Dear Editor

Higginson & Ramjeeawon’s commentary highlights that multidisciplinary, multicomponent, and multi-setting palliative care services achieve the greatest benefits. The 2022 UK Health and Care Act requires palliative care to be commissioned by integrated care boards and specifies that a skilled workforce and appropriate equipment should be available to all patients with palliative care needs. Statutory guidance clearly specifies that teams should have access to a rehabilitation workforce, including physiotherapists and occupational therapists, with expertise in palliative care. However, unlike other medical specialities, physiotherapists or occupational therapists are rarely core members of palliative care multi-disciplinary teams (MDTs). Even in hospices, provision is ad hoc with wide variation across the sector.

When approaching end of life, people still want to be able to live as normally as possible at home and don’t want to be a burden on their families. Losing function in daily activities is associated with symptom burden, reduced independence, increasing demands on family caregivers and is a frequently reported area of unmet need [1]. There is a large increase in secondary care use in the last year of life[2]and frequent admissions are associated with increasing disability[3]. People approaching the end of life and their families often need to be seen more quickly than other patients to maintain function, manage decline and avoid crises[4]. Hospital and community generalist rehabilitation teams may not have the flexibility in referral mechanisms or capacity to identify and prioritise people in a palliative phase of illness while they have time to benefit, which could lead to further loss of function, increased carer burden, and potentially unnecessary hospital admissions. When integrated in palliative care, rehabilitation interventions act synergistically with others provided by the MDT. Rehabilitation contributes value in palliative care for patients and their families during episodic periods of functional recovery and decline, and when permanent physical decline in inevitable. Timely access provides practical, pragmatic and low-cost effective interventions, including exercise[5], symptom self-management[6] and assistive devices[7], while people have time to benefit. Such interventions have potential to reduce the frequency of crisis events associated with poorly managed symptoms, immobility and falls. A multi-national trial of a scalable, short-term model of rehabilitation to optimise functioning and symptom self-management for people with advanced cancer in palliative care, INSPiRE, is currently in progress and will provide further evidence for commissioning MDTs in palliative care[8].

Despite having both policy and research demonstrating the need for integrated rehabilitation in palliative care, we know there is still huge disparity in provision. In the Better End of Life Report from 2024 [9] just 14% of bereaved relatives reported that their loved one had had contact from an occupational therapist and even fewer, 11% had contact with a physiotherapist in the last three months of life.

Investment in a sustainable rehabilitation workforce for specialist and generalist palliative care is needed. Qualifying programmes for rehabilitation professionals need to introduce education and training in palliative care onto the curriculum.

Both palliative care and rehabilitation are key health strategies in World Health Organisation policy on Universal Health Coverage[10]. To optimise synergies for effective palliative care in the UK, we urge the commission and expert panel to ensure that rehabilitation is commissioned as part of multi-disciplinary, multi-component, multi-setting palliative care in the new NHS 10-year plan.

1. Chochinov, H.M., et al., The Landscape of Distress in the Terminally Ill. Journal of Pain and Symptom Management, 2009. 38(5): p. 641-649.
2. Diernberger, K., et al., Healthcare use and costs in the last year of life: a national population data linkage study. BMJ Supportive & Palliative Care, 2021. 14(e1): p. e885-e892.
3. Gill, T.M., et al., The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older people. bmj, 2015. 350.
4. Nottelmann, L., et al., Early, integrated palliative rehabilitation improves quality of life of patients with newly diagnosed advanced cancer: The Pal-Rehab randomized controlled trial. Palliative Medicine, 2021: p. 02692163211015574.
5. Toohey, K., et al., The effects of physical exercise in the palliative care phase for people with advanced cancer: a systematic review with meta-analysis. Journal of Cancer Survivorship, 2023. 17(2): p. 399-415.
6. Brighton, L.J., et al., Holistic services for people with advanced disease and chronic breathlessness: a systematic review and meta-analysis. Thorax, 2018: p. thoraxjnl-2018-211589.
7. Manning, B., R. Kelly, and K. Broome, Assistive technology in palliative care: a statewide equipment programme. BMJ Supportive & Palliative Care, 2024. 14(e1): p. e500-e503.
8. Bayly, J., et al., Integrated Short-term Palliative Rehabilitation to improve quality of life and equitable care access in incurable cancer (INSPIRE): a multinational European research project. Palliative care and social practice, 2023. 17: p. 26323524231179979.
9. Johansson, T., et al., Time to care: Findings from a nationally representative survey of experiences at the end of life in England and Wales. 2024, Research report. London (UK): Marie Curie. 2024. http://mariecurie. org. uk ….
10. World Health Organisation Regional Office for Europe, Policy brief on integrating rehabilitation into palliative care services. 2023: Copenhagen.

Dear Editor

The 3 published responses are all reasonable, but they all miss an important point, which is that it is not just a matter of what you should do but a much stronger duty than that.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) section 27 requires those with disability which would include all forms of neurodiversity to have access to reasonable accommodations and equal access to education and employment. These in the United Kingdom are enshrined in the Equality Act 2010.

One of the best ways you can support neurodiverse colleagues in the NHS, which has an appalling record of discrimination, is to understand the Equality Act 2010 and be willing to support and advocate for colleagues and be willing to witness against discrimination by employers in grievances, disciplinary processes and even at tribunals.

Recent results using the Disability Discrimination Awareness Questionnaire show that the understanding of the Equality Act and the duties it puts on all doctors regarding both patients and colleagues is, in my opinion, woefully inadequate.

So maybe the 1st step to supporting neurodivergent and other disabled colleagues is to ensure that we and our employers get comprehensive training in the expectations of the Equality Act 2010.

Dear Editor

We thank readers for their comments.

Rittenberg suggests that abandoned procedures were included in our evidence synthesis. Six clinical experts on our guideline panel, blinded to study results, independently reviewed all study interventions and grouped them into categories, excluding trials evaluating procedures that are not commonly used in practice. (1)

He suggests that pooling across spinal regions, procedure approaches, and conditions is inappropriate. We conducted subgroup analyses of these factors and found no evidence for systematic differences in treatment effects. (see Supplementary Table 24 in our network meta-analysis) We acknowledged that, due to limited representation, we were unable to explore subgroup effects for all clinical conditions. We did not, however, find evidence of statistical variability across treatment effects in our outcome networks or in assessments of between-study variances within the closed loops of evidence. (1)

Consider the following example. Epidural steroid injections may be delivered transforaminal, interlaminar, or caudal; however, prior systematic reviews have found no difference in effect based on approach. (2-4) Further, our assessment for subgroup effects on pain relief based on whether epidural injection of local anaesthetic vs. local anaesthetic + steroids for radicular pain differ based on approach (interlaminar, caudal, transforaminal, unclear, or a combination of transforaminal and interlaminar) showed no credible subgroup effect (test of interaction p-value 0.7). (see Figure 1 here: https://mcmasteru365-my.sharepoint.com/:f:/g/personal/wangx431_mcmaster_...) We therefore combined across different approaches for delivering this procedure.

Rittenberg claims “there are not enough high-quality RCTs in interventional spine care to perform a well-powered meta-analysis in this area”. Our review identified 132 RCTs of common interventional procedures for chronic spine pain, and network meta-analysis provided moderate certainty evidence for the lack of effectiveness of five procedures on pain relief and six procedures on physical functioning. (1) We agree with Rittenberg and Shanthanna that further research is warranted and acknowledged that additional evidence may alter recommendations. (1,5)

Rittenberg advises that many patients elect to receive interventional procedures when informed of “their potential to provide meaningful pain relief and functional improvement”. We agree that advising patients that interventional procedures can be effective will convince many to pursue these treatments. However, such claims are not supported by the current best evidence, which shows that all common interventional procedures supported by moderate or low certainty evidence provide little to no improvement in pain relief or physical functioning compared with sham procedures. (1)

Jason W. Busse, Stéphane Genevay, Gordon H. Guyatt, and Thomas Agoritsas; on behalf of the Rapid Recommendation authors.

References
1. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025; 388: e079971.
2. Chang-Chien G, et al. Transforaminal versus interlaminar approaches to epidural steroid injections: a systematic review of comparative studies for lumbosacral radicular pain. Pain Physician. 2014; 17(4): E509-24.
3. Liu J, Zhou H, Lu L, et al. The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: A systematic review and meta-analysis. Medicine (Baltimore). 2016;95(18): e3373
4. Lee JH et al. Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis. Spine J. 2018 Dec;18(12):2343-2353.
5. Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025; 388: e079970.

Dear Editor

We thank readers for their comments.

Rittenberg advises that no outcome data between any of the 132 randomized trials our review identified should be pooled, as differences in how the same types of procedures are administered, where along the spine they are administered, and types of complaints will introduce unacceptable heterogeneity.

Our panel experts were less certain, and we therefore elected to explore pooling to maximize power to detect effects, improve generalizability, and facilitate subgroup analyses. (1) Example subgroup analyses of pairwise meta-analyses included: 1] whether pain relief afforded by epidural injection of local anaesthetic vs. local anaesthetic + steroids differed based on approach (interlaminar, caudal, transforaminal, unclear, or a combination of transforaminal and interlaminar) (Figure 1; test of interaction p-value 0.7), and 2] whether pain relief afforded by joint radiofrequency vs. joint targeted injection of local anaesthetic + steroid differed based on whether joint radiofrequency was pulsed or non-pulsed (Figure 2; test of interaction p-value 0.3). We found no evidence of credible subgroup effects based on these or other factors. (Supplementary Table 24)

We then explored if pooling introduced problematic heterogeneity to our network meta-analyses. We found no evidence of credible subgroup effects (e.g., Supplementary Tables 28, 38, 48, 58), statistical variability across treatment effects in our outcome networks, or in assessments of between-study variances within the closed loops of evidence. (2)

Rittenberg claims that we omitted an eligible trial from our review (Ghahreman et al., 2010). (3) We did not. Our review focussed on chronic spine pain, whereas this trial enrolled mostly patients with acute pain (80 of 150), and did not report results separately for patients with chronic pain.

Rittenberg suggests that the 24-patient trial by Lord et al. (1996) is the “strongest RCT on cervical medial branch radiofrequency neurotomy” with clearly defined diagnostic blocks.(4) However, the Bone and Joint Decade 2000–2010 Task Force on Neck Pain concluded this trial was scientifically inadmissible for their review due to critical limitations, including: 1] selection of patients “on the basis of a nonvalidated response to facet blocks”; 2] small sample size failed to balance critical prognostic factors – 83% of subjects in the sham group were involved in litigation due to their neck injury vs. 33% of patients in the intervention group (5); and 3] blinding was in doubt as 42% of patients in the active treatment arm developed long-term anesthetic or dysaesthetic areas of skin vs. 0% of control patients. (6)

We extracted technical details reported for administering interventional procedures from all eligible trials (Supplementary table 6).(2) We agree with Rittenberg that trial authors should clearly report such details, and that there is variability in this regard.

Our previous reply addressed concerns raised by Gharibo. No intervention designated as sham in our review was pharmacologically active. We assessed risk of bias for all included trials and conducted subgroup analyses to explore for differences in treatment effect between trials at high and low risk of bias. We found a credible subgroup effect for radiofrequency ablation vs. sham procedures that fully explained heterogeneity. Specifically, 7 trials that did blind providers showed a pooled effect on pain relief of -0.23 cm on a 10 cm VAS (-0.60 to 0.14) that was associated with an I2 of 0%. (Supplement Table 24)

Figure 1: Example subgroup analysis for chronic radicular spine pain [https://mcmasteru365-my.sharepoint.com/:f:/g/personal/wangx431_mcmaster_...

Figure 2: Example subgroup analysis for chronic axial spine pain[https://mcmasteru365-my.sharepoint.com/:f:/g/personal/wangx431_mcmaster_...

We agree with Tafur that researchers and clinicians should critically evaluate current practices and seek reliable and relevant evidence to guide treatment choices. We hope our work (2,8) will prove helpful in this regard.

Xiaoqin Wang, Liang Yao, and Jason W. Busse; On behalf of review authors

References
1. Gotzsche PC. Why we need a broad perspective on meta-analysis. It may be crucially important for patients. BMJ. 2000; 321(7261): 585-6.
2. Wang X, Martin G, Sadeghirad B, et al. Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. BMJ. 2025; 388: e079971.
3. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med 2010; 11(8): 1149-68.
4. Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med 1996; 335(23): 1721-6.
5. Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA. 2005; 293(13): 1644-52.
6. Carragee EJ, Hurwitz EL, Cheng I, et al; Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008; 33(4 Suppl): S153-69.
7. Akl EA, Sun X, Busse JW, et al. Specific instructions for estimating unclearly reported blinding status in randomized trials were reliable and valid. J Clin Epidemiol 2012; 65: 262-7.
8. Busse J W, Genevay S, Agarwal A, Standaert C J, Carneiro K, Friedrich J et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline BMJ. 2025; 388: e079970