The Diabetes Prevention Program in Pain and Primary Care

The Diabetes Prevention Program is a coached lifestyle intervention targeting 7 percent weight loss and 150 minutes of weekly activity. A referral from a pain or primary care practice should carry a documented baseline (A1c, fasting glucose, fasting insulin, kidney function and body composition) and an early recheck, because participants who see a result stay.

Lifestyle intervention cut diabetes incidence by more than half in the trial that defined it. At national scale it reaches a sliver of eligible adults and delivers least to those at highest risk.

The Diabetes Prevention Program is the strongest randomized evidence in American medicine that a coached lifestyle intervention changes metabolic outcomes, and it is also the clearest demonstration that proof is not delivery. For primary care, pain, endocrine and geriatric practices the practical question is not whether to refer. It is what should travel with the referral, and what measurement keeps the effect from leaking away between enrollment and week 52. The chapter video, Empowered Individuals Change Their Communities, presents the final chapter of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD; source-level grading is in the book companion for chapter 22.

How well does the Diabetes Prevention Program work?

The original trial randomized 3,234 adults with impaired glucose tolerance to placebo, metformin or a lifestyle program targeting 7 percent weight loss and 150 minutes of weekly activity. Over an average of 2.8 years, lifestyle reduced diabetes incidence by 58 percent and metformin by 31 percent, with 6.9 people needing the lifestyle program over three years to prevent one case. At 15 years the lifestyle hazard ratio was still 0.73, though cumulative incidence had reached 55 percent against 62 percent on placebo, and at 21 years the cumulative reduction stood at 24 percent.

The ceiling came from established diabetes. Look AHEAD randomized 5,145 adults with type 2 diabetes to intensive lifestyle intervention; weight fell 8.6 percent at one year, and the cardiovascular composite did not differ, a hazard ratio of 0.95. What it did deliver was remission in 11.5 percent at one year against 2.0 percent with education.

Where national scale loses the effect

Scaled nationally, the program enrolled 455,954 people in eight years, set against an at-risk adult population of more than 88 million. Among the first 14,747 participants, median attendance was 14 sessions, 35.5 percent reached the 5 percent weight-loss goal, and each additional session was worth 0.3 percent of body weight. In-person delivery produced 4.4 percent average weight loss against 2.6 percent online, and participants who stayed for 22 sessions exceeded the 5 percent goal in every format.

The losses concentrate where risk is highest. In-person weight loss ran 5.1 percent in non-Hispanic White participants against 3.3 percent in non-Hispanic Black and American Indian or Alaska Native participants, and 3.3 percent at ages 18 to 34 against 5.1 percent at 65 and older. Early success predicted staying: 41.0 percent of those who had lost nothing were retained, against 73.9 percent of those who had lost at least half a percent. Medicare has covered the program since 2018; in six years 9,015 beneficiaries participated, against roughly 5.2 million eligible, with about 1.5 delivery sites per 100,000 beneficiaries.

What should a Diabetes Prevention Program referral include?

The retention data argue for a documented baseline and an early recheck, because participants who see a result stay. That baseline should include more than glucose.

• A1c and fasting glucose, with remission and progression defined in advance.
• Fasting insulin or a HOMA-IR estimate, because insulin resistance can move substantially while glucose moves little; one company-funded remote-care cohort reported a 55 percent fall in HOMA-IR at one year.
• Kidney function. In 1,779 Diabetes Prevention Program participants reassessed about 21 years after randomization, painful neuropathic symptoms tracked weight and lower eGFR and were not associated with glycemia.
• Body composition, particularly when BMI is under 27. In 20 people with type 2 diabetes at that BMI, a 6.5 percent weight loss produced remission in 70 percent, and roughly one in six patients is diagnosed at that weight.
• A weight target expressed as a percentage, with the musculoskeletal threshold noted for pain patients: knee osteoarthritis relief was anticipated at about 7 percent loss.

For pain practices the musculoskeletal evidence is real and modest. Weight-loss interventions improved osteoarthritis pain by a standardized 0.54 against minimal care but were not better than exercise alone in knee osteoarthritis; pair the referral with dosed movement. Effects on pain beyond the joints are inferred from mechanism.

Who should be referred to a Diabetes Prevention Program?

• Adults with prediabetic glycemia, including those previously told their A1c was nothing to worry about.
• Chronic pain patients with a metabolic phenotype: elevated glucose or A1c, a high triglyceride-to-HDL ratio, central adiposity.
• Patients with type 2 diabetes and a normal BMI, in whom body composition changes the conversation.
• Patients with painful neuropathic symptoms, where weight and kidney function deserve measurement alongside glycemia.
• Household members of enrolled patients, since untreated spouses in lifestyle trials lost weight alongside the enrolled partner.

Practice criteria are summarized under selection criteria.

Measurement as the retention tool

Education has a dose and a half-life. Diabetes self-management education lowered A1c by 0.57 on average with ten or more contact hours as the threshold, and pooled trajectories after face-to-face education showed an early reduction of about 1.3 percent drifting back toward baseline by 52 weeks, independent of program intensity. Feedback holds part of the gain: continuous glucose monitoring added 0.29 over fingersticks, and among 9,768 smart-scale users a gap of 30 days without weighing was associated with 1.37 kilograms of gain in those with obesity.

Measura [Cardiometabolic and Autonomic Health Analysis] supplies the office-based side of that feedback loop. It is a testing service that reports to the ordering physician and does not treat or diagnose disease on its own. Laboratory panels provide the glycemic, lipid and renal markers, and bioimpedance body composition separates fat and lean mass so that a participant losing muscle is not recorded as a success. Repeat measurement at defined intervals turns a referral into a tracked episode rather than a handoff; the case for standing orders applies directly.

The consultation is part of the dose

How the referral is delivered changes what it does. In a 1987 trial of 200 general practice patients without a definite diagnosis, 64 percent were better at two weeks after a positive consultation against 39 percent after a negative one, while treatment itself made little difference. In 406 patients with newly chronic back pain, each point of perceived risk that the pain would persist slowed recovery at a hazard ratio of 0.91. Among 720 medical inpatients, hopelessness about one’s condition carried an adjusted odds ratio of 5.69 for a positive suicide screen, against 2.29 for chronic pain. Only 15.7 percent of primary care visits included counseling on diet, activity or stress.

Standing orders and documentation

A reproducible workflow is a standing order that attaches A1c, fasting glucose and insulin, a lipid panel, kidney function and body composition to every prevention-program referral, with a scheduled repeat early, when retention is decided, and again before the first year ends, when education effects fade. At an annual wellness visit, the same data support the cardiometabolic documentation tracked under HEDIS and value-based care, as quality documentation rather than an indication in itself. Filing results as structured fields through getting results into the record keeps the trend visible to every clinician in the chain. The mood and metabolic screening that precedes many of these referrals is in depression and insulin resistance screening; patients can read the patient version.

Frequently asked questions

References

• Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A., Nathan, D. M., & Diabetes Prevention Program Research Group (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine, 346(6), 393–403. https://doi.org/10.1056/NEJMoa012512
• Diabetes Prevention Program Research Group (2015). Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. The Lancet Diabetes & Endocrinology, 3(11), 866–75. https://doi.org/10.1016/S2213-8587(15)00291-0
• Crandall, J. P., Dabelea, D., Knowler, W. C., Nathan, D. M., Temprosa, M., & Diabetes Prevention Program Research Group (2025). The Diabetes Prevention Program and Its Outcomes Study: NIDDK’s Journey Into the Prevention of Type 2 Diabetes and Its Public Health Impact. Diabetes Care, 48(7), 1101–1111. https://doi.org/10.2337/dc25-0014
• Cannon, M. J., Ng, B. P., Lloyd, K., Reynolds, J., & Ely, E. K. (2022). Delivering the National Diabetes Prevention Program: Assessment of Enrollment in In-Person and Virtual Organizations. J Diabetes Res, 2022, 2942918. https://doi.org/10.1155/2022/2942918
• Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A National Effort to Prevent Type 2 Diabetes: Participant-Level Evaluation of CDC’s National Diabetes Prevention Program. Diabetes Care, 40(10), 1331–1341. https://doi.org/10.2337/dc16-2099
• Ng, B. P., Ely, E., Papali’i, M., & Cannon, M. J. (2024). Delivering the National Diabetes Prevention Program: Assessment of Retention, Physical Activity, and Weight Loss Outcomes by Participant Characteristics and Delivery Modes. J Diabetes Res, 2024, 8461704. https://doi.org/10.1155/2024/8461704
• Look AHEAD Research Group, Wing, R. R., Bolin, P., Brancati, F. L., Bray, G. A., Clark, J. M., Coday, M., Crow, R. S., Curtis, J. M., Egan, C. M., Espeland, M. A., Evans, M., Foreyt, J. P., Ghazarian, S., Gregg, E. W., Harrison, B., Hazuda, H. P., Hill, J. O., Horton, E. S., … Yanovski, S. Z. (2013). Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med, 369(2), 145–54. https://doi.org/10.1056/NEJMoa1212914
• Herman, W. H., Ciarleglio, A., Callaghan, B. C., Edelstein, S. L., Goldberg, R., White, N. H., & Albers, J. W. (2025). Nonglycemic and Glycemic Risk Factors for Painful Neuropathic Symptoms and for Distal Symmetrical Polyneuropathy (DSPN) in the Diabetes Prevention Program/Diabetes Prevention Program Outcomes Study. Diabetes Care, 48(10), 1676–1684. https://doi.org/10.2337/dc25-0596
• Taylor, R., Barnes, A. C., Hollingsworth, K. G., Irvine, K. M., Solovyova, A. S., Clark, L., Kelly, T., Martin-Ruiz, C., Romeres, D., Koulman, A., Meek, C. M., Jenkins, B., Cobelli, C., & Holman, R. R. (2023). Aetiology of Type 2 diabetes in people with a ‘normal’ body mass index: testing the personal fat threshold hypothesis. Clinical Science, 137(16), 1333–1346. https://doi.org/10.1042/CS20230586
• Dughmosh, R., Hamdan, A., Moghassabi, W., Al-Kahlout, L., Syed, A., Alwisi, N., Al-Sharif, N., Othman, M., & Doi, S. A. R. (2026). Glycemic trajectory after face-to-face diabetes self-management education: a dose-response meta-analysis. Diabetes Research and Clinical Practice, 238, 113375. https://doi.org/10.1016/j.diabres.2026.113375

Related reading

• Depression and Insulin Resistance: Screening the Pain Patient
• Laboratory Panels

Depression and Insulin Resistance: Screening the Pain Patient

Screen a pain patient with depression for insulin resistance: fasting glucose, A1c, the triglyceride-to-HDL ratio and body composition belong beside the PHQ-9. The two conditions predict each other, and the metabolic pattern predicts how far chronic pain spreads and how procedures perform.

A positive depression screen in a pain patient usually produces a behavioral health referral. The metabolic data that predict how that patient’s mood, pain and procedures will behave rarely travel with it.

Depression and insulin resistance tend to be charted by different clinicians, yet in patients with chronic pain the two predict each other, predict how far the pain spreads, and predict how an injection or an operation performs. A positive PHQ-9 in a pain or primary care clinic generates a referral; the fasting glucose, A1c, lipid ratio and body composition that belong beside it usually do not. The video You Cannot Separate the Mind from the Metabolism covers chapter 21 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. Evidence grading sits in the book companion for chapter 21; the concern here is what a primary care, pain, endocrine or geriatric practice should measure once mood and pain arrive together.

How common is depression in chronic pain patients?

In a synthesis of 376 studies and 347,468 people with chronic pain, clinically significant depressive symptoms ran 39.3 percent and diagnosed major depressive disorder 36.7 percent, with fibromyalgia at 54.0 percent. Heterogeneity approached 99 percent and screens were pooled with formal diagnoses, so the diagnosed figure is the conservative one. Pain also impairs the recognition and treatment of depression, so a busy procedural or primary care schedule underdetects it by default.

A depression screen that ends the workup tells the patient her pain is psychological. A screen that extends the workup into the metabolic terrain does the reverse.

Does insulin resistance predict depression, or the reverse?

Cross-sectionally the association is modest, a pooled standardized effect of 0.19 in data excluding prevalent diabetes. Prospectively it is more informative. Baseline depression predicted incident type 2 diabetes at a relative risk of 1.60, and baseline diabetes predicted incident depression at 1.15. In the NESDA cohort, 601 adults without lifetime depression or anxiety were followed nine years: a higher triglyceride-to-HDL ratio predicted first-onset major depression at a hazard ratio of 1.89, fasting glucose at 1.37, waist circumference at 1.11, and prediabetes developing within two years at 2.66. These are surrogate measures rather than clamp studies, and new-onset lipid ratio elevation was not associated, but the metabolic signal preceded the mood disorder.

The inflammatory subgroup is real and bounded. Across 37 studies, CRP exceeded 3 mg/L in 27 percent of depressed patients and 1 mg/L in 58 percent, at odds of 1.46 and 1.47 against matched controls, without variation by antidepressant treatment, age or BMI. Roughly three quarters fall below the higher threshold. CRP stratifies; it does not diagnose.

Pharmacotherapy sits inside the same loop. In 294,719 adults in the UK Clinical Practice Research Datalink, antidepressant use carried an adjusted rate ratio of 1.21 for at least 5 percent weight gain, persisting at least six years, with one additional weight-gain episode per 27 patients treated in year two. Neither finding argues against prescribing. Both argue for a documented baseline weight, body composition and fasting glucose before the first dose.

How does metabolic status change pain and procedure outcomes?

In MIDUS, 24.2 percent of 781 adults showed a metabolic dysregulation phenotype defined by fasting glucose, HbA1c, HOMA-IR, triglycerides, waist-hip ratio and low HDL. About seven years later that phenotype carried a relative risk ratio of 2.00 for high-interference chronic pain and 2.03 for pain at three or more sites, while it did not predict the presence of chronic pain, an odds ratio of 1.18. The metabolic terrain forecasts spread and interference, which are the outcomes pain practices are asked to change.

It also forecasts procedural yield. Across 346 patients in seven hospitals receiving epidural steroid injections, sacroiliac injections or facet radiofrequency ablation, depressive symptoms lowered the odds of success by an adjusted 0.94 per unit of score, obesity reduced relief, and poor baseline function cut the odds to 0.59. With metabolic syndrome, spine surgery carried 1.6 times the wound complications and 4.48 times the renal complications. Across 44 studies and 21,452 spine surgery patients, depressed patients started 0.52 standardized units worse and finished 0.52 worse, with identical improvement: the operation worked and the depression stayed.

A documented mood and metabolic phenotype sets expectations before a procedure. It justifies treating layers together; in SCAMP, 250 primary care patients with musculoskeletal pain and a PHQ-9 of at least 10 who received optimized antidepressant therapy plus pain self-management reached combined improvement in depression and pain at 26.0 percent against 7.9 percent, a relative risk of 3.3. And it names the social driver neither specialty owns: in older Chinese adults without chronic pain at baseline, loneliness carried an odds ratio of 1.61 for incident chronic pain over seven years.

Which pain patients should be screened for insulin resistance?

• Chronic pain patients with a positive PHQ-9 or a documented depressive disorder.
• Pain that is spreading to new sites or increasingly interfering with function.
• Patients about to start or escalate an antidepressant associated with weight gain.
• Candidates for epidural, sacroiliac, radiofrequency or spinal surgical procedures who have depressive symptoms, obesity or poor baseline function.
• Patients with prediabetic glycemia or an elevated triglyceride-to-HDL ratio who have never been screened for mood.

Selection thresholds for a practice are listed in selection criteria.

What Measura measures in this pathway

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service: it measures, returns results to the ordering physician, and does not diagnose depression or treat. Laboratory panels are the route for the glycemic, lipid and inflammatory markers used in the cohorts above. Bioimpedance body composition separates fat from lean mass, which matters when an antidepressant or a sedentary year shifts weight and when BMI understates risk. Heart rate variability adds an autonomic dimension; baseline autonomic measures did not predict improvement in 665 NESDA participants with multisite pain, so it serves as a trended descriptor, not a prognostic score. In older patients whose complaints include memory or processing change, the cognitive assessment and fall prevention workflow documents a separate domain; a cognitive test is not a depression instrument and should not be read as one.

Standing orders and documentation

The reproducible version is a standing order that attaches fasting glucose, A1c, a lipid panel with the triglyceride-to-HDL ratio, C-reactive protein and body composition to any positive depression screen in a chronic pain patient, and to any pre-procedure evaluation in a patient with depressive symptoms. The baseline then exists before the antidepressant, the injection or the referral, and a scheduled repeat shows whether a combined plan is moving the terrain. The same results support the documentation that MIPS and quality reporting frameworks already track, and filing them as structured data through getting results into the record keeps them visible to the behavioral clinician and the interventionalist at once. The broader argument is in why metabolic health belongs in a pain practice.

The limits, stated once

The evidence is largely observational, the markers are surrogates, and the inflammatory signal describes a subgroup. The practice position stands: mood and metabolism are one system, and small effects that stack are the honest offer. Measure both layers at baseline, treat them together, and remeasure. What happens when that plan leaves the clinic is the subject of referral to diabetes prevention with measurement; patients can read the patient version.

Frequently asked questions

References

• Aaron, R. V., Ravyts, S. G., Carnahan, N. D., Bhattiprolu, K., Harte, N., McCaulley, C. C., Vitalicia, L., Rogers, A. B., Wegener, S. T., & Dudeney, J. (2025). Prevalence of Depression and Anxiety Among Adults With Chronic Pain: A Systematic Review and Meta-Analysis. JAMA Network Open, 8(3), e250268. https://doi.org/10.1001/jamanetworkopen.2025.0268
• Kan, C., Silva, N., Golden, S. H., Rajala, U., Timonen, M., Stahl, D., & Ismail, K. (2013). A systematic review and meta-analysis of the association between depression and insulin resistance. Diabetes Care, 36(2), 480–9. https://doi.org/10.2337/dc12-1442
• Mezuk, B., Eaton, W. W., Albrecht, S., & Golden, S. H. (2008). Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care, 31(12), 2383–90. https://doi.org/10.2337/dc08-0985
• Watson, K. T., Simard, J. F., Henderson, V. W., Nutkiewicz, L., Lamers, F., Nasca, C., Rasgon, N., & Penninx, B. W. J. H. (2021). Incident Major Depressive Disorder Predicted by Three Measures of Insulin Resistance: A Dutch Cohort Study. Am J Psychiatry, 178(10), 914–920. https://doi.org/10.1176/appi.ajp.2021.20101479
• Osimo, E. F., Baxter, L. J., Lewis, G., Jones, P. B., & Khandaker, G. M. (2019). Prevalence of low-grade inflammation in depression: a systematic review and meta-analysis of CRP levels. Psychol Med, 49(12), 1958–1970. https://doi.org/10.1017/S0033291719001454
• Gafoor, R., Booth, H. P., & Gulliford, M. C. (2018). Antidepressant utilisation and incidence of weight gain during 10 years’ follow-up: population based cohort study. BMJ, 361, k1951. https://doi.org/10.1136/bmj.k1951
• Liang, Y., & Booker, C. (2024). Allostatic load and chronic pain: a prospective finding from the national survey of midlife development in the United States, 2004-2014. BMC Public Health, 24(1), 416. https://doi.org/10.1186/s12889-024-17888-1
• Cohen, S. P., Doshi, T. L., Kurihara, C., Reece, D., Dolomisiewicz, E., Phillips, C. R., Dawson, T., Jamison, D., Young, R., & Pasquina, P. F. (2021). Multicenter study evaluating factors associated with treatment outcome for low back pain injections. Regional Anesthesia and Pain Medicine, 47(2), 89–99. https://doi.org/10.1136/rapm-2021-103247
• Javeed, S., Benedict, B., Yakdan, S., Saleem, S., Zhang, J. K., Botterbush, K., Frumkin, M. R., Hardi, A., Neuman, B., Kelly, M. P., Steinmetz, M. P., Piccirillo, J. F., Goodin, B. R., Rodebaugh, T. L., Ray, W. Z., & Greenberg, J. K. (2024). Implications of Preoperative Depression for Lumbar Spine Surgery Outcomes: A Systematic Review and Meta-Analysis. JAMA Network Open, 7(1), e2348565. https://doi.org/10.1001/jamanetworkopen.2023.48565
• Kroenke, K., Bair, M. J., Damush, T. M., Wu, J., Hoke, S., Sutherland, J., & Tu, W. (2009). Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA, 301(20), 2099–110. https://doi.org/10.1001/jama.2009.723

Related reading

• The Sudomotor Test in Mixed Pain: What It Adds and What It Cannot
• The Diabetes Prevention Program in Pain and Primary Care
• Laboratory Panels

The Sudomotor Test in Mixed Pain: What It Adds and What It Cannot

A sudomotor test measures sweat-gland function driven by small autonomic nerve fibers in the hands and feet, an objective look at the small-fiber loss behind many kinds of neuropathic pain. It supports the examination-based grade; it does not locate a focal nerve lesion or name the pain generator.

Neuropathic pain is graded by examination, not detected by a single test. Objective small-fiber and autonomic measurement belongs beside that grade, as long as nobody expects it to name the generator.

Neuropathic pain inside a nociceptive diagnosis is common, under-named and treated in the wrong language. Among 473,815 US nursing home residents, coded neuropathic pain ran 14.6 percent, and 28.2 percent of those residents received no treatment for it at all. The sudomotor test is often proposed as the missing objective step, and it has a legitimate place, provided nobody asks it to name the generator. The chapter video, Nerve or Joint? Pain Speaks Two Languages, presents chapter 20 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. The graded evidence is in the book companion for chapter 20; the focus here is where objective small-fiber and autonomic measurement belongs in the workup.

How is neuropathic pain diagnosed?

The NeuPSIG grading system earns possible from a relevant lesion and a neuroanatomically plausible distribution, probable from sensory signs in that distribution, and definite from a confirmatory test; probable should usually be sufficient to initiate treatment, and negative signs outweigh positive ones. Uptake has been poor: only 56 of 220 clinical studies, 25 percent, used the system, and screening questionnaires are not to be used alone. At the bedside, a cluster of 8 history and examination items reached 72 percent sensitivity and 80 percent specificity for lumbosacral root compression.

The joint European assessment guideline gives a strong recommendation to DN4 and LANSS and to skin biopsy, a weak one to quantitative sensory testing, and supports neither functional neuroimaging nor nerve blocks for diagnosis. A diagnostic block still has a role in locating a generator for treatment planning; it simply does not grade neuropathic pain.

How often does nerve pain hide inside a joint or surgical diagnosis?

In hip osteoarthritis, 29 percent screened possible and 9 percent probable neuropathic-like on painDETECT. After thoracic surgery, persistent postoperative pain ran 38.1 percent across 19,001 patients, with a neuropathic component in 33.0 percent of those. Before knee arthroplasty in two cohorts of 524 patients, an unclear painDETECT band carried odds of 2.19 and a neuropathic-like band 2.83 for moderate-to-severe pain at a year; a Korean cohort of 148 using DN4 found no effect, with only about 22 neuropathic patients. Across a Swedish national registry of 6,579,612 adults, first-year pain medication use after a lower-limb nerve injury carried a relative risk of 5.60.

The social driver is the default pathway. A nociceptive label arrives with a nociceptive prescription and a procedural referral, and nobody is assigned to re-grade the pain when the response disappoints.

What does a sudomotor test measure?

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service reporting to the ordering physician; it does not diagnose disease on its own and does not treat. Sudomotor testing measures sweat-gland function mediated by small autonomic fibers in the distal limbs, an objective window on the same small-fiber population whose loss drives many neuropathic phenotypes. Cardiac autonomic reflex tests and broader autonomic nervous system testing characterize cardiovagal and sympathetic function when the history suggests wider autonomic involvement.

Three limits should be stated once. First, none of these tests locates a focal lesion: a superior cluneal neuropathy, meralgia paresthetica or an infrapatellar saphenous branch injury will not declare itself on a distal sweat measurement. Second, Measura cannot diagnose a joint generator or exclude one; that remains examination and diagnostic injection. Third, small-fiber structure does not grade pain. Skin biopsy, the Level A confirmatory test and a different test done elsewhere, does not correlate with pain intensity, and intraepidermal density separated painful from painless diabetic neuropathy only at a standardized 0.31 across 664 patients. Read an abnormal sudomotor result as evidence of a substrate, not as a pain diagnosis.

What changes when a sudomotor test is abnormal?

Phenotype, then drug. Cluster analysis of 902 patients with peripheral neuropathic pain found sensory loss in 42 percent, thermal hyperalgesia in 33 percent and mechanical hyperalgesia in 24 percent. Oxcarbazepine’s number needed to treat was 3.9 in the irritable nociceptor phenotype against 13 without it, with a barely significant interaction; a phenotype-stratified lacosamide trial found no difference and closed early. In 30 patients with painful diabetic neuropathy, conditioned pain modulation correlated with duloxetine response at 0.628. Documented small-fiber loss moves a patient toward the neuropathic side of that ledger and toward the first-line agents built for it.

Metabolism, alongside. In recordings from people with diabetes, 79 percent of sampled C-fibers were pathologically altered, and 72 percent of nociceptors fired spontaneously in painful neuropathy against 15 percent in painless neuropathy. A small-fiber finding without laboratory panels for glycemia is half a result. Normative intraepidermal density also falls by 1.35 fibers per millimeter every five years, so age belongs in any interpretation.

Falls. Distal small-fiber and autonomic dysfunction belong in the same conversation as balance in older patients. Pair a positive result with the cognitive assessment and fall prevention workflow rather than filing it alone.

Who should get a sudomotor test?

• Pain labeled as a joint or disc problem with burning quality, allodynia or a sensory deficit on examination.
• Persistent pain after arthroplasty or thoracic surgery that has not responded to nociceptive treatment.
• Patients with diabetes or a prediabetic A1c reporting distal burning or numbness.
• Preoperative arthroplasty candidates in an unclear or neuropathic-like painDETECT band.

Selection criteria are summarized under who to test, and results support documentation in MIPS and quality reporting. The humility belongs here too: Dr. Padda has said he has treated a nerve in the language of a joint, as most of us have. The upstream error, choosing clinics and workups by the wrong measure, is taken up in comprehensive pain assessment. Patients can read the patient version.

Frequently asked questions

References

• Mbrah, A. K., Nunes, A. P., Hume, A. L., Zhao, D., Jesdale, B. M., Bova, C., & Lapane, K. L. (2022). Prevalence and treatment of neuropathic pain diagnoses among U.S. nursing home residents. Pain, 163(7), 1370-1377. https://doi.org/10.1097/j.pain.0000000000002525
• Finnerup, N. B., Haroutounian, S., Kamerman, P., Baron, R., Bennett, D. L. H., Bouhassira, D., Cruccu, G., Freeman, R., Hansson, P., Nurmikko, T., Raja, S. N., Rice, A. S. C., Serra, J., Smith, B. H., Treede, R. D., & Jensen, T. S. (2016). Neuropathic pain: an updated grading system for research and clinical practice. Pain, 157(8), 1599–1606. https://doi.org/10.1097/j.pain.0000000000000492
• Truini, A., Aleksovska, K., Anderson, C. C., Attal, N., Baron, R., Bennett, D. L., Bouhassira, D., Cruccu, G., Eisenberg, E., Enax-Krumova, E., Davis, K. D., Di Stefano, G., Finnerup, N. B., Garcia-Larrea, L., Hanafi, I., Haroutounian, S., Karlsson, P., Rakusa, M., Rice, A. S. C., … Veluchamy, A. (2023). Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on neuropathic pain assessment. European Journal of Neurology, 30(8), 2177-2196. https://doi.org/10.1111/ene.15831
• Mistry, J., Heneghan, N. R., Noblet, T., Falla, D., & Rushton, A. (2020). Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back related leg pain: a systematic review and narrative synthesis. BMC Musculoskeletal Disorders, 21(1), 532. https://doi.org/10.1186/s12891-020-03436-6
• Wall, A. J. W., Leyland, K. M., Kiran, A., Arden, N. K., Cooper, C., Wanigasekera, V., Javaid, M. K., Price, A. J., Tracey, I. M. C., & Irani, A. (2025). PainDETECT as a Potential Tool for Personalized Medicine: Predicting Outcome One Year After Knee Arthroplasty. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 9(5), 100649. https://doi.org/10.1016/j.mayocpiqo.2025.100649
• Lauria, G., Hsieh, S. T., Johansson, O., Kennedy, W. R., Leger, J. M., Mellgren, S. I., Nolano, M., Merkies, I. S. J., Polydefkis, M., Smith, A. G., Sommer, C., & Valls-Solé, J. (2010). European Federation of Neurological Societies/Peripheral Nerve Society guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. European Journal of Neurology, 17(7), 903-912, e44-e49. https://doi.org/10.1111/j.1468-1331.2010.03023.x
• Gad, H. Y., Devigili, G., Merkies, I., Gilron, I., MacDonald, R., Lauria, G., & Malik, R. A. (2026). Corneal confocal microscopy and skin biopsy to differentiate painful from painless diabetic neuropathy: A systematic review with multiple meta-analyses. European Journal of Neurology, 33(3), e70576. https://doi.org/10.1111/ene.70576
• Baron, R., Maier, C., Attal, N., Binder, A., Bouhassira, D., Cruccu, G., Finnerup, N. B., Haanpää, M., Hansson, P., Hüllemann, P., Jensen, T. S., Freynhagen, R., Kennedy, J. D., Magerl, W., Mainka, T., Reimer, M., Rice, A. S. C., Segerdahl, M., Serra, J., … Treede, R. D. (2017). Peripheral neuropathic pain: a mechanism-related organizing principle based on sensory profiles. Pain, 158(2), 261–272. https://doi.org/10.1097/j.pain.0000000000000753
• Demant, D. T., Lund, K., Vollert, J., Maier, C., Segerdahl, M., Finnerup, N. B., Jensen, T. S., & Sindrup, S. H. (2014). The effect of oxcarbazepine in peripheral neuropathic pain depends on pain phenotype: A randomised, double-blind, placebo-controlled phenotype-stratified study. Pain, 155(11), 2263–2273. https://doi.org/10.1016/j.pain.2014.08.014
• Becker, A. K., Babes, A., Düll, M. M., Khalil, M., Kender, Z., Gröner, J., Namer, B., Reeh, P. W., & Sauer, S. K. (2023). Spontaneous activity of specific C-nociceptor subtypes from diabetic patients and mice: Involvement of reactive dicarbonyl compounds and (sensitized) transient receptor potential channel A1. Journal of the Peripheral Nervous System, 28(2), 202–225. https://doi.org/10.1111/jns.12546

Related reading

• Comprehensive Pain Assessment: Measuring What the Short Visit Skips
• Depression and Insulin Resistance: Screening the Pain Patient
• Sudomotor Testing

Comprehensive Pain Assessment: Measuring What the Short Visit Skips

A comprehensive pain assessment finds the pain generator by examination, then screens the terrain: A1c for glycemia, sleep apnea, and depression and anxiety. All are common in chronic pain, and all are easy to miss in a short visit graded on satisfaction.

Satisfaction scores reward the fulfilled request. The findings that change a chronic pain plan rarely surface in a visit organized around that score.

A chronic pain practice is graded on satisfaction, and satisfaction is earned by the fulfilled request. The workup that changes the plan, the prediabetic A1c, the untested apnea, the hip behind the back pain, earns nothing on that scale because the patient never sees it happen. The chapter video, Kindness Is the Baseline, Not the Achievement, presents chapter 19 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. Study-level detail and limits are in the book companion for chapter 19; the focus here is what a comprehensive pain assessment should measure and how to make that reproducible in primary care, pain, endocrinology and geriatric practice.

Do patient satisfaction scores get in the way of a full pain workup?

In 1,319 family medicine visits, denying a patient’s request cost satisfaction by request type: 19.75 percentile points for a referral, 10.72 for pain medication and 9.19 for a laboratory test. The last figure is the non-obvious one. A requested lab that is refused is penalized; a lab nobody thought to discuss is invisible. The score therefore punishes saying no and is blind to not looking. In a survey of 155 self-selected physicians in one state, 59 percent reported compensation tied to satisfaction ratings, with a 3.9 percent response rate that limits how far the finding travels. The structural driver is plain enough: the metric rewards the visible transaction, and terrain screening is not visible.

How often does a second look change the pain diagnosis?

Extrapolated from three US observational studies, about 5.08 percent of adults experience an outpatient diagnostic error each year. Among 286 primary care referrals to a tertiary center, selected for diagnostic uncertainty, the referral diagnosis matched the final diagnosis in 12 percent, was refined in 66 percent and was distinctly different in 21 percent. In a single surgeon’s consecutive series of 200 back pain patients, 17.5 percent had hip or sacroiliac pathology alongside the spine, 8 percent had it without spine pathology, and 10 percent remained undefined after the workup.

None of those generators is found by a measurement service. They are found by examination and, where indicated, a diagnostic injection. The terrain is a separate question, and it is where objective testing earns its place.

What does screening find in people with chronic pain?

Glycemia. Point-of-care A1c in 84 hand clinic patients with carpal tunnel syndrome, trigger finger, Dupuytren’s contracture or De Quervain’s disease found 58.3 percent in the prediabetic range and 4.8 percent in the diabetic range; 43.4 percent of those with abnormal values had no primary care provider. The conditions were chosen for their known diabetes association, so the yield transfers to that presentation rather than to all pain.

Sleep-disordered breathing. Among opioid-treated Canadian pain clinic patients who completed polysomnography, 58.8 percent had sleep apnea, and each one-unit rise in STOP-Bang raised the odds of moderate-to-severe disease by 70 percent. In 90 consecutive Danish patients with high-impact chronic pain, 51.1 percent had obstructive apnea and 31.1 percent moderate or severe disease; Berlin ran 78.6 percent sensitivity and 45.2 percent specificity, STOP-BANG 71.4 and 58.1, and pain, disability and sleepiness did not distinguish the patients with apnea.

Mood and autoimmunity. Pooled across 376 studies, clinically significant depressive and anxiety symptoms ran 39.3 and 40.2 percent, rising to 54.0 and 55.5 percent in fibromyalgia samples. Thyroid peroxidase antibody positivity carried an odds ratio of 3.41 in fibromyalgia across five small case-control studies.

Low-yield tests. After full adjustment in 349,221 UK adults, vitamin D status carried odds ratios of 1.01 or lower for regional musculoskeletal pain; only deficiency below 25.0 nmol/L held a signal for widespread pain, at 1.26. Celiac screening in 62 Brazilian fibromyalgia patients found no cases. A comprehensive pain assessment is not every test; it is the tests the presentation points to.

Who needs a comprehensive pain assessment?

• Chronic musculoskeletal or tendon-region pain in a patient without a recent A1c, or whose last value sat in the prediabetic band.
• Patients on long-term opioid therapy, who warrant formal sleep testing rather than reliance on a questionnaire.
• Patients carrying a fibromyalgia label, where mood screening and the metabolic panel belong in the same encounter.
• Candidates for neuromodulation, since depression predicted first-year spinal cord stimulator explant at 1.39 in claims data.
• Pain that has absorbed repeated procedures without a documented diagnosis.

Practice-level criteria are summarized under selection criteria.

Where Measura fits and where it does not

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service that reports to the ordering physician; it does not diagnose disease on its own and it does not treat. Two measurements carry this pathway: laboratory panels, which put A1c and fasting insulin in the chart, and bioimpedance body composition, which shows whether weight is muscle or adipose tissue. In older patients with chronic pain, cognitive assessment fits the same encounter, with the cognitive assessment and fall prevention workflow holding the two records side by side. Polysomnography, validated depression instruments and diagnostic blocks sit outside the service and should be ordered in parallel.

Metabolic health is the exception, not the default. The metabolically healthy share of American adults was under 12.2 percent on NHANES 2009–2016 and fell under 7 percent on the stricter criteria applied after 2021. In our clinic, under 1 percent of chronic pain patients qualify; that is a practice-reported figure from our own population rather than a trial outcome, and individual results vary. Dr. Padda’s own confession is that for years he read a borderline A1c as reassurance. That is the error a standing order is designed to remove.

Standing orders, documentation and follow-up in numbers

A standing order that attaches metabolic labs and body composition to new chronic pain referrals removes the decision from a crowded visit. The same results support cardiometabolic and cognitive documentation in MIPS and quality reporting as quality documentation rather than as an indication in themselves.

Follow-up needs its own numbers. Across 116 randomized trials and 49,785 patients, feeding patient-reported outcomes back to clinicians improved communication at a standardized 0.36, diagnosis and notation at a risk ratio of 1.73, and disease control at 1.25, while pain itself moved 0.00. Measurement is how a practice learns whether a plan worked, not the plan. Agree on the target up front: IMMPACT counts 30 percent as moderate and 50 percent as substantial improvement, and 110 patients defining success named 56 percent. Outcome tracking is described under what changes for the patient. The related tendon referral pathway is in tendinopathy as a metabolic signal, and patients can read the patient version.

Frequently asked questions

References

• Jerant, A., Fenton, J. J., Kravitz, R. L., Tancredi, D. J., Magnan, E., Bertakis, K. D., & Franks, P. (2018). Association of Clinician Denial of Patient Requests With Patient Satisfaction. JAMA Internal Medicine, 178(1), 85–91. https://doi.org/10.1001/jamainternmed.2017.6611
• Zgierska, A., Rabago, D., & Miller, M. M. (2014). Impact of patient satisfaction ratings on physicians and clinical care. Patient Preference and Adherence, 8, 437–446. https://doi.org/10.2147/PPA.S59077
• Heiting, C., Wickes, C. B., Katakam, S., Herrera, C., Li, B., Intravia, J., Nolan, J. E., & Nellans, K. W. (2026). Occurrence of Undiagnosed Diabetes Mellitus With Musculoskeletal Disorders of the Upper Extremity: Prospective Screening With Point-of-Care Haemoglobin A1c Fingerstick Testing. Musculoskeletal Care, 24(3), e70256. https://doi.org/10.1002/msc.70256
• Chung, F., Wong, J., Bellingham, G., Lebovic, G., Singh, M., Waseem, R., Peng, P., George, C. F. P., Furlan, A., Bhatia, A., Clarke, H., Juurlink, D. N., Mamdani, M. M., Horner, R., Orser, B. A., & Ryan, C. M. (2019). Predictive factors for sleep apnoea in patients on opioids for chronic pain. BMJ Open Respiratory Research, 6(1), e000523. https://doi.org/10.1136/bmjresp-2019-000523
• Larsen, D. B., Bendix, L., Abeler, K., Petersen, K. K., Sprehn, M., Bruun, K. D., Blichfeldt-Eckhardt, M. R., & Vaegter, H. B. (2021). Obstructive sleep apnea is common in patients with high-impact chronic pain – an exploratory study from an interdisciplinary pain center. Scandinavian Journal of Pain, 22(1), 106–117. https://doi.org/10.1515/sjpain-2021-0112
• Aaron, R. V., Ravyts, S. G., Carnahan, N. D., Bhattiprolu, K., Harte, N., McCaulley, C. C., Vitalicia, L., Rogers, A. B., Wegener, S. T., & Dudeney, J. (2025). Prevalence of Depression and Anxiety Among Adults With Chronic Pain: A Systematic Review and Meta-Analysis. JAMA Network Open, 8(3), e250268. https://doi.org/10.1001/jamanetworkopen.2025.0268
• Xie, Y., Farrell, S. F., Armfield, N., & Sterling, M. (2024). Serum Vitamin D and Chronic Musculoskeletal Pain: A Cross-Sectional Study of 349,221 Adults in the UK. The Journal of Pain, 25(9), 104557. https://doi.org/10.1016/j.jpain.2024.104557
• Sembrano, J. N., & Polly, D. W. (2009). How often is low back pain not coming from the back? Spine (Phila Pa 1976), 34(1), E27-E32. https://doi.org/10.1097/BRS.0b013e31818b8882
• Gibbons, C., Porter, I., Gonçalves-Bradley, D. C., Stoilov, S., Ricci-Cabello, I., Tsangaris, E., Gangannagaripalli, J., Davey, A., Gibbons, E. J., Kotzeva, A., Evans, J., van der Wees, P. J., Kontopantelis, E., Greenhalgh, J., Bower, P., Alonso, J., & Valderas, J. M. (2021). Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice. Cochrane Database of Systematic Reviews, 10(10), CD011589. https://doi.org/10.1002/14651858.CD011589.pub2
• Van Such, M., Lohr, R., Beckman, T., & Naessens, J. M. (2017). Extent of diagnostic agreement among medical referrals. Journal of Evaluation in Clinical Practice, 23(4), 870–874. https://doi.org/10.1111/jep.12747

Related reading

• Quality-Adjusted Life Years: Measuring What Spine Care Returns
• The Sudomotor Test in Mixed Pain: What It Adds and What It Cannot
• Laboratory Panels

Quality-Adjusted Life Years: Measuring What Spine Care Returns

A quality-adjusted life year counts a year in full health as one and a year at half of full health as half, and spine trials use it to express what an intervention returns. Applied to a referral, it only means something when a baseline health utility score is recorded before the referral.

Every spine trial that reports value reports it in years of health. Few referral letters record the baseline those years are counted from, or the metabolic terrain that decides whether they accrue.

The quality-adjusted life year (QALY) is the unit most spine trials use to express what an intervention returns: a year in full health counts as one, and a year at half of full health counts as half. It is usually quoted in policy work, but underneath it sits a clinical measurement, the health utility score, and that score is rarely recorded before a referral. The video for Chapter 18 of The Pained Brain, by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD, works through the spine evidence in those units; study-level detail and limits are in the Chapter 18 book companion. Here the unit is treated as what it is for the ordering physician: an outcome measure, with a baseline, a horizon and blind spots.

What is the health utility score inside a QALY?

US population norms place mean utility at 0.824 for adults aged 65 to 74. A Danish national catalog put dorsalgia at 0.619 and fibromyalgia at 0.490, lower than dementia at 0.546, and listed both among the conditions with the largest modeled loss of quality of life. Among 1,194 patients scheduled for degenerative lumbar spine surgery in Singapore, mean preoperative utility was 0.43, with 93.6 percent reporting pain or discomfort. Chronic pain removes a third to a half of a year of health from each year lived with it.

The instrument has a known weakness: the value set changes the number. Among 34,254 Swedish osteoarthritis patients, the same people scored 0.792 on a Swedish experience-based value set and 0.605 on a UK hypothetical one. Utilities borrowed across countries are unreliable. Recorded in one practice, with one instrument, repeated over time, they become a usable longitudinal outcome.

Why does the starting utility score decide the benefit?

The clearest evidence that starting utility predicts surgical return comes from arthroplasty. In a German multicenter study of 4,182 hip and 3,645 knee replacements, the minimal clinically important change in utility was 0.2, and patients starting above 0.7 for a hip or 0.6 for a knee gained no meaningful benefit. Those thresholds are decision aids from joint surgery, not spine rules, but the principle transfers: an operation cannot restore utility a patient has not lost. Decision support changes real choices, too. When a large health system introduced decision aids for hip and knee osteoarthritis, hip replacements fell 26 percent and knee replacements 38 percent. Neither finding can be applied to an individual unless a baseline exists in the chart before the referral.

What do spine trials show when patients are followed longer?

Two-year spine outcomes and eight-year outcomes are different findings. In the SPORT stenosis cohort, the surgical advantage in years three and four was reduced by approximately 75 percent from the first two years, and no significant effect of surgery remained in years six through eight. By then, 70 percent randomized to surgery and 52 percent randomized to non-operative care had been operated on, which dilutes intention-to-treat contrasts in both directions. The spondylolisthesis cohort analyzed as treated, by contrast, kept its surgical advantage at eight years.

The fusion question is where the unit is most informative. At two years, adding fusion to a stenosis decompression added −0.01 quality-adjusted life years. For chronic low back pain without a slip, fusion against intensive rehabilitation produced a 0.068 difference that was not significant, and at eleven years the fusion advantage on a 100-point disability scale was −0.7 points. Pooled, fusion for degenerative disc disease carried 21.46 times the complication rate of non-operative care. Randomized trials in Sweden and Norway found decompression alone comparable or non-inferior; an American trial reported a reoperation rate of 14 percent with fusion versus 34 percent without.

What can a QALY miss?

A utility score can miss a real clinical gain. In 325 older adults with insomnia and osteoarthritis pain, six telephone sessions of cognitive behavioral therapy lowered insomnia severity and joint symptoms by 2.6 points each and added 89 nights without insomnia over twelve months, yet the utility difference was −0.01. Lifetime gains are also often projected rather than measured: the 0.06 quality-adjusted life years in the British diabetes remission trial were driven by modeled life expectancy, not measured two-year utility. The practical conclusion is to pair utility with measures that move faster and are harder to dispute, namely function, body composition, metabolic markers and cognition.

Terrain as a measurable predictor

The patient at the center of the video had a lumbar MRI in the second week of her pain and no hemoglobin A1c in four years. When it was drawn, it was 6.4. In a series of 678 posterolateral fusions for degenerative spondylolisthesis, age did not remain a significant predictor of medical complications after adjustment, while anesthesia risk score and body mass index did. The lifestyle arm of the Diabetes Prevention Program cut diabetes incidence by 34 percent, and in knee osteoarthritis with class III obesity, a modeled gastric bypass strategy lowered opioid use from 13 to 4 percent. Those are two biological drivers, insulin resistance and adipose mass, plus a structural one: care pathways that begin with an image or an opioid. In a veterans cohort, an opioid as the opening treatment in place of physical therapy was associated with 1.69-fold odds of spine surgery inside one year and 17.8 times the odds of chronic opioid use. The book is candid that early conservative care is not a guaranteed win; in the randomized trial, the early physical therapy benefit stayed below the threshold of clinical importance.

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service; it does not read imaging or recommend surgery. For a patient headed toward a spine referral it documents:

• Metabolic status through laboratory panels, including glucose and insulin markers.
• Body composition through bioimpedance body composition, replacing body mass index with measured fat and lean compartments.
• Cognition through a cognitive assessment in older candidates, with fall-prevention screening paired in the same visit.

Workflow: blood before the scan

The sequence the book argues for is blood before scan, block before burn, bridge before fusion, with named exceptions: cauda equina syndrome is decompressed within 48 hours, and a herniated disc that has failed everything goes to the surgeon promptly. For the rest, a standing order can attach metabolic labs, body composition and a baseline utility instrument to new chronic back pain referrals before advanced imaging, so the first data point is the terrain. The annual wellness visit is a natural home for that baseline in older patients, and filing results as discrete data keeps them visible when the surgical consult returns. How a dose total displaced the patient in pain care is examined in morphine milligram equivalents as a risk variable.

Frequently asked questions

References

• Jiang, R., Janssen, M. F. B., & Pickard, A. S. (2021). US population norms for the EQ-5D-5L and comparison of norms from face-to-face and online samples. Quality of Life Research, 30(3), 803–816. https://doi.org/10.1007/s11136-020-02650-y
• Hvidberg, M. F., Petersen, K. D., Davidsen, M., Witt Udsen, F., Frølich, A., Ehlers, L., & Alava, M. H. (2023). Catalog of EQ-5D-3L Health-Related Quality-of-Life Scores for 199 Chronic Conditions and Health Risks in Denmark. MDM Policy & Practice, 8(1), 23814683231159023. https://doi.org/10.1177/23814683231159023
• Li, X., Chern, C. W. J., Teo, A. Q. A., Tan, J. H. J., Vasan Thakumar, A., Luo, N., Hey, H. W. D., & Cheng, L. J. (2026). Factors associated with preoperative health-related quality of life in patients undergoing lumbar spine surgery: a multi-ethnic Asian cohort. Quality of Life Research, 35(6). https://doi.org/10.1007/s11136-026-04257-1
• Langenberger, B., Steinbeck, V., & Busse, R. (2024). Who Benefits From Hip Arthroplasty or Knee Arthroplasty? Preoperative Patient-reported Outcome Thresholds Predict Meaningful Improvement. Clinical Orthopaedics and Related Research, 482(5), 867–881. https://doi.org/10.1097/CORR.0000000000002994
• Tosteson, A. N. A., Tosteson, T. D., Lurie, J. D., Abdu, W., Herkowitz, H., Andersson, G., Albert, T., Bridwell, K., Zhao, W., Grove, M. R., Weinstein, M. C., & Weinstein, J. N. (2011). Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine, 36(24), 2061–2068. https://doi.org/10.1097/BRS.0b013e318235457b
• Lurie, J. D., Tosteson, T. D., Tosteson, A., Abdu, W. A., Zhao, W., Morgan, T. S., & Weinstein, J. N. (2015). Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine, 40(2), 63–76. https://doi.org/10.1097/BRS.0000000000000731
• Rivero-Arias, O., Campbell, H., Gray, A., Fairbank, J., Frost, H., & Wilson-MacDonald, J. (2005). Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ, 330(7502), 1239. https://doi.org/10.1136/bmj.38441.429618.8F
• Yeung, K., Zhu, W., McCurry, S. M., Von Korff, M., Wellman, R., Morin, C. M., & Vitiello, M. V. (2022). Cost-effectiveness of telephone cognitive behavioral therapy for osteoarthritis-related insomnia. Journal of the American Geriatrics Society, 70(1), 188–199. https://doi.org/10.1111/jgs.17469
• Aimar, E., Iess, G., Mezza, F., Gaetani, P., Messina, A. L., Todesca, A., Tartara, F., & Broggi, G. (2022). Complications of degenerative lumbar spondylolisthesis and stenosis surgery in patients over 80 s: comparative study with over 60 s and 70 s. Experience with 678 cases. Acta Neurochir (Wien), 164(3), 923-931. https://doi.org/10.1007/s00701-022-05118-9
• Schmidt, C., Borgia, M., Zhang, T., Gochyyev, P., Shireman, T. I., & Resnik, L. (2023). Initial treatment approaches and healthcare utilization among veterans with low back pain: a propensity score analysis. BMC Health Serv Res, 23(1), 275. https://doi.org/10.1186/s12913-023-09207-y

Related reading

• Morphine Milligram Equivalents Are Not a Risk Assessment
• Comprehensive Pain Assessment: Measuring What the Short Visit Skips
• Laboratory Panels

Morphine Milligram Equivalents Are Not a Risk Assessment

A morphine milligram equivalent total is a screening flag, not a risk assessment. In a Medicare cohort, federal dose-based measures captured 29.29 percent of overdose episodes against 90.57 percent for models that weighed dose with other predictors, so the record needs more than the milligram.

A daily dose total is the easiest number on a pain chart to extract, which is why quality measures count it. It is also among the weakest predictors that chart holds.

A morphine milligram equivalent total is the easiest risk variable to pull from a pharmacy claim, which is why it anchors health-plan quality measures and point-of-sale edits. It is also a conversion with wide error bars, applied to patients whose metabolism changes what a milligram does. The chapter video A Dose Is Not a Diagnosis presents Chapter 17 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD; the study-level evidence, with each paper’s limits, is in the Chapter 17 book companion. For the ordering physician, the practical question is what belongs in the record next to the dose.

Where did the 90 MME threshold come from?

The 2016 federal guideline told prescribers that any increase to 90 MME or beyond should be avoided or carefully justified, and it described its recommendations as voluntary. A quality-measurement body then specified high-dosage use as an average of 90 MME or more for at least 15 days, instructed that "a lower rate indicates better performance," and had moved its line down from 120 to 90 in 2019 for alignment. Medicare directed drug plans to install a care-coordination edit at 90. The agency’s 2024 guidance says those edits "should not be implemented as a prescribing limit or as a substitute for clinical judgment," while a 2026 memorandum reports high-dosage use monthly to plan sponsors, with several such measures displayed as Part D Star Rating measures. That is the structural driver: a plan’s public rating moves with the milligram total, and the incentive flows down to the practice. The practice position concedes that prescribing ran too high and that the milligram is a real hazard. The objection is to treating a conversion as a diagnosis.

How accurate is a morphine milligram equivalent conversion?

Conversion variance is large enough to move a patient across the line. Asked to convert identical doses, 319 clinicians produced a mean of 176 milligrams for a 75-microgram fentanyl patch, with a standard deviation of 117, and 193 milligrams for 40 milligrams of methadone, with a standard deviation of 201. The most recent systematic evaluation of conversion factors found 24 studies supporting factors across 29 mapped opioids and called for continued validation. The 2022 guideline took the specific number out of its recommendation statement, stated that no dosage threshold eliminates risk, and directed that buprenorphine not be counted in the daily total because of its ceiling effect on respiratory depression. A metric that cannot represent a partial agonist, and cannot be reproduced by two pharmacists reading one chart, is a screening flag. It is not a risk assessment.

What predicts opioid overdose better than dose?

The cleanest head-to-head comparison used 560,057 fee-for-service Medicare beneficiaries without cancer. The federal dose-based measures captured 29.29 percent of overdose episodes over twelve months; machine-learning models captured 90.57 percent. Total dose ranked among the top ten predictors, next to substance use disorder diagnoses, age, disability status and benzodiazepine fills, out of 268 candidates. The limit is real: positive predictive value ran 0.18 to 0.22 percent because overdose is rare. A simpler five-variable model validated at a c-statistic of 0.75.

Single variables carry larger effects than dose bands. In opioid-naive adults starting a first prescription, comorbid substance use disorder carried an adjusted hazard ratio of 2.74, and age 75 or older 3.22. Concurrent benzodiazepines carried a hazard of 5.05 in the first 90 days of overlap, falling to 1.87 on days 91 to 180, so a new co-prescription is a different exposure from a long-stable one. At the population level, high-dose prescribing alone accounted for an attributable fraction of 0.07 of fatal overdoses, while critical encounters such as a nonfatal overdose or release from incarceration accounted for 0.37.

Terrain variables a dose total cannot hold

The milligram enters a person whose physiology changes its effect. CYP2D6 poor metabolizers form 96 percent less morphine from codeine; ultrarapid metabolizers form 45 percent more. After hip and knee arthroplasty, the direction of an opioid receptor variant’s effect on morphine dose reversed with diabetes status, even though diabetes, genotype and their interaction explained only 2.7 percent of dosing variance. A perioperative review describes excess adiposity altering distribution, hepatic clearance and renal elimination, and notes that sleep apnea is common in the same population. Those are two biological drivers, hepatic enzyme capacity and an insulin-resistant, adipose terrain, sitting under the structural one above.

Measura [Cardiometabolic and Autonomic Health Analysis] does not offer pharmacogenetic genotyping or sleep studies; both are different tests done elsewhere. What it adds is the terrain that the chart otherwise infers:

• Metabolic status. Laboratory panels document the insulin and glucose picture. The patient described in the book had a fasting insulin of 31 that six years of dose-centered care never recorded.
• Body composition. Bioimpedance body composition measures fat and lean compartments rather than inferring them from weight.
• Cognition and balance in older patients. Age 75 or older is itself among the stronger overdose predictors above. A cognitive assessment and vestibular and balance testing give that patient a documented baseline, and pairing cognitive assessment with fall prevention keeps both in one visit.

When a dose change is already under discussion

None of this is a dosing recommendation, and the evidence on changes cuts both ways. What it shows consistently is that the manner matters. Monthly reductions above 30 percent carried an adjusted overdose hazard of 5.33 the following month, while reductions of 10 percent or less carried none. In a trial emulation of stable patients, eleven-month overdose or suicide risk was 0.96 percent with no change, 1.10 percent with tapering and 1.28 percent with abrupt discontinuation. After tapering, adherence to antihypertensive and diabetes medications fell to 0.60 and 0.69 of baseline, a measurable reason to hold a metabolic baseline before any plan changes. In high-risk veterans, a mandated interdisciplinary case review in place of a cut reduced discontinuation by 11.16 percentage points and all-cause mortality by 3.31. Measurement belongs in that review.

Documentation, standing orders and quality reporting

A high-dosage measure counts milligrams; nothing in it records whether anyone looked for the generator or the terrain. The chart can. A standing order can attach metabolic labs and body composition to patients on long-term therapy for chronic non-cancer pain, and cognitive and balance testing to those 75 and older, so the decision is reproducible across clinicians. Findings entered as structured fields in the chart sit next to the dose when a plan review or a pharmacy edit arrives. The same findings support the cardiometabolic documentation that MIPS and quality reporting already expects. Locating the generator is its own workup, covered in documentation before the diagnostic nerve block, and what the easiest first treatment takes from a patient over years is taken up in quality-adjusted life years in spine care.

Frequently asked questions

References

• National Committee for Quality Assurance (2026). Use of Opioids at High Dosage (HDO) – HEDIS measure page. NCQA HEDIS Measure Library. https://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality-report/use-of-opioids-at-high-dosage-hdo/
• Centers for Medicare & Medicaid Services (2024). Frequently Asked Questions about Formulary-Level Opioid Point-of-Sale Safety Edits (July 5, 2024). CMS.gov (guidance document). https://www.cms.gov/files/document/frequently-asked-questions-about-formulary-level-opioid-point-sale-safety-edits-july-5-2024.pdf
• Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., & Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022. MMWR. Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1
• Rennick, A., Atkinson, T., Cimino, N. M., Strassels, S. A., McPherson, M. L., & Fudin, J. (2016). Variability in Opioid Equivalence Calculations. Pain Medicine, 17(5), 892–898. https://doi.org/10.1111/pme.12920
• Lo-Ciganic, W.-H., Huang, J. L., Zhang, H. H., Weiss, J. C., Wu, Y., Kwoh, C. K., Donohue, J. M., Cochran, G., Gordon, A. J., Malone, D. C., Kuza, C. C., & Gellad, W. F. (2019). Evaluation of Machine-Learning Algorithms for Predicting Opioid Overdose Risk Among Medicare Beneficiaries With Opioid Prescriptions. JAMA Network Open, 2(3), e190968. https://doi.org/10.1001/jamanetworkopen.2019.0968
• Larochelle, M. R., Bernstein, R., Bernson, D., Land, T., Stopka, T. J., Rose, A. J., Bharel, M., Liebschutz, J. M., & Walley, A. Y. (2019). Touchpoints – Opportunities to predict and prevent opioid overdose: A cohort study. Drug and Alcohol Dependence, 204, 107537. https://doi.org/10.1016/j.drugalcdep.2019.06.039
• Hernandez, I., He, M., Brooks, M. M., & Zhang, Y. (2018). Exposure-Response Association Between Concurrent Opioid and Benzodiazepine Use and Risk of Opioid-Related Overdose in Medicare Part D Beneficiaries. JAMA Network Open, 1(2), e180919. https://doi.org/10.1001/jamanetworkopen.2018.0919
• Jurewicz, A., Gasiorowska, A., Leźnicka, K., Maciejewska-Skrendo, A., Pawlak, M., Machoy-Mokrzyńska, A., Bohatyrewicz, A., & Tarnowski, M. (2025). Do Diabetes and Genetic Polymorphisms in the OPRM1 and COMT Genes Modulate the Postoperative Opioid Demand and Pain Perception in Osteoarthritis Patients After Total Knee and Hip Arthroplasty? Journal of Clinical Medicine, 14(13), 4634. https://doi.org/10.3390/jcm14134634
• Glanz, J. M., Xu, S., Narwaney, K. J., McClure, D. L., Rinehart, D. J., Ford, M. A., Nguyen, A. P., & Binswanger, I. A. (2023). Association Between Opioid Dose Reduction Rates and Overdose Among Patients Prescribed Long-Term Opioid Therapy. Substance Abuse, 44(3), 209–219. https://doi.org/10.1177/08897077231186216
• Li, Y., Barr, K. D., Trafton, J. A., Oliva, E. M., Garrido, M. M., Frakt, A. B., & Strombotne, K. L. (2023). Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial. Subst Abus, 44(4), 292–300. https://doi.org/10.1177/08897077231198299

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• Laboratory Panels

Delirium in Elderly Patients: Rule Out Pain Before Sedation

In elderly patients with dementia, untreated pain is a measurable driver of delirium: across 30 studies of older inpatients, severe pain carried 3.42 times the odds. Pain belongs on the workup before any sedative is ordered.

Acute confusion and agitation in an older patient with dementia are usually treated as behavior. The evidence places untreated pain among the drivers, and the workup that separates the two can be built into routine geriatric screening.

Delirium in elderly patients with dementia is usually charted as a behavioral event and managed as one, although a measurable share of it tracks pain that nobody assessed. The distinction changes the order: an analgesic workup before a sedative, and baselines that let a change in cognition or balance be recognized as a change. The chapter video, Does She Hurt? Pain in the Elderly, presents chapter 16 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. Each study, with what it can and cannot show, is summarized in the book companion for chapter 16.

Is pain a risk factor for delirium in elderly patients?

Among 541 hip-fracture patients without delirium at enrollment, 16 percent became delirious. In cognitively intact patients, severe pain carried a relative risk of 9.0, and receiving under 10 milligrams of parenteral morphine equivalents a day carried 5.4; too much pain and too little analgesia behaved as the same exposure. Pooled across 30 studies of older inpatients, pain at rest carried an odds ratio of 2.14 for delirium and severe pain 3.42, while pain on movement did not reach significance. Before elective orthopedic surgery, in 200 patients with a median age of 69, preoperative chronic pain independently predicted postoperative delirium at an adjusted odds ratio of 2.488.

The inpatient picture in established neurocognitive disorder is starker. In 292 hospitalized patients with a mean age of 87.8, observational pain behaviors were present in 62.4 percent, and only 20.3 percent of those were receiving an analgesic at admission. Three-month mortality carried an adjusted hazard of 2.39. That is a single-center observational association, not a causal estimate, but it describes a group in which pain is common, untreated and prognostically meaningful.

Why is pain under-recorded where agitation orders are written?

Only 24.4 percent of nursing-home admissions with severe cognitive impairment were assessed by staff observation rather than a self-report instrument they could not use. When the two approaches were compared in separate samples, self-report recorded moderate to severe pain in 9.60 percent and staff observation in 34.04 percent. The chart therefore under-records pain precisely where agitation orders are written.

The trial evidence is directional and honest in both directions. In 352 residents with dementia and agitation across 60 Norwegian units, a stepwise analgesic protocol reduced agitation by 17 percent, a treatment effect of −7.0, and the effect faded to −3.2 by week 12 after withdrawal. Anxiety and irritability items did not change significantly. Scheduled acetaminophen given to 95 residents selected for low quality of life rather than pain or agitation did nothing. Selection is the variable: treat identified pain, not everyone.

Meanwhile the sedative has a number attached. In veterans with dementia, the number needed to harm for one excess death within 180 days was 26 for haloperidol and 50 for quetiapine.

What drives missed pain and sedative harm in older patients?

The first biological driver is nociception itself, which in dementia surfaces as resistance to care, calling out and nighttime restlessness rather than a verbal report. The second is pharmacokinetic: hepatic clearance of most drugs falls 10 to 40 percent with age and the aging brain is more sensitive at a given level, so each sedating agent adds more than its dose suggests. Emergency visits for medication harm ran 12.1 per 1,000 adults over 65 against 5.0 in younger adults. The structural driver is measurement design. When a quality metric tracked antipsychotics alone, prescribing shifted toward other psychotropics. And in the one emergency department trial of a dementia pain scale, 602 older adults with suspected fractures waited a median of 83 minutes for analgesia against 82. A scale without an attached order changes the chart, not the patient.

Dr. Padda’s own position is the one he reaches after decades of practice: the medication list of an older patient is itself a diagnosis to be read, and the answer to a behavior is a search for its generator.

Where Measura fits: baselines that make change visible

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service. It performs no procedures and no treatment, does not diagnose delirium or measure pain, and returns results to the ordering physician. Its role is the reference record that makes a later change interpretable.

• Cognition. A cognitive assessment documents memory and executive function at baseline, so an acute decline can be distinguished from the trajectory. It is not a pain instrument, and a score does not stand in for observational pain assessment.
• Orthostatic physiology. Continuously measured initial orthostatic hypotension appeared in 29.0 percent of adults 65 and over against 5.6 percent with intermittent readings. Cardiac autonomic reflex tests document heart rate and blood pressure responses to position change and breathing.
• Balance. Pain in two or more sites raised fall rates 1.53-fold in adults 70 and older; vestibular and balance testing documents the fall-risk side of that equation.
• Muscle and metabolism. Sarcopenia and chronic pain co-occur at an odds ratio of 1.52, and in patients 65 and over grip strength predicted epidural response at 1.142 per kilogram, with thresholds of 26.5 kg in men and 16.5 kg in women. Bioimpedance body composition and laboratory panels document lean mass and the glycemic picture; 29.2 percent of Americans over 65 have diabetes and 48.8 percent prediabetes.

Standing orders, the annual wellness visit and documentation

The annual wellness visit already asks for cognitive status and fall risk, which is where a cognitive baseline, a standing blood pressure and balance findings belong, recorded before the admission that makes them urgent. The cognitive assessment and fall prevention pairing keeps both in one encounter. A standing order can specify that new agitation or acute confusion in a patient with dementia triggers an observational pain assessment and a medication review before any sedating agent is added, which converts the scale into an action. Documentation supports HEDIS and value-based care reporting as a record of care delivered, not as the reason for it.

What the evidence does not settle

Much of this is observational, and the trials that would settle it have not enrolled patients in their late eighties. Deprescribing alone did not reduce falls in community trials at high certainty, and dose changes cut both ways: in older adults on long-term opioid therapy, rapid tapering lowered overdose but raised all-cause mortality 1.28-fold. Removing a drug is a decision about a list; treating the patient requires finding the generator. Family-facing guidance on the standing reading is in what a seated blood pressure misses, and the earlier argument on injections is metabolic screening before repeat joint injections.

Frequently asked questions

References

• Morrison, R. S., Magaziner, J., Gilbert, M., Koval, K. J., McLaughlin, M. A., Orosz, G., Strauss, E., & Siu, A. L. (2003). Relationship between pain and opioid analgesics on the development of delirium following hip fracture. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 58(1), 76-81. https://doi.org/10.1093/gerona/58.1.m76
• White, N., Bazo-Alvarez, J. C., Koopmans, M., West, E., & Sampson, E. L. (2024). Understanding the association between pain and delirium in older hospital inpatients: systematic review and meta-analysis. Age and Ageing, 53(4), afae073. https://doi.org/10.1093/ageing/afae073
• Mancinetti, F., Travaglini, E. G., Speziali, L., Gaspari, M., Ercolani, S., Mecocci, P., & Boccardi, V. (2026). Pain as an underrecognized geriatric syndrome in hospitalized older adults with major neurocognitive disorder: clinical correlates and outcomes. European Geriatric Medicine, 17(3), 1479-1488. https://doi.org/10.1007/s41999-026-01450-w
• Dube, C. E., Morrison, R. A., Mack, D. S., Jesdale, B. M., Nunes, A. P., Liu, S.-H., & Lapane, K. L. (2020). Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes. Journal of Pain Research, 13, 2663-2672. https://doi.org/10.2147/JPR.S270689
• Shippee, T. P., Qin, X., Vick, R., Shippee, N. D., Parikh, R. R., Parsons, H. M., & Virnig, B. (2025). Underreporting of Pain for Short-Stay Nursing Home Residents in the Minimum Data Set 3.0?: Staff-Report, Self-Report, and the Role of Cognitive Impairment and Racial/Ethnic Identity. Journal of the American Medical Directors Association, 27(1), 105970. https://doi.org/10.1016/j.jamda.2025.105970
• Husebo, B. S., Ballard, C., Sandvik, R., Nilsen, O. B., & Aarsland, D. (2011). Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 343, d4065. https://doi.org/10.1136/bmj.d4065
• van Dam, P. H., Achterberg, W. P., Husebo, B. S., & Caljouw, M. A. A. (2020). Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial. BMC Medicine, 18(1), 407. https://doi.org/10.1186/s12916-020-01858-6
• Lee, S., Lo, A. X., Hogan, T. M., van Oppen, J. D., Gettel, C. J., Lapointe-Shaw, L., Seidenfeld, J., Hirata, K., Aliberti, M. J. R., Healy, H. S., & Liu, S. W. (2026). A Systematic Review Evaluating Pain Assessment Strategies for Patients With Dementia in the Emergency Department: The Geriatric ED Guidelines 2.0. Academic Emergency Medicine, 33(2), e70230. https://doi.org/10.1111/acem.70230
• Tran, J., Hillebrand, S. L., Meskers, C. G. M., Iseli, R. K., & Maier, A. B. (2021). Prevalence of initial orthostatic hypotension in older adults: a systematic review and meta-analysis. Age and Ageing, 50(5), 1520-1528. https://doi.org/10.1093/ageing/afab090
• Kim, S. H., Park, S. J., Yoon, K. B., Jun, E.-K., Cho, J., & Kim, H. J. (2022). Influence of Handgrip Strength and Psoas Muscle Index on Analgesic Efficacy of Epidural Steroid Injection in Patients With Degenerative Lumbar Spinal Disease. Pain Physician, 25(7), E1105-E1113. https://pubmed.ncbi.nlm.nih.gov/36288597/

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Corticosteroid-Induced Hyperglycemia After Joint Injections

Corticosteroid-induced hyperglycemia after a joint injection is measurable: in patients with type 2 diabetes, one immediate-release triamcinolone knee injection produced a median maximum-glucose rise of 169.1 mg/dL over days 1 to 3, and 93 percent exceeded 250 mg/dL. A review of 7 studies found a rise in every study and advised monitoring for up to a week.

Most injection referrals document the joint and leave out the patient’s metabolism. The evidence on systemic steroid effects and regenerative outcomes argues for measuring glucose control, body composition and fall risk before the next procedure is scheduled.

Corticosteroid-induced hyperglycemia after a joint or epidural injection rarely appears in the referring chart, yet the literature now describes systemic effects that primary care owns: glycemic excursions, adrenal suppression and fracture. The same metabolic variables predict which patients fail a regenerative injection. The chapter video, The Goal Was Never to Manage Your Pain Forever, presents chapter 15 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. Trial-level detail, with the limits of each study, is in the book companion for chapter 15.

What does a steroid injection do to blood sugar, adrenal function and bone?

Three signals deserve a place in the referring chart. In patients with type 2 diabetes and an A1c of 6.5 to 9.0 percent, continuous glucose monitoring after one immediate-release triamcinolone knee injection showed a median maximum-glucose rise of 169.1 mg/dL over days 1 to 3; 93 percent exceeded 250 mg/dL, and time in range fell to 48 percent against 62 percent with the extended-release formulation. That was a post hoc analysis of thirty-three patients, but a systematic review of 7 studies and 72 patients found a rise in every study and advised monitoring for up to a week.

A double-blind comparison of epidural triamcinolone found hypothalamic-pituitary-adrenal suppression lasting 19.7 days at 40 mg against 8.0 days at 20 mg, with no difference in analgesia. And among 25,062 Medicare patients given epidural steroid for radiculopathy, mean age 76 and 74 percent female, fractures at typical osteoporotic sites ran 49.1 per 1,000 person-years against 35.2 in unexposed patients, a hazard of 1.39 overall and 1.54 at the vertebrae, with higher early risk after three or more injections in a year.

Why do the side effects of repeat steroid injections go untracked?

Two biological drivers concentrate the risk. Insulin resistance determines how far glucose travels after a steroid load, and adiposity raises both the mechanical demand on the joint and the likelihood that the injection will be repeated. The third driver is structural. Each injection is documented as a discrete procedure, relief arrives quickly, and nobody owns the cumulative record across episodes. Of osteoarthritis patients in British primary care, 10.8 percent had a steroid injection, and 40 percent of that group had repeat injections. The rheumatology guideline that strongly recommends the injection sets no numeric cap on frequency, so the running total is tracked only if the referring physician tracks it.

Dr. Padda has said plainly that he spent years reassuring patients whose A1c sat in the prediabetic band. That reassurance does not survive the regenerative outcome data, and it has no place in a referral note.

Does diabetes make PRP less likely to work?

Where platelet-rich plasma is under consideration, the metabolic workup becomes prognostic. In a retrospective case-control study of 120 patients with Achilles or patellar tendinopathy, 60 of them with diabetes or prediabetes, the odds of failing to reach the minimal important difference were 2.41, and 2.54 for a 20-point improvement. Glycated hemoglobin independently predicted a poor outcome at an odds ratio of 1.16, and body mass index at 1.02. In knee cohorts, body mass index and radiographic grade were the independent predictors of failure, which reached 15.3 percent at a mean of nearly five years.

Growth-factor content in the preparation did not differ between lean and obese patients. Inflammatory content did track body mass: interleukin-18 rose with body mass index and predicted weaker functional gains in a small single-injection series. The preparation is not the main variable. The recipient is, and the recipient can be measured before the procedure is scheduled.

Who should have blood sugar checked before a steroid injection?

Metabolic health is the exception rather than the default in adults: under 12.2% of US adults qualified on NHANES 2009–2016, and under 7% on the tighter criteria applied after 2021. Reasonable candidates include:

• Patients with known diabetes or an A1c in the prediabetic range, before any corticosteroid injection, so glucose monitoring for the following week can be planned in advance.
• Patients with obesity, where body mass index conflates fat mass with lean mass.
• Older adults receiving epidural steroid, particularly those approaching three or more injections in a year, where fracture exposure and fall risk belong in one plan.
• Patients referred for a regenerative injection, where A1c and body composition inform the expected response.
• Patients within three months of planned knee arthroplasty. Across 58,337 primary knee replacements, corticosteroid injection in that window carried an infection odds ratio of 1.21 on a 2.74 percent base rate, and hyaluronic acid 1.55, a timing signal the surgeon and the referring physician should share.

What Measura measures, and what it does not

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service. It performs no injections, no imaging and no treatment, and results return to the ordering physician. Three measurements apply to this pathway: laboratory panels for the glycemic and lipid picture; bioimpedance body composition for fat and lean compartments; and vestibular and balance testing for older patients whose fracture exposure after epidural steroid makes fall risk a management question. None of these measures bone density, and a balance result does not substitute for one. Pairing balance findings with a cognitive baseline follows the cognitive assessment and fall prevention workflow.

Standing orders, the referral letter and documentation

A standing order that attaches a laboratory panel including A1c and a body composition measurement to referrals for joint or epidural injection takes the decision out of the individual encounter, which is the only way the cumulative record gets built. Results filed as discrete data in the record remain visible when the procedure note returns. The referral letter can ask that the note record the agent, formulation and dose, since the glycemic and adrenal effects scale with them. One Medicare contractor policy already allows no more than four epidural steroid sessions in a spinal region over a rolling year and rejects a predetermined series as not medically reasonable. Cardiometabolic findings also support documentation that MIPS and quality reporting asks practices to capture, as documentation rather than a reason to test.

What the evidence does not settle

The cohort harm signals carry confounding by indication. When steroid was compared against hyaluronic acid, which ensured both arms had knees judged worth injecting, joint-space narrowing progressed at a rate ratio of 1.00. The fracture data are claims-based in a population that may be frailer at baseline, and the tendinopathy outcome data are retrospective. Exercise remains the comparator an injection has to beat: in a randomized trial of 273 patients, a year of exercise-based physical therapy outperformed a glucocorticoid injection by 22.70 WOMAC points. The practice position is that the injection is a bridge and the metabolic work is the destination, which makes measuring the terrain the referring physician’s share of the plan. The patient-facing version is what a cortisone shot does to blood sugar.

Frequently asked questions

References

• Spitzer, A. I., Rodbard, H. W., Iqbal, S. U., Nakazawa, M., DiGiorgi, M., & Winston, R. (2024). Extended-Release Versus Immediate-Release Triamcinolone Acetonide in Patients Who Have Knee Osteoarthritis and Type 2 Diabetes Mellitus. The Journal of Arthroplasty, 39(9 Suppl 2), S218-S223.e1. https://doi.org/10.1016/j.arth.2024.05.055
• Choudhry, M. N., Malik, R. A., & Charalambous, C. P. (2016). Blood Glucose Levels Following Intra-Articular Steroid Injections in Patients with Diabetes: A Systematic Review. JBJS Reviews, 4(3), e5. https://doi.org/10.2106/JBJS.RVW.O.00029
• Sim, S. E., Hong, H. J., Roh, K., Seo, J., & Moon, H. S. (2020). Relationship Between Epidural Steroid Dose and Suppression of Hypothalamus-Pituitary-Adrenal Axis. Pain Physician, 23(4S), S283-S294. https://pubmed.ncbi.nlm.nih.gov/32942788/
• Yun, H., Liu, Y., Curtis, J. R., Saag, K., D’Erasmo, G., Haseltine, K., & Stein, E. M. (2025). Epidural steroid injections and fracture incidence among older individuals with radiculopathy. Journal of Bone and Mineral Research, 40(2), 176–183. https://doi.org/10.1093/jbmr/zjae162
• Whitehouse, M. R., Judge, A., Hawley, S., Prats Uribe, A., Delmestri, A., Matharu, G., Moore, A., Palmer, C., Wylde, V., Anderson, E., Donovan, R., Jameson, C., Snelling, N., Blom, A. W., Gooberman-Hill, R., Barker, K., & Prieto-Alhambra, D. (2025). RecUrrent Intra-articular Corticosteroid injections in Osteoarthritis: the RUbICOn mixed-methods study. Health Technology Assessment, 29(56), 1-167. https://doi.org/10.3310/LFAJ9337
• Abate, M., Paganelli, R., Pellegrino, R., Di Iorio, A., & Salini, V. (2024). Platelet Rich Plasma Therapy in Achilles and Patellar Tendinopathies: Outcomes in Subjects with Diabetes (A Retrospective Case-Control Study). Journal of Clinical Medicine, 13(18), 5443 (article number from DOI; PubMed record lists volume 13, issue 18). https://doi.org/10.3390/jcm13185443
• Alessio-Mazzola, M., Lovisolo, S., Sonzogni, B., Capello, A. G., Repetto, I., Formica, M., & Felli, L. (2021). Clinical outcome and risk factor predictive for failure of autologous PRP injections for low-to-moderate knee osteoarthritis. Journal of Orthopaedic Surgery (Hong Kong), 29(2), 23094990211021922. https://doi.org/10.1177/23094990211021922
• Wiciński, M., Szwedowski, D., Wróbel, Ł., Jeka, S., & Zabrzyński, J. (2022). The Influence of Body Mass Index on Growth Factor Composition in the Platelet-Rich Plasma in Patients with Knee Osteoarthritis. International Journal of Environmental Research and Public Health, 20(1), 40 (article number from DOI; PubMed record lists volume 20, issue 1). https://doi.org/10.3390/ijerph20010040
• Richardson, S. S., Schairer, W. W., Sculco, T. P., & Sculco, P. K. (2019). Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty. The Journal of Bone and Joint Surgery. American Volume, 101(2), 112-118. https://doi.org/10.2106/JBJS.18.00454
• Lee, M., Jing, C., & Lee, K. (2025). Physical therapy vs. glucocorticoid injection in patients with meniscal tears and knee osteoarthritis: a multi-center, randomized, controlled trial. BMC Medicine, 23(1), 277. https://doi.org/10.1186/s12916-025-04113-y

Related reading

• Tendinopathy as a Metabolic Signal: Screening Before the Procedure
• Delirium in Elderly Patients: Rule Out Pain Before Sedation
• Laboratory Panels

Tendinopathy as a Metabolic Signal: Screening Before the Procedure

Recalcitrant tendinopathy is a metabolic signal: an A1c above 5.7 percent, the triglyceride-to-HDL pattern and the metabolic syndrome all track with it, even when body mass index is matched. Screening those numbers and body composition before the procedure sets expectations and puts metabolic work on the same care plan as the tendon.

Chronic tendinopathy arrives as a musculoskeletal complaint and leaves as a referral. The glycemic, lipid and body composition data that predict how it responds are rarely part of the handoff.

Recalcitrant tendinopathy usually enters the chart as a musculoskeletal complaint and leaves it as a referral: to physical therapy, to an injection, to a percutaneous tenotomy, occasionally to a stimulator trial. What rarely travels with it is the metabolic context that predicts how the tendon will respond to any of those. The chapter video, Wash Out the Lesion, Don’t Jam the Signal, presents chapter 14 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD. The procedure evidence and its grading are in the book companion for chapter 14; the focus here is what a primary care, pain, endocrine or geriatric practice should measure around that decision.

Is tendinopathy linked to the metabolic syndrome?

A Danish population cohort followed 5,856 people for three years. A hemoglobin A1c above 5.7 percent was associated with approximately a threefold risk of hospital-treated tendon injury in the lower extremities, and the metabolic syndrome with approximately 2.5 times the risk in upper and lower extremities alike. In a case-control study of 60 patients with midportion Achilles tendon disease against 60 controls matched for age, sex and body mass index, patients had higher triglycerides, lower HDL, a higher triglyceride-to-HDL ratio and higher apolipoprotein B. A pooled analysis of 17 studies and 2,612 participants found triglycerides 0.33 mmol/L and LDL cholesterol 1.00 mmol/L higher in people with tendon pain or altered tendon structure.

Adiposity adds its own gradient. Across 22 studies and 49,914 participants, obesity carried odds ratios of 3.81 for Achilles tendon disease in class I and 6.56 in class III, and 2.97 for plantar fascia disease; a body mass index above 27 carried an odds ratio of 3.7 for plantar fasciopathy, most strongly outside athletic populations. The evidence tier is observational and largely case-control, with reverse causation possible. The direction is nonetheless consistent, and the BMI-matched lipid finding argues that the signal is metabolic rather than purely mechanical.

How does a metabolic finding change tendinopathy management?

Loading is the treatment the rest of the plan exists to enable. In a randomized trial of 204 people with gluteal tendon pain, education plus exercise outperformed corticosteroid injection by 20.4 percent in global success at one year, a number needed to treat of 4.9. Pooled dose data favor added external load over body weight, 1.4 against 0.9 in within-arm effect size, and less-than-daily over daily sessions.

The terrain changes how far that loading goes. In a retrospective comparison of 28 patients with the metabolic syndrome and 28 matched controls on an identical eccentric program for insertional Achilles tendon disease, the metabolic group reported higher pain throughout follow-up, lower satisfaction and greater analgesic use. After bariatric surgery in 163 patients with plantar fasciitis, a mean excess weight loss of 51.0 percent accompanied symptom resolution in 90 percent, without a way to separate unloading from metabolic change.

Practically, a documented metabolic phenotype does three things. It sets expectations before a procedure or a rehabilitation block, so that a slow response is interpreted rather than escalated. It puts metabolic work on the same care plan as the tendon work instead of in a separate silo. And it gives the interventionalist and therapist the context their notes usually lack; only 44 percent of published tenotomy studies prescribed structured rehabilitation at all. The social driver is the handoff itself: each specialist in the chain sees the tendon, and nobody is assigned the terrain.

Which tendinopathy patients should be screened?

• Tendon pain or plantar fasciopathy that has not settled with an adequate loading program.
• Lower-extremity tendon disease in a patient with obesity, or with a body mass index above 27 and heel pain.
• Any patient being referred for a percutaneous tendon procedure or a neuromodulation evaluation for tendon-region pain.
• Patients previously told they are not diabetic whose last A1c sat in the prediabetic band.
• A medication history that includes fluoroquinolone exposure, which carried an odds ratio of 3.95 for Achilles tendinitis in pooled studies, documented as a risk factor in the history.

Practice-level criteria are summarized under selection criteria.

What Measura measures in this pathway

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service; it does not perform tenotomy, injections or any treatment, and it reports to the ordering physician. The relevant measurements are laboratory panels for the glycemic and lipid picture, and bioimpedance body composition to separate lean from fat mass in patients whose BMI understates or overstates their metabolic risk. Where an older patient with hip or foot tendon pain also reports unsteadiness or a prior fall, vestibular and balance testing belongs in the same visit, and the cognitive assessment and fall prevention workflow keeps that documentation together.

Standing orders and documentation

The reproducible version is a standing order that attaches metabolic labs and body composition to any referral for recalcitrant tendinopathy, so the baseline exists before the procedure note does. At an annual wellness visit, the same results support the cardiometabolic documentation that HEDIS and value-based care frameworks already track, as quality documentation rather than as an indication in itself. Repeat measurement during rehabilitation shows whether the terrain is moving alongside the tendon. The related question of what precision a procedure needs is in the diagnostic nerve block referral.

The limits, stated once

Percutaneous tenotomy is graded Level 4 by systematic review, with no sham-controlled trial of tissue removal yet, and nerve stimulation has never been tested against a tendon lesion in a randomized trial. The metabolic associations are observational. The practice position is unchanged by either fact: a procedure is a bridge that buys a window for loading, and the metabolic terrain decides whether that window becomes a repair. Measure the terrain first, and keep measuring it. Patients can read the patient version. The joint version of this pattern shows up in hands that bear no weight, laid out in metabolic screening in osteoarthritis.

Frequently asked questions

References

• Skovgaard, D., Siersma, V. D., Klausen, S. B., Visnes, H., Haukenes, I., Bang, C. W., Bager, P., Grävare Silbernagel, K., Gaida, J., Magnusson, S. P., Kjaer, M., & Couppé, C. (2021). Chronic hyperglycemia, hypercholesterolemia, and metabolic syndrome are associated with risk of tendon injury. Scandinavian Journal of Medicine & Science in Sports, 31(9), 1822–1831. https://doi.org/10.1111/sms.13984
• Gaida, J. E., Alfredson, L., Kiss, Z. S., Wilson, A. M., Alfredson, H., & Cook, J. L. (2009). Dyslipidemia in Achilles tendinopathy is characteristic of insulin resistance. Medicine and Science in Sports and Exercise, 41(6), 1194–1197. https://doi.org/10.1249/MSS.0b013e31819794c3
• Tilley, B. J., Cook, J. L., Docking, S. I., & Gaida, J. E. (2015). Is higher serum cholesterol associated with altered tendon structure or tendon pain? A systematic review. British Journal of Sports Medicine, 49(23), 1504–1509. https://doi.org/10.1136/bjsports-2015-095100
• Macchi, M., Spezia, M., Elli, S., Schiaffini, G., & Chisari, E. (2020). Obesity Increases the Risk of Tendinopathy, Tendon Tear and Rupture, and Postoperative Complications: A Systematic Review of Clinical Studies. Clinical Orthopaedics and Related Research, 478(8), 1839–1847. https://doi.org/10.1097/CORR.0000000000001261
• van Leeuwen, K. D., Rogers, J., Winzenberg, T., & van Middelkoop, M. (2015). Higher body mass index is associated with plantar fasciopathy/’plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors. British Journal of Sports Medicine, 50(16), 972–981. https://doi.org/10.1136/bjsports-2015-094695
• Park, Y. H., Kim, W., Kim, J. Y., Choi, G. W., & Kim, H. J. (2021). Clinical Impact of Metabolic Syndrome on Eccentric Exercises for Chronic Insertional Achilles Tendinopathy. Journal of Foot and Ankle Surgery, 61(4), 726–729. https://doi.org/10.1053/j.jfas.2021.03.020
• Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H., & Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ, 361, k1662. https://doi.org/10.1136/bmj.k1662
• Pavlova, A. V., Shim, J. S. C., Moss, R., Maclean, C., Brandie, D., Mitchell, L., Greig, L., Parkinson, E., Alexander, L., Tzortziou Brown, V., Morrissey, D., Cooper, K., & Swinton, P. A. (2023). Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis. British Journal of Sports Medicine, 57(20), 1327–1334. https://doi.org/10.1136/bjsports-2022-105754
• Buttinger, J. N., Johnson, A. J., Twohey, E. E., Gibson, D. J., Nagelli, C. V., Johnson, S. E., & Romero, J. M. (2026). A systematic review of post-procedural rehabilitation protocols following percutaneous needle tenotomy and ultrasonic debridement for gluteal, proximal hamstring, and patellar tendinopathy. American Journal of Physical Medicine & Rehabilitation. online ahead of print (2026-06-17). https://doi.org/10.1097/PHM.0000000000003031
• Maag, L., Linder, S., Hackett, L., Mitchkash, M., Farley, T., Lamar, D., Fisher, N., & Burnham, B. (2024). Effectiveness of percutaneous needle tenotomy for tendinopathies: A systematic review. Sports Health, 17(4), 834–842. https://doi.org/10.1177/19417381241275659

Related reading

• Before the Diagnostic Nerve Block: What the Referring Chart Needs
• Corticosteroid-Induced Hyperglycemia After Joint Injections
• Laboratory Panels

Before the Diagnostic Nerve Block: What the Referring Chart Needs

A diagnostic nerve block referral should carry a measured baseline, such as bioimpedance body composition rather than body mass index alone, and the result should come back with how the block was done: imaging, volume and sedation. Without that record, an inaccurate block and an accurate negative one look identical in the chart.

A block result is only as reliable as the address it reached and the patient reporting relief. The referring physician controls neither, but controls what is measured and documented before the referral is written.

A diagnostic nerve block is a measurement, and like any measurement it carries error that the referring chart rarely sees. The primary care or pain physician who orders the referral does not hold the needle, but does decide what is documented before it, and that record shapes how the result is read afterward. The chapter video, Injecting Blindly Is Accepting Failure, presents chapter 13 of The Pained Brain by Dr. Gurpreet Singh Padda, MD, MBA, MHP, and Dr. KrisJay Fucanan, MD; the study-level detail, with the limits of each paper, is in the book companion for chapter 13.

How accurate is a diagnostic nerve block?

The multispecialty lumbar facet guideline reports that a medial branch block under fluoroscopy misses its target nerve less than 2 percent of the time, while attempts to enter the facet joint itself fail 29 to 38 percent of the time. Selectivity is a separate problem from placement. In the cervical guideline, raising the injectate from a quarter to 0.5 milliliter more than doubled spread beyond the intended level, 16 percent versus 38. Light sedation more than doubled the positive rate at a 50 percent relief threshold and tripled it at 80, which is why that committee recommends performing the block without sedation.

Then there is the false negative. Intravascular uptake occurs in 4 to 19 percent of lumbar medial branch blocks, and when the anesthetic drains into a vein the generator is declared innocent. An uncontrolled single cervical block carries reported false-positive rates of 36 to 55 percent, and a single sacroiliac injection about 20 percent. Both directions of error land in the referring record as a clean yes or no.

Why does block selection change ablation results?

The randomized comparison of zero, one or two blocks before lumbar facet denervation is honest in both directions. Among patients who actually proceeded to denervation, success rose from 33 percent with no block to 64 percent after comparative blocks, although per randomized patient the no-block arm did as well because blocks screen out some eventual responders. The largest negative ablation trial enrolled its sacroiliac arm on a single lenient block that only 24 percent of screened patients failed, so a loose selection step became a population result. The exception also belongs in the note: before cooled genicular ablation, a prognostic block produced 58.6 percent success against 64.0 percent without it.

The practice position is to block twice, imaged, with an awake patient. For the referring physician, the operational point is simpler. A result labeled non-responder is only interpretable if the chart records how the block was done.

Why is landmark placement less accurate in patients with obesity?

Blind placement performs worst in exactly the patients primary care sees most. Palpation of the intercristal line placed the fourth lumbar interspace correctly in 75.3 percent of participants overall and 34 percent of obese participants. In a scoped knee series, landmark accuracy fell at a body mass index of 30 or more. Across 106 consecutive blind shoulder injections, providers could not predict which of their own injections had landed, regardless of experience.

Two biological drivers compound that. Adiposity alters the anatomy a landmark assumes, and insulin resistance shapes the tissue the procedure is meant to buy time for. The third driver is structural: the referral pathway returns a procedure note to primary care, not a record of guidance, contrast or sedation, so an inaccurate block and an accurate negative one look identical in the chart. Documenting bioimpedance body composition rather than body mass index alone gives the receiving interventionalist a better description of the patient, and gives the referring physician a baseline for the rehabilitation phase that follows any successful block.

What Measura adds before the referral

Measura [Cardiometabolic and Autonomic Health Analysis] is a testing service. It performs no injections, no imaging and no treatment, and its findings return to the ordering physician. Its place in this pathway is the terrain the procedure lands in, which the book treats as the half of the plan that decides whether the bridge leads anywhere.

• Metabolic status. Laboratory panels document the insulin-resistance picture that a pain referral almost never includes.
• Body composition. Fat and lean compartments, measured rather than inferred from weight and height.
• Small-fiber function. When the complaint is distal burning rather than axial pain, sudomotor testing documents sweat-gland function of the small nerve fibers in the hands and feet, a question no facet block is designed to answer.
• Cognition. A diagnostic block’s endpoint is patient-reported relief, recorded by an awake patient. A cognitive assessment baseline is already part of annual wellness documentation, and pairing it with fall-prevention screening keeps both in the same visit.

Standing orders, documentation and quality reporting

None of this requires a new pathway, only a reproducible one. A standing order can attach metabolic, body composition and, where indicated, small-fiber testing to referrals for interventional pain evaluation, so the decision does not depend on who saw the patient that day. Results filed as discrete data in the record stay visible when the procedure note comes back. The same findings support cardiometabolic documentation that MIPS and quality reporting already ask practices to capture, as documentation rather than as a reason to test.

A useful addition to the referral letter costs one sentence: request image guidance with contrast, and an awake patient for any diagnostic block, and ask that the procedure note state both. That sentence turns an unreadable negative into data.

What the evidence does not settle

Accuracy and outcome are separate claims. Across 19 shoulder trials, the Cochrane reviewers found ultrasound-guided steroid injection better than unguided by only 0.5 points on a ten-point scale, because corticosteroid diffuses and works from a near miss. That is exactly why steroid trials are the wrong test for a diagnostic block, whose value is the question rather than the drug. Novices needed about 28 supervised attempts to reach competence in ultrasound needle visualization on cadavers. The position stands: image every diagnostic block, keep the patient awake, and treat the procedure as a bridge whose far bank is the metabolic and functional work measured before and after it. Patients can read the patient-facing explanation.

Frequently asked questions

References

• Cohen, S. P., Bhaskar, A., Bhatia, A., Buvanendran, A., Deer, T., Garg, S., Hooten, W. M., Hurley, R. W., Kennedy, D. J., McLean, B. C., Moon, J. Y., Narouze, S., Pangarkar, S., Provenzano, D. A., Rauck, R., Sitzman, B. T., Smuck, M., van Zundert, J., Vorenkamp, K., … Zhao, Z. (2020). Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia and Pain Medicine, 45(6), 424–467. https://doi.org/10.1136/rapm-2019-101243
• Hurley, R. W., Adams, M. C. B., Barad, M., Bhaskar, A., Bhatia, A., Chadwick, A., Deer, T. R., Hah, J., Hooten, W. M., Kissoon, N. R., Lee, D. W., Mccormick, Z., Moon, J. Y., Narouze, S., Provenzano, D. A., Schneider, B. J., van Eerd, M., Van Zundert, J., Wallace, M. S., … Cohen, S. P. (2022). Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Regional Anesthesia and Pain Medicine, 47(1), 3–59. https://doi.org/10.1136/rapm-2021-103031
• Cohen, S. P., Williams, K. A., Kurihara, C., Nguyen, C., Shields, C., Kim, P., Griffith, S. R., Larkin, T. M., Crooks, M., Williams, N., Morlando, B., & Strassels, S. A. (2010). Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology, 113(2), 395–405. https://doi.org/10.1097/ALN.0b013e3181e33ae5
• Juch, J. N. S., Maas, E. T., Ostelo, R. W. J. G., Groeneweg, J. G., Kallewaard, J. W., Koes, B. W., Verhagen, A. P., van Dongen, J. M., Huygen, F. J. P. M., & van Tulder, M. W. (2017). Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA, 318(1), 68–81. https://doi.org/10.1001/jama.2017.7918
• McCormick, Z. L., Hurley, R. W., Anitescu, M., Bhaskar, A., Bhatia, A., Cassidy, R. C., Chen, A. S., Dawson, T. C., De Andrés Ares, J., de Campos, J. L., Hayek, S. M., Hernández-Porras, B. C., Kissoon, N. R., Kohan, L. R., Elgueta Le Beuffe, M. F., Moon, J. Y., Provenzano, D. A., Reece, D. E., Schuster, N. M., … Cohen, S. P. (2025). Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group. Pain Medicine, 26(12), 817–917. https://doi.org/10.1093/pm/pnaf129
• McCormick, Z. L., Reddy, R., Korn, M., Dayanim, D., Syed, R. H., Bhave, M., Zhukalin, M., Choxi, S., Ebrahimi, A., Kendall, M. C., McCarthy, R. J., Khan, D., Nagpal, G., Bouffard, K., & Walega, D. R. (2018). A Prospective Randomized Trial of Prognostic Genicular Nerve Blocks to Determine the Predictive Value for the Outcome of Cooled Radiofrequency Ablation for Chronic Knee Pain Due to Osteoarthritis. Pain Medicine, 19(8), 1628–1638. https://doi.org/10.1093/pm/pnx286
• Malik, M., & Ismail, S. (2019). Accuracy of Tuffier’s Line Identification by Palpation Method: Cross-Sectional Comparative Study Among Obese, Pregnant and Control Groups. Turkish Journal of Anaesthesiology and Reanimation, 48(2), 108–114. https://doi.org/10.5152/TJAR.2019.82346
• Zadro, J., Rischin, A., Johnston, R. V., & Buchbinder, R. (2021). Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain. Cochrane Database of Systematic Reviews, 8(8), CD009147. https://doi.org/10.1002/14651858.CD009147.pub3

Related reading

• Epidural Steroid Injection Overuse: Measuring the Terrain First
• Tendinopathy as a Metabolic Signal: Screening Before the Procedure
• Bioimpedance Body Composition