Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

Regional Anesthesia & Pain Medicine · 2025-02-26 · 11 citations

BACKGROUND: Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians. METHODS: Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus. RESULTS: This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection. CONCLUSIONS: In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Eyes on the Future: Integrating Virtual Care Models with XR and Digital Innovation in Ophthalmology

Biomedical engineering · 2025-09-19

The Bascom Palmer Eye Institute (BPEI) at the University of Miami has pioneered the integration of digital health innovations and medical extended reality (MXR) to transform ophthalmic care and education. This chapter reviews BPEI’s journey in adopting teleophthalmology, artificial intelligence (AI)-assisted diagnostics, and immersive MXR technologies, encompassing virtual reality (VR), augmented reality (AR), and mixed reality (MR), to enhance access, clinical precision, and trainee engagement. The Virtual Eye Care (VEC) program exemplifies a comprehensive telehealth ecosystem that has expanded patient access through synchronous, asynchronous, and hybrid care models, supported by a centralized VEC HUB optimizing workflows and patient triage. Between 2020 and 2025, BPEI delivered over 36,000 virtual visits, with high patient satisfaction and minimal appointment wait times. Meanwhile, MXR-based platforms are serving as ophthalmic screening solutions in eye clinics, as well as educational tools. The Bascom Palmer Verse metaverse platform and VR surgical simulators are revolutionizing ophthalmic training by providing immersive, risk-free environments that improve skills acquisition and knowledge retention. These technologies also empower patient education and remote monitoring. Challenges remain in regulatory compliance, data security, and equitable technology deployment, yet BPEI’s iterative, patient-centered approach offers a scalable model for other academic institutions. Looking forward, continued collaboration among healthcare providers, educators, technologists, and policymakers will be essential to embed digital health and extended reality as integral components of ophthalmic care. This paradigm shift promises to enhance diagnostic accuracy, streamline clinical workflows, and ultimately improve patient outcomes while advancing the next generation of ophthalmic clinicians.

Tele-ophthalmology as an effective triaging tool for acute ophthalmic concerns

Frontiers in Ophthalmology · 2025-01-14 · 3 citations

Introduction: The purpose of this study is to determine baseline demographics and utilization trend of an on-demand, synchronous tele-ophthalmology triage program in evaluating acute ophthalmic concerns during the COVID-19 Public Health Emergency. Methods: Setting: Single-center retrospective chart review of telemedicine visits conducted by ophthalmologists and optometrists from University of Miami's Bascom Palmer Eye Institute. Patient population: 6227 patients comprised 7138 telehealth encounters. All patient encounters were included in the retrospective review without exclusions and only the primary diagnoses were categorized from October 1, 2020 to April 30, 2023. Main outcomes measures: Descriptive statistics of the telemedicine model, utilization trends, baseline patient demographics, and primary diagnoses were performed for all virtual eye care encounters during the study period. Results: Utilization of the synchronous telemedicine platform increased during the study period. The median age of patients was 51 (IQR, 36-65) years. Patients predominantly self-identified as female (63.27%), White (72.7%), and non-Hispanic/Latino (48.2%). General external adnexa (44.1%), conjunctival disorders (15.5%) and ocular surface symptoms (15.4%), made up 75.0% of the visits during the study period. Furthermore, 63.4% of patients were new to Bascom Palmer Eye Institute, 67.1% had never engaged in telemedicine, and 96.5% of encounters were successfully completed through video conferencing. Discussion: During the COVID-19 pandemic, there was significant utilization of an on-demand synchronous ocular telemedicine program to address acute concerns. This retrospective chart review demonstrates the utility of telemedicine as an important and effective tool to triage and provide care during the COVID-19 Public Health Emergency.

Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

Regional Anesthesia & Pain Medicine · 2024 · 18 citations

• Medicine
• Anesthesia
• Physical therapy

BACKGROUND: There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS: Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS: This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS: In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder

Regional Anesthesia & Pain Medicine · 2023-04-25 · 24 citations

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids: an infographic

Regional Anesthesia & Pain Medicine · 2023-01-03 · 8 citations

The past two decades have seen an exponential increase in the use of cannabis and cannabinoids in the USA, as a result of both regulatory changes and public interest in possible therapeutic benefits. Patients presenting for surgery are using cannabis and cannabinoids with increasing frequency and

Debunking myths in headache diagnosis for the pain practitioner

Regional Anesthesia & Pain Medicine · 2023-10-10 · 3 citations

With headache being one of the most common chief complaints, it is essential for pain practitioners to interpret and differentiate a variety of headache characteristics to accurately diagnose and treat specific headache disorders. Certain misconceptions often lead to misdiagnosis. This article presents and discusses six myths about several common headache disorders (migraine, tension-type headache, cluster headache, cervicogenic headache, sinus headache, and occipital neuralgia) often encountered in clinical practice. The discussion is based primarily on the International Classification of Headache Disorders, 3rd edition and the latest studies. Recognizing and understanding the intricacies behind key headache diagnoses will help providers devise appropriate plans to better care for their patients.

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids

Regional Anesthesia & Pain Medicine · 2023-01-03 · 87 citations

BACKGROUND: The past two decades have seen an increase in cannabis use due to both regulatory changes and an interest in potential therapeutic effects of the substance, yet many aspects of the substance and their health implications remain controversial or unclear. METHODS: In November 2020, the American Society of Regional Anesthesia and Pain Medicine charged the Cannabis Working Group to develop guidelines for the perioperative use of cannabis. The Perioperative Use of Cannabis and Cannabinoids Guidelines Committee was charged with drafting responses to the nine key questions using a modified Delphi method with the overall goal of producing a document focused on the safe management of surgical patients using cannabinoids. A consensus recommendation required ≥75% agreement. RESULTS: Nine questions were selected, with 100% consensus achieved on third-round voting. Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes. CONCLUSIONS: Specific clinical recommendations for perioperative management of cannabis and cannabinoids were successfully created.

Cannabis as a Therapeutic or Snake Oil? A Desperate Call for Critical Appraisal of the Literature

Anesthesia & Analgesia · 2023-12-15 · 2 citations

See Article, pages 5, 16, 31, 42, 54 The global use of cannabinoids for both recreational and medicinal purposes is accelerating at a remarkable pace. In the United States, cannabis has seemingly achieved a stature as a therapeutic for ailments from cancer to pain without the scientific rigor or regulatory oversight required for other traditional therapeutics. By 2030, the cannabinoid market capitalization is predicted to be approximately US $100 billion, which will far surpass that of the largest pharmaceutical company in the world.1 In a large meta-analysis recently published in The Journal of the American Medical Association (JAMA), researchers at the Karolinska Institute concluded the immense positive media attention received by cannabis may shape the magnitude of placebo responses in future trials.2 As the push for legalization at home and abroad grows, it is important for the anesthesiologist to understand the implications of increasing cannabinoids, delta-9-tetrahydrocannabinol (THC), or cannabidiol (CBD) levels in the body, and their potential (or lack of) therapeutic benefits. In this special issue, this month’s Journal features articles on the basic science of cannabis, the legal and regulatory aspects of medical cannabis in the United States, and a discussion of its use as a therapeutic. What one will quickly appreciate is that while the basic science of cannabis is rich, it does not often and reliably translate to important clinical outcomes in humans, and understanding how cannabis data are presented is often key to this misalignment. In the article “Basic Science of Cannabinoids,”3 Sideris et al review the immensely complex receptor pharmacology of cannabinoid receptors (CB1 and CB2), commenting, “in short, the neuronal endocannabinoid signaling system is an elegant and tightly coordinated neuromodulatory system—effectively functioning as a circuit breaker.”4 CB1 is the most abundant G-protein–coupled receptor in the mammalian nervous system. It is found and expressed in the central nervous system in the association areas of the brain, such as the amygdala and basal ganglia, rather than the primary somatosensory complex. CB2, by contrast, is predominantly expressed on immune cells and largely produces anti-inflammatory effects. The authors comment on the role of cannabis as an antiemetic at certain doses; however, at this time they are unable to provide any comparative efficacy of cannabis to other neuromodulatory pathways such as serotonin (5-HT) pathways on nausea and vomiting. The reader will find the authors have presented the basic science of this increasingly complex molecule in an easily digestible format. As we read the subsequent articles by Boeknke et al5 and Sideris and Doan,6 we must be aware of the significant limitations with respect to cannabis research such that no false conclusions can be drawn unnecessarily by the reader. As a general rule of thumb, as we continue to read peer-reviewed publications on cannabis, we recommend that we appraise their content expecting the same standard of scientific rigor expected of other research-related publications. We must be mindful that results of cannabis research (like other therapeutics) are reported in multiple formats (eg, controlled clinical trial, observational study, retrospective review, cross-sectional study, conference abstract), each with their own set of limitations including sample size, risk of bias, quality control issues with dosage, frequency of consumption, different routes of administration, and self-reported data. Given the magnitude of the cannabinoid market, it is also important to note studies that were industry-funded. As we continue to critically review literature on cannabis, any definitive claims of efficacy (eg, analgesia, effects on opioid consumption) need to be supported by balanced and objective discussion. When stating “statistically significant” effects, authors instead ought to state the quantitative differences with confidence intervals if possible and comment if the effects were clinically significant and based on a predetermined primary outcome or not. Why does this all matter? It matters in part because clinical trials presented are focused on efficacy—not serious adverse events. If the authors do not specifically state in their methods how they planned to systematically capture adverse events, then the results for this outcome will be unreliable. Our concern for the anesthesiologist-reader is to avoid accepting cannabis publications as “dogma” with respect to potential clinical therapeutic applications of CBD, rather than endorse what is needed today—a healthier dose of skepticism of its touted benefits—noting that clinicians are directly responsible for the correct education of patients. No doubt the history of marijuana legalization for medicinal and recreational purposes is fraught with legal twists and turns at the federal and state levels. Hong et al7 clearly acknowledge the limitations of appropriately studying cannabis as a therapeutic owing to its Schedule 1 classification by the Federal Drug Enforcement Administration (FDA). As we move through the article, it is important for the reader to understand what pieces of (scientific) evidence were utilized in these legal proceedings to guide legislation. Collectively, the history and frequent policy changes have resulted in the status quo—where it is challenging for the American physician to navigate the legality of recommending cannabis for pain and other indications. And for the anesthesiologist in particular, there are specific challenges for patients consuming cannabis presenting for surgery. In a survey of patients conducted by the American Society of Anesthesiologists in 2019, 34% of patients surveyed did not feel the need to discuss using cannabis products with their doctor, and 40% believe the CBD sold at grocery stores or dispensaries is approved by the FDA.8 And what is even more alarming is inaccurate labeling to the public. In a 2017 study published in JAMA analyzing 84 CBD commercially available products, THC was detected in nearly 25% of the samples, and some of the products had levels of THC roughly equivalent to “a few deep puffs on a joint.”9 This widespread use of cannabis products and the lack of education among physicians and patients alike have triggered the American Society of Regional Anesthesia and Pain Medicine to create a practice guideline on the management of the perioperative patient on cannabis and cannabinoids.10 It is encouraging to note that Lee et al11 maintained similar conclusions about implications in the perioperative phase of care. Having a critical mind in conjunction with the current regulatory environment adds color and context to the scientific reader. It is crucial to point out limitations of utilizing “big data” via large sample size systematic reviews and meta-analyses (SR-MA). They lead to inconsistent and invalid results due to pooling results from very heterogenous studies comparing different cannabis products with different doses and routes of administrations, coupled with high risk of bias and poor quality of the underlying studies. Nevertheless, cannabis is one of the fastest growing industries in the United States and projected to be a $100 billion industry by 2030. The medical, social, and political landscape of cannabis is fluid, changing on an almost daily basis. For cannabis derivatives to become useful therapeutics, widespread clinical experience and progress in research will need to occur, alongside some possible regulatory oversight of labeling. Clinicians will demand more defined language in terms of use, timing of use, frequency of use and milligram dose consumed and will likely seek to internally validate the effectiveness of cannabis on their patients against published literature. Recently, on January 23, 2023, the FDA issued its final guidance on clinical trials of cannabis and cannabis-derived compounds, offering updated direction on federally authorized sources for cannabis and providing references to pertinent quality considerations.12 Hopefully in the near-term future, the growth of strong clinical studies will keep pace with the growth of the US legal cannabis industry—a result that no doubt we will be delighted to welcome. DISCLOSURES Name: Shalini Shah, MD, MBA, FASA. Contribution: This author helped develop underlying idea and write and review the manuscript. Name: Samer Narouze, MD, PhD, MMM. Contribution: This author helped develop underlying idea and write and review the manuscript. This manuscript was handled by: Michael J. Barrington, MBBS, FANZCA, PhD.

Telemedicine Implementation in Pain Medicine: A Survey Evaluation of Pain Medicine Practices in Spring 2020.

PubMed · 2022-08-01 · 10 citations

BACKGROUND: The COVID-19 pandemic resulted in a novel challenge for healthcare delivery and implementation in the United States (US) in 2020 and beyond. Telemedicine arose as a significant and effective medium for safe and efficacious physician-patient interactions. Prior to the COVID-19 pandemic, telemedicine while available, had infrequently been utilized in pain medicine practices due to difficulties with reimbursement, the learning curve associated with new technology usage, and the need for new logistical systems in place to implement telemedicine effectively. Given the unique constraints on the healthcare system during the COVID-19 pandemic, the ubiquitous utilization of telemedicine among pain medicine physicians increased, giving insight into potential future roles for the technology beyond the pandemic. OBJECTIVES: To survey and understand the state of implementation of telemedicine into pain medicine practices across practice settings and geographical areas; to identify potential barriers to the implementation of telemedicine in pain medicine practice; and to identify the likelihood of telemedicine continuing beyond the pandemic in pain medicine practice. STUDY DESIGN: Online questionnaire targeting Pain Medicine physicians in the US. Participants were asked questions related to the use of telemedicine during the first peak of the COVID-19 pandemic. SETTING: Online-based questionnaire distributed to academic and private practice pain medicine physicians nationally in the United States. METHODS: A 34 web-based questionnaires were distributed by the American Society of Regional Anesthesia and Pain Medicine and the Spine Intervention Society to all active members. Data were analyzed using SAS v9.4. RESULTS: Between December 3, 2020, and February 18, 2021, 164 participants accessed the survey with a response rate of 14.3%. Overall, academic physicians were more likely to implement telemedicine than private practice physicians. Telemedicine was also more frequently utilized for follow-up appointments rather than initial visits. LIMITATIONS: Although our n = 164, the overall low response rate of 14.3% warrants further investigation into the utilization of telemedicine throughout the COVID-19 pandemic. CONCLUSIONS: Telemedicine as an emerging technology for efficient communication played a key role in mitigating the adverse effects of the COVID -19 pandemic on chronic pain patients. The utilization of telemedicine remarkably increased after the start of the pandemic within 1 to 2 weeks. Overall, private hospital-based centers were significantly less likely to implement telemedicine than academic centers, possibly due to limited access to secure telemedicine platforms and high start-up costs. Telemedicine was used more frequently for follow-up visits than initial visit encounters at most centers. In spite of the unforeseen consequences to the healthcare system and chronic pain practices in the US from COVID-19, telehealth has emerged as a unique model of care for patients with chronic pain. Although it has flaws, telehealth has the ability to increase access to care beyond the end of the pandemic. Further identification of barriers to the use of telemedicine platforms in private practices should be addressed from a policy perspective to facilitate increased care access.