Fundamentals of Pain Medicine, 1st ed

Pain is a unifying presenting symptom across many medical specialties. Nearly all physicians are routinely asked to provide quality care to patients whose primary request is assistance with pain control. However, most physicians feel ill-equipped to manage pain, especially in the chronic setting, which inevitably leads to increased patient suffering. In many cases, physicians without specialty training in pain are tasked with treating complex pain patients when pain physicians are not readily available. Fundamentals of Pain Medicine aims to level the playing field, so to speak, for physicians across varying fields who aspire to better treat their patients’ pain complaints. This text offers invaluable information regarding diagnosis, understanding, and treatment of both basic and complex pain states. Fundamentals of Pain Medicine is offered as a paperback text, as well as an eBook. The 359 pages of this book are easily viewed via the eBook platform, which also allows for zooming for improved visualization of the numerous figures used throughout to illustrate complex concepts. The 36 chapters are well organized in easy to manage sections that allow for quick reference to pertinent topics. The text covers 9 distinct topics: diagnosis of pain states, management of pain states, acute pain, chronic musculoskeletal pain, radicular pain, neuropathic pain, chronic visceral pain, headaches, and painful disease states in special populations (pediatrics, geriatrics, and the critically ill). The book is organized logically and with progressively more detail to allow for further investigation by the reader, as dictated by their interest. The sections can easily be referenced for rapid assistance in patient management, or the whole text can be taken in as a guide in the overarching themes of successful pain medicine. A strength of this text is its structure and ability to break pain states down by etiology, leading to improved clinical utility and more appropriate treatment plans. As is well known by pain physicians, the cause of the pain states often dictates the utility of various modalities and likelihood of success in treatment. In short, not all patients’ pain complaints can be treated using the same pharmacological and interventional techniques, and this text clarifies this concept and appropriate approaches. The chapters are broken down into etiologies of pain and their evidence-based treatment courses, which allows for improved patient response, particularly for physicians who may be less familiar with some of the rarer pain etiologies. For example, chapter 23 describes complex regional pain syndrome pathophysiology, epidemiology, diagnosis, and management. This chapter may prove quite valuable in directing the multimodal treatment of complicated, refractory pain patients seen by physicians who do not routinely treat complex regional pain syndrome patients. The author provides thorough details regarding levels of evidence, as well as a cogent summary of recommendations at the end of each chapter, allowing for improved understanding and more effective delivery of patient care. Fundamentals of Pain Medicine reads easily and functions as an excellent reference for those needing a quick refresher course on the nuts and bolts of pain medicine. In fact, many physicians in various fields could offer significantly improved pain management for their patients, namely those in primary care settings without immediate access to pain physicians, simply by consulting relevant chapters. This book may be especially useful for primary care physicians tasked with providing long-term care for patients with complicated, chronic pain conditions. For the trained pain physician, Fundamentals of Pain Medicine offers a concise, well-written summary and reference in a pinch but may fall short when it comes to in-depth analysis of physiological mechanisms of pain and more innovative, up-and-coming interventions. However, following the summary of each chapter, a comprehensive list of suggested readings offers an opportunity for a more detailed perusal into various topics as may pertain more so to specific patient populations, allowing for a more thorough understanding. For physicians of specialties outside the realm of pain management looking to improve efficacy of pain interventions in their patient populations, Fundamentals of Pain Medicine provides a concise overview of the physiological mechanisms, etiologies, and appropriate management of a multitude of pain states that is easy to read and comprehend. The text is extremely practical in its delivery of recommendations, including both pharmacological and more complementary and integrative techniques. This book serves as an excellent initial stepping stone in providing quality pain treatment for patients with common pain states and should be considered a staple desk reference for all physicians interested in improving their patients’ pain control. Caitlin D. Tourje, MDAmanda M. Kleiman, MDDepartment of AnesthesiologyUniversity of VirginiaCharlottesville, Virginia[email protected]

Orthopedic resident education on postoperative pain control: bridging knowledge gaps to enhance patient safety

As the United States population continues to age, the number of orthopedic procedures continues to grow.1 Not infrequently, many of these patients who are admitted for orthopedic surgical procedures are already on complex pain regimens preoperatively. This is due not only to the increasing comorbid state of our aging population but also the wide variety of analgesic management strategies employed throughout the nation amid chronic opioid use.2 Expanding surgical volumes, particularly when involving increasingly complex and opioid-tolerant chronic pain patients, pose significant challenges for perioperative management. Inpatient hospital pain services3,4 can be of tangible benefit for these complex pain patients.5 Miaskowski and colleagues found that patients cared for by an acute pain service were discharged sooner, had lower pain intensity scores, lower incidences of pruritis, sedation and nausea compared to those without the anesthesia service involvement.5 With a growing number of surgical cases, pain management consultations have increased to a number that is not always sustainable, leading some hospitals to adopt a nurse care model.6 There is minimal medical literature assessing the types of pain management consultations.4 A local and unpublished study on resource utilization at Mayo Clinic Rochester demonstrated that orthopedic surgeons place roughly 40% of all surgical specialty consultation requests for acute postoperative pain management. The majority of these consultations are requests for pharmacologic analgesia management, such as titrating oral narcotic medications. A smaller number of these requests are focused on interventional pain procedures, such as joint injections. Since not all hospitals have dedicated inpatient pain services, this places additional pressure on surgeons in the perioperative period, making pain education for these specialties even more important. To improve postoperative pain management, the inpatient pain medicine service at Mayo Clinic, a subspecialized physician practice with credentials specifically in Pain Medicine, founded an educational seminar for the incoming orthopedic surgery residents. The purpose of this program was to optimize their understanding of the role that the inpatient pain service plays in managing postoperative pain, as well as to educate them in the founding principles of pharmacologically-directed pain management. Educational Seminar In 2011, the Orthopedic Staff Leadership Committee (OSLC) at the Mayo Clinic, which consists of a core group of staff nurses and nursing leadership, participated in an educational seminar with new orthopedic residents to help guide them through the dynamic perioperative hospital course to ensure safe, satisfactory patient care. These residents received clinical education from various hospital groups, including physical and occupational therapy, social services and pharmacy. The seminars guided them through clinical techniques, such as surgical wound management, pressure ulcer prevention, and proper application of splints and casts. As an extension of this training, the OSLC, in conjunction with the Anesthesiology Division of Pain Medicine, developed a seminar to orient the resident trainees to common strategies of postoperative pain management. The training seminar consists primarily of a one-day, three-hour discussion and didactic lecture. This lecture is presented by a core faculty member of the division of Pain Medicine. The core principles it addresses are the nuances of the functions of the Anesthesia Acute Pain Management Hospital Service, as well as the pharmacodynamic and pharmacokinetic principles of a number of common medications used in the postoperative setting. These include medications such as oral and IV narcotics, NSAIDs, Tylenol, topical local anesthetics, and Tramadol. Specific information on opioid titration, parenteral to oral opioid conversion, and postoperative opioid weaning strategies (once healed from surgery) was also provided. The content consisted of defining the concept of multimodal analgesia, reviewing opioid pharmacokinetics and pharmacodynamics, demonstrating how to calculate oral morphine equivalents, understanding the utility of regional anesthesia, and reviewing methadone and pharmacokinetics and pharmacodynamics. A pre and post-assessment, audience response system test was given to improve attention and retention.

Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service

ABSTRACT Background The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. Aims To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. Methods Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. Results Six months postoperatively, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. Conclusions The TPS enabled almost half of opioid-naïve patients and one in four opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.

Use of Spinal Cord Stimulation in Elderly Patients with Multi-Factorial Chronic Lumbar and Non-Radicular Lower Extremity Pain.

Spinal cord stimulation (SCS) is an effective treatment for chronic back and limb pain. The criteria for use of SCS for specific problems such as failed back surgery syndrome (FBSS), peripheral neuropathic pain and residual pain after joint replacement is well established. With an aging population, there are more patients presenting with a combination of various multi-factorial chronic pain problems rather than from a single clear cause. It is not uncommon to see patients with chronic back pain years after spine surgery with new additional pain in the area of joint replacement or due to peripheral neuropathy. In most of these patients, one area is the primary cause of their pain, while the other more secondary. Multiple chronic problems complicate the pain management of the primary cause and also can diminish the effect of SCS that only targets the primary problem. The primary and secondary causes of pain were ranked by the patient including the duration of their chronic pain for each area. This helped establish criteria for use of SCS in these complex pain patients. The patients were evaluated initially with an epidural stimulator trial and if they obtained 50% or greater pain relief to the primary pain generating area, permanent implantation of one or more arrays of spinal cord electrodes was performed but planned to cover also the secondary pain areas. Post-implant follow-up evaluation at one, three and six months included measurement of visual analog scale (VAS), use of pain medication and degree of functional activity and behavior. This report looks at the effectiveness of using multiple overlapping electrodes for SCS in patients with multi-factorial chronic pain.

A national survey of pain clinics within the United Kingdom and Ireland focusing on the multidisciplinary team and the incorporation of the extended nursing role.

Inconsistencies in the availability and quality of pain service provision have been noted nationally, as have lengthy waiting times for appointments and lack of awareness of the Pain Clinic role. The 2013 NHS England report stated that specialist pain services must offer multispecialty and multidisciplinary pain clinics. This national survey of multidisciplinary pain service provision in the United Kingdom and Ireland provides a snapshot of pain service provision in order to review and highlight what variations exist in multidisciplinary team (MDT) provision and working patterns. A common perception among clinicians is that financial pressures have led to alternate ways of staff utilisation with variable degrees of success. The survey included 143 pain clinics, focusing principally on MDT working patterns, MDT composition and adoption of the extended role. The results identified that the majority of Pain Clinics utilise the MDT approach. However, provision of critical components such as regular MDT meetings is highly variable as is the composition of the MDT itself and also working patterns of the individual clinicians. The survey reports the successful use of the extended roles for specialist nurses in follow up clinics. In contrast, the survey highlights that a large proportion of clinicians surveyed have reservations about both the effectiveness and the safety of utilising specialist nurses in the extended role to see new referrals of complex pain patients to pain clinics. This survey underlines the essential requirement for incorporation of greater MDT working locally and nationally and allocation of appropriate resources to facilitate this.

Case report: Percutaneous electrical neural field stimulation in two cases of sympathetically-mediated pain.

Background: Fibromyalgia and complex regional pain syndrome (CRPS) are both chronic pain syndromes with pathophysiologic mechanisms related to autonomic nervous system dysregulation and central sensitization. Both syndromes are considered difficult to treat with conventional pain therapies. Case presentations: Here we describe a female veteran with fibromyalgia and a male veteran with CRPS, both of whom failed multiple pharmacologic, physical and psychological therapies for pain, but responded to percutaneous electrical neural field stimulation (PENFS) targeted at the auricular branches of the cranial nerves. Discussion: While PENFS applied to the body has been previously described for treatment of localized pain, PENFS effects on cranial nerve branches of the ear is not well-known, particularly when used for regional and full-body pain syndromes such as those described here. PENFS of the ear is a minimally-invasive, non-pharmacologic therapy that could lead to improved quality of life and decreased reliance on medication. However, further research is needed to guide clinical application, particularly in complex pain patients.

(542) Innovation for complex pain patients who do not fit into evolving care models

The Patient-Centered Medical Home (PCMH) is meant to organize primary care in an effort to meet the Triple Aim; provide a higher quality of care, lower global healthcare costs, and achieve a high patient satisfaction. In our chronic pain population, many patients simply drift from one provider to another through the healthcare system without an all-encompassing plan of care despite PCMHs being in place. In the chronic pain population, the lack of healthcare cohesiveness is even more predominant and costly for those with poor psychosocial health. In a collaborative effort with our local HMO, we developed a homegrown approach to identify the highest risk patients and to manage their care with the goal to positively affect the Triple Aim. Our collaborative care management program uses a patient management tool to gather patient reported data. The summary of the data is used to educate patients, help guide utilization, provide a basis for coordination efforts, and provide outcomes of care. The collected data is combined with payer data to determine global impact of intense care management for these high-risk patients. Through intense communication and educational efforts, as well as care manager consistency, these high-risk patients are showing promise of improved health literacy, compliance with treatment regimens, and decreased global utilization and costs. Preliminary data shows estimated global savings twelve months post treatment to be around twenty percent per member per month. Additionally, we are seeing a reduction in targeted utilization markers.

TelePain: A Community of Practice for Pain Management.

Comprehensive pain management services are primarily located in urban areas, limiting specialist consultation opportunities for community healthcare providers. A community of practice (CoP) for pain management could create opportunities for consultation by establishing professional relationships between community healthcare providers and pain management specialists. A CoP is a group of people with a common concern, set of problems, or a passion for something they do. Members of a CoP for pain management increase their knowledge of evidence-based pain management strategies in a way that is meaningful and relevant. In this article, we provide evidence that TelePain, an interdisciplinary, case-based pain management teleconference consultation program through the University of Washington, qualifies as a CoP and present preliminary evidence of TelePain's effectiveness as a CoP for pain management. Specific behaviors and conversations gathered through participant observation during TelePain sessions were analyzed based on the 14 indicators Wegner developed to evaluate the presence of a CoP. To demonstrate preliminary effectiveness of TelePain as a CoP for pain management, descriptive statistics were used to summarize TelePain evaluation forms. TelePain is an example of a successful CoP for pain management as demonstrated by the presence of Wegner's 14 indicators. Additionally, evaluation forms showed that TelePain enhanced community healthcare providers' knowledge of pain management strategies and that continued participation in TelePain lead to community healthcare providers' increased confidence in their ability to provide pain management. TelePain, a CoP for pain management, facilitates multidisciplinary collaboration and allows members to develop interdisciplinary care plans for complex pain patients through case study discussions. Evidence-based pain management strategies gained through CoP membership could be disseminated to other healthcare providers in members' clinics, which has the potential of improving the care of chronic pain patients.

Optimizing perioperative analgesia for the complex pain patient: medical and interventional strategies

The purpose of this article is to review the literature and to highlight current practice regarding the management of the chronic pain patient presenting for surgery. It can be difficult to achieve adequate postoperative analgesia in patients who present for surgery with preexisting chronic pain. Such complex pain patients require a care plan that involves preoperative, intraoperative, and postoperative considerations. Preoperatively, it is important to identify these patients' specific concerns, to address anxiety, to review expectations of care, and to consider premedication. Intraoperatively, it is important to consider local anesthetic regional anesthesia techniques and to supplement as necessary with pharmaceutical agents, e.g., ketamine, dexamethasone, ketorolac, and opioids. Postoperatively, it is important to continue multimodal analgesia techniques. It is vital to maintain a healthy therapeutic alliance with the patient and withallied health professionals. Nonspecific treatment effects can bolster efforts to achieve adequate analgesia. Successful management of the complex pain patient requires knowledge of the art and science of perioperative medicine.

Klinische Schmerzkonsile

The aim of this investigation was to describe the performance profile and the requirements for the management of complex pain patients for the structures of a consultation service. The content and number of all inpatient consultations of the pain department (as an independent service in addition to acute pain and palliative care services) were evaluated for the period from 2008-2010. During the study, 1,391contacts were made in 882patients; in approx. 50% of the consultations diagnostic or specific (interventional) procedures were requested. Beside additional diagnostic tests, physiotherapy (19.2%), psychological and psychiatric care (11.1%), and other therapeutic approaches (e.g., mirror therapy, transcutaneous electrical nerve stimulation, progressive muscle relaxation) or the long-term follow-up in specialized pain service (20.5%) were recommended. Within the scope of the pain consultation, a wide spectrum of pain diagnoses and difficult patients are examined. Mixed forms of acute, chronic, and tumor-related pain are often present. Therapeutically, optimization of only the pharmacological regimen is often not sufficient. Similar requirements for a multimodal diagnosis and therapeutic concept as established in ambulatory and/or specialist care are ultimately needed.

Overcoming Fears, Frustrations, and Competing Demands: An Effective Integration of Pain Medicine and Primary Care to Treat Complex Pain Patients

In the United States, the number of pain specialists is insufficient to manage the tens of millions of patients suffering from chronic pain. Also, multidisciplinary pain clinics are on the “endangered list” and not widely available. Therefore, most patients with pain are being managed in the primary care setting. Primary care providers (PCPs) encounter patients daily with chronic pain and its attendant comorbidities, but may lack the knowledge, experience, and time to tackle all the complexities involved—frustrating both patients and providers. PCPs have become increasingly aware of research documenting the under-treatment of pain, but feel unprepared to adequately address this public health problem because of their limited training in pain and addiction medicine [1], and are inexperienced in the nuances of using opioids, treatment agreements, and urine drug tests. Time pressures are faced routinely by PCPs. While these pressures are not unique to primary care; juggling a variety of competing demands by PCPs is unique and may be particularly onerous [2]. In addition to addressing patients' acute complaints and concerns at a particular visit, PCPs are expected to manage several comorbid chronic diseases (diabetes mellitus, hypertension, heart disease, and many others), provide preventative care (cancer screening and vaccinations), offer counseling and education, order indicated laboratory and radiographic …

Spinal Cord Stimulation for Complex Pain: Initial Experience with a Dual Electrode, Programmable, Internal Pulse Generator

Abstract: The objective of this study was to engage in an 18-month follow-up of 20 chronic complex pain patients using a dual electrode, programmable, fully implantable internal pulse generator (IPG) for spinal cord stimulation (SCS). Implant status, stimulation mode, anode-cathode configuration (array), cathode position, paresthesia overlap, complications, Visual Analog Scores (VAS), and overall satisfaction were prospectively examined in 20 patients implanted with dual 4 contact, staggered, percutaneous electrodes (Pisces 3487A, Medtronic, Minneapolis, Minnesota) internalized to a fully implantable, programmable IPG (Synergy 7466, Medtronic, Minneapolis, Minnesota). All patients had undergone initial implantation for chronic complex axial and extremity pain (eg, Failed Back Surgery Syndrome (FBSS), Complex Regional Pain Syndrome (CRPS)) with dual octapolar, radiofrequency (RF) SCS systems (Advanced Neuromodulation Systems 2098, Plano, Texas).1–3 All patients required conversion to the current dual IPG systems due to RF system receiver sensitivity, preventing further antenna coupling).1 Dual quadrupolar IPG SCS outcomes were compared to previous long-term, dual octapolar RF SCS complex pain reports.1–3 Data was collected and analyzed by a disinterested third party. At 18 months, all 20 patients remained implanted. All patients reported using 1 or 2 “best” guarded tripolar or bipolar arrays to maintain favorable paresthesia overlap (77.5%), VAS reduction (9.78 → 4.40), and overall patient satisfaction (80%). Eighty-five percent of “best” anode-cathode configurations were activated on both electrode columns about the physiologic midline of the C 3/4 vertebral segments for upper extremity pain, and the T 9/10 vertebral segments for low back and lower extremity pain. Sixty-seven and one half percent of all electrodes were thoracic and 32.5% were cervical. “Best” arrays were activated as narrow (adjacent contact) guarded cathode tripoles (75%), extended (nonadjacent contact) bipoles/tripoles (15%), or as narrow bipoles (10%). The mean number of active contacts per “best” array was 5.6, with 3.75 anodes and 1.85 cathodes. All patients preferred the current IPG to the prior RF SCS implant, citing RF receiver site sensitivity, difficulty maintaining coupling of the RF antennae, and time intensive RF programming. Conversely, 13 patients (65%) reported IPG site sensitivity that did not affect overall satisfaction. That is, none would convert their current IPG to a smaller IPG to resolve this issue, unless it was of equal longevity. Sixteen patients (80%) were satisfied with the overall level of pain relief, and all (100%) would repeat the IPG SCS implant. This study demonstrates improved overall outcome and patient satisfaction after long-term, dual octapolar RF SCS conversion to dual quadrupolar IPG SCS systems in the same patient population. It also validates prior dual SCS electrode reports of common array configuration, electrode positioning about the physiologic midline, and patient preference of single or dual programmability in the treatment of chronic complex pain.1,4,5 Follow-up of this initial experience with a multicenter study is warranted.