The Spaulding Rehabilitation Hospital is a 132-bed rehabilitation teaching hospital located in Boston, Massachusetts. It is the official teaching hospital for Harvard Medical School’s Department of Physical Medicine and Rehabilitation and the main campus of the Spaulding Rehabilitation Network. The hospital is a member of Partners Continuing Care under Partners HealthCare, a non-profit organization that owns several hospitals in Massachusetts.
PURPOSE:More than 80% of patients with advanced malignancy experience pain as they approach death, and up to 30% fail to achieve adequate relief from systemic analgesics or cannot tolerate their side effects. For these patients, externalized epidural or intrathecal catheters offer a targeted alternative, delivering analgesic agents directly to the neuraxis. This narrative review examines patient selection, technical approaches, pharmacological regimens, clinical outcomes, and complications associated with externalized epidural and intrathecal catheter systems for refractory cancer pain at end of life. RECENT FINDINGS:The available literature comprises predominantly small, single-center retrospective cohort studies and prospective case series, with one double-blind randomized controlled trial identified. Neuraxial analgesia was consistently associated with three benefits: reductions in pain intensity from severe baseline levels (NRS 7-10) to mild-to-moderate ranges (NRS 2-5), with some patients achieving near complete relief; opioid-sparing effects, including systemic opioid discontinuation in a subset of patients; and functional improvements sufficient to support discharge to home or hospice. Infectious complications were the leading cause of early catheter removal, with epidural abscess rates as high as 12% reported in one cohort; tunneled subcutaneous port systems appeared to confer lower infectious risk than percutaneous catheters. Externalized catheters provide meaningful pain relief, opioid sparing, and functional benefits for carefully selected patients with refractory cancer pain at the end of life. Given the heterogeneity of study designs and inconsistent outcome reporting, prospective multicenter studies employing standardized pain, functional, and complication metrics are needed to better define the role of neuraxial analgesia in this population.
BACKGROUND:Expectations shape therapeutic outcomes, yet their systematic assessment remains limited in clinical and research settings. To address this gap, we developed and validated the Brief Instrument for the Assessment of Treatment Expectations in Chronic Pain (BITEC) using Item Response Theory. METHODS:The study comprised four phases. (I) Twenty-one items were generated from expectation constructs and refined to 11 through a Delphi review (≥ 80% agreement). (II) Comprehensibility was tested in 30 women with fibromyalgia, and the scale was applied to 484 chronic pain patients; items (0-10) were recoded into four categories, and IRT reduced them to nine. (III) The final version was administered to 1127 adults with chronic pain (79.3% fibromyalgia; 20.7% nociceptive/neuropathic), and latent-class modelling defined low-high expectation cutoffs. (IV) Construct validity was assessed via discriminant analyses in calibration (n = 1127) and validation (n = 242) samples to evaluate whether BITEC levels differentiated diagnostic groups, pain impact and catastrophizing. (V) We developed a bedside app to support expectation-level classification. RESULTS:The nine-item BITEC showed discrimination between high and low expectations (AUC 0.915; 95% CI 0.897-0.933; sensitivity 79%, specificity 96%). Across both samples, BITEC demonstrated construct validity, distinguishing expectation categories based on symptom severity, catastrophizing and pain burden. Expectation levels varied across pain phenotypes, decreasing from nociceptive pain (56.1%) to fibromyalgia (42.7%) and multiple pain conditions (26.9%). Higher symptom severity was associated with higher expectations. CONCLUSION:BITEC is a brief, reliable, theory-grounded instrument for stratifying treatment expectations in chronic pain; applicability across treatment modalities and clinical contexts warrants further investigation. SIGNIFICANCE STATEMENT:Expectations strongly shape therapeutic outcomes but remain difficult to measure. The BITEC, a brief IRT-based tool, offers a reliable way to classify treatment expectations in chronic pain, supporting personalised care and improving clinical decision-making.
Social interaction supports brain health and recovery after neurological injury. Yet no validated tool exists for real-time measurement in individuals with and without neurological deficits. We developed SocialBit, a lightweight, privacy-preserving machine learning algorithm that detects social interactions using ambient audio features on a commercial smartwatch. In a prospective validation study, we evaluated SocialBit against livestream minute-by-minute human-coded ground truth in 153 hospitalized stroke patients who wore the device for up to 8 days, generating 88,918 min of observation. In these patients, the stroke severity and cognition spanned broad clinical ranges (NIH Stroke Scale 0–25; Montreal Cognitive Assessment 8–30), and 24 patients had aphasia across diverse subtypes, including severe presentations. SocialBit achieved high overall performance (sensitivity 0.87, specificity 0.88, area under the curve 0.94) and maintained accuracy in patients with language deficits (AUC 0.93). Despite lower temporal sampling, SocialBit produced interaction frequency distributions closely matching minute-by-minute human coding. Performance was robust across environments and interaction types. Of clinical relevance, SocialBit showed that patients with more severe strokes engaged in less social interaction, paralleling human-coded results. SocialBit is an accurate digital biomarker of social interaction with potential applications in remote monitoring and clinical trials.
BACKGROUND:Evidence supporting prehabilitation before cardiac procedures is growing, but the efficacy of different components remains unclear. OBJECTIVES:The primary aim was to assess the efficacy of prehabilitation on clinical outcomes based on recent randomized controlled trials (RCTs). The secondary aim was to identify effective intervention and which patient subgroups benefit most. METHODS:We searched Medline, Web of Science, PsycINFO, Embase, Scopus, and Cochrane Central Register of Controlled Trials Library for RCTs comparing prehabilitation with standard care in cardiac patients up to August 2024. Trials were screened by 2 reviewers and meta-analyses were performed using random-effects models. RESULTS:Forty-four RCTs including 3,925 patients were identified. Prehabilitation improved preprocedural functional capacity (6-minute walk distance) and recovery (in-hospital length of stay, intensive care unit stay, and occurrence of postprocedural pneumonia). Six trials (n = 600) showed improved 6-minute walk distance (mean difference [MD] 68.87 m; 95% CI: 12.76-124.98 m; P = 0.020). In 18 studies (n = 1,568), length of stay was shorter (MD -0.95 days; 95% CI: -1.77 to -0.13 days; P = 0.026) and meta-regression showed greater effect in studies including more women (P = 0.015). In 16 trials (n = 1,149), intensive care unit stay was reduced (MD -6.03 hours; 95% CI: -12.01 to -0.06 hours; P = 0.048). In 5 studies (n = 729), postprocedural pneumonia occurred less frequently (OR: 0.33; 95% CI: 0.15-0.72; P = 0.017). The analysis revealed substantial heterogeneity and risk of bias. Analysis of specific components showed no consistent effects. CONCLUSIONS:Prehabilitation before cardiac procedures may enhance preprocedural functional capacity and postprocedural recovery, particularly in women. Further multicenter studies are needed.
Measuring neuromotor control after stroke is crucial for identifying the mechanisms underlying asymmetrical walking and guiding rehabilitation. The lower extremity portion of the Fugl-Meyer (FM-LE) and the number of muscle synergies are commonly used measures, but have important limitations. The dynamic motor control index has emerged as a complementary metric, yet its relationship to established clinical measures (i.e., FM-LE), muscle synergy number, and gait biomechanics remains unclear. This study evaluated the ability of the dynamic motor control index to quantify post-stroke neuromotor impairment relative to FM-LE and muscle synergy number and examined its relationship with propulsion asymmetry. Electromyography data from 22 individuals post-stroke and 31 neurotypical controls were analyzed using non-negative matrix factorization. The dynamic motor control index and not the muscle synergy number differentiated paretic, non-paretic, and neurotypical limbs (χ2(2) = 27.57, p < .001). It also differed significantly between less and more impaired individuals classified by FM-LE ( p = .05) and demonstrated good discriminative performance between these groups (AUC: 0.777, p = .017). The index also moderated the relationship between FM-LE and propulsion asymmetry (ΔR 2 = 0.223, p = .007). These findings support the dynamic motor control index as a clinically relevant msarker of post-stroke neuromotor impairment and recovery.
