Chapter 10: Pain Medicine 2026

Dr Thomas Haag

Why do this QI project?

Chronic pain of the knee, hip, and shoulder that persists despite conservative management significantly impairs function and quality of life. Interventions such as diagnostic nerve block (DNB) and radiofrequency denervation (RFD) can provide both diagnostic confirmation and targeted analgesia. ¹-³ This project supports the implementation of a standardised, evidence-based pathway for DNB and RFD in patients with chronic knee, hip, or shoulder pain. Adherence to patient selection criteria, standardised procedural technique, and systematic outcome measurement aligns with Faculty of Pain Medicine (FPM) Core Standards.

Background 

DNB involves perineural injection of local anaesthetic around the articular sensory branches responsible for joint pain. A reduction in pain of ≥50 % is generally considered a pragmatic threshold when selecting patients for subsequent RFD. ²

RFD delivers controlled thermal energy to interrupt nociceptive fibres supplying the joint, producing sustained analgesia.³^-⁷ Conventional RFD typically applies 80–90 °C for 60–90 seconds, whereas cooled RFD allows larger lesion volumes at lower electrode temperatures. ³^,⁴

Best Practice

Current NICE guidance supports RFD for patients with chronic osteoarthritis-related knee pain who have failed conservative measures and demonstrated a positive response to diagnostic blocks⁸.
Evidence for hip RFD is emerging, showing moderate improvement in pain and function. ⁵ Evidence for shoulder RFD remains limited but shows very promising results in preliminary analyses, particularly as far as sustained functional improvements are concerned. ⁶^,⁷.
Across all joints, systematic reviews and prospective studies demonstrate that RFD can provide meaningful analgesia, improved function, and high patient satisfaction with low complication rates. ¹^-⁷

Suggested data to collect

Process Measures

• Proportion of eligible patients entering the care pathway
• Proportion of patients undergoing the appropriate consent process.
• Documentation of target nerves, imaging modality, and clinical indication.
• Positive DNB response (≥50 % pain reduction) prior to RFD.²
• Recording of lesion parameters (temperature, duration, electrode type)³^,⁴.
• SOP compliance ≥90 %.

Outcome Measures

• ≥50 % reduction in pain at 3 months post-RFD.¹^-⁷
• Functional improvement at 3 and 12 months (e.g., WOMAC, Oxford Hip/Knee/Shoulder Score, SPADI).

Balancing measures

• Complication rate <5 %.³^-⁵
• Re-intervention rate <25 % within 12 months.¹^-⁷

QI methodology and suggested implementation plan

At implementation, the service should have

• MDT establishment (pain consultant/interventionalist, physiotherapy, radiography/sonography, data lead).

Develop and embed a local SOP specifying eligibility, procedural technique, and follow-up.⁹^-¹¹

• Defined eligibility criteria to enter pathway
• Pre-assessment with baseline PROMs; informed consent highlighting evidence strength by joint.
• Standardised procedural checklist.
• Availability of imaging (fluoroscopy or ultrasound) and trained operators.
• Standardised consent and procedural documentation.
• Post-procedure plan: early flare management, timely rehab, safety-netting.
• Governance oversight, including peer review
  • Ratify SOP (eligibility, imaging, parameters, aftercare).
  • Regular audit, feedback and pathway refinement; training/competency sign-off.⁹^-¹¹

Continuous data collection to monitor completeness, DNB response, procedural parameters, and RFD outcomes.

• Continuous data collection to monitor predictive value of DNB and clinical effectiveness of RFD.¹^-⁷
• Monitor patient-reported pain and functional outcomes at 3, 6 and 12 months.¹^-⁷
• Benchmark local outcomes against national guidance and published evidence.⁸^-¹¹
• Consider potential barriers, mitigation and quality control

Barrier	Mitigation
Variation in technique	Joint-specific SOP; supervised lists; peer review and image audits.
Imaging capacity/skill mix	Protected interventional sessions; cross-training; ultrasound where appropriate.
Anticoagulation/comorbidity	Pre-procedure optimisation; clear anticoagulant pathways.
Patient attrition/poor follow-up	Book follow-ups at discharge, remote PROMs, and reminders
Expectation mismatch (hip/shoulder evidence)	Standardised counselling; written information; shared decision-making.

 

References

 1. Davis T, Loudermilk E, DePalma M, et al. Prospective, multicentre, randomised, crossover clinical trial comparing cooled radiofrequency ablation with corticosteroid injection for osteoarthritic knee pain. Reg Anesth Pain Med2018;43(1):84–91. doi:10.1097/AAP.0000000000000690.
2. McCormick ZL, Reddy R, Korn M, et al. A prospective randomised 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 Med 2018;19(8):1628–1638. doi:10.1093/pm/pnx286.
3. Hong T, Wang H, Li G, et al. Systematic review and meta-analysis of randomised controlled trials evaluating the efficacy of invasive radiofrequency treatment for knee pain and function. Biomed Res Int 2019;2019:9037510. doi:10.1155/2019/9037510.
4.  Jamison DE, Cohen SP, et al. Radiofrequency techniques to treat chronic knee pain: a comprehensive review of anatomy, effectiveness, treatment parameters, and patient selection. J Pain Res 2018;11:1879–1888. doi:10.2147/JPR.S144633.
5. Kapural L, Lee N, Neal K, Burchell M. Cooled radiofrequency neurotomy of the articular sensory branches of the obturator and femoral nerves – combined approach using fluoroscopy and ultrasound guidance: technical report and observational study. Pain Physician 2018;21(3):279–284.
6. Pushparaj H, Hoydonckx Y, Mittal N, et al. A systematic review and meta-analysis of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain. Eur J Pain 2021;25(5):986–1011. doi:10.1002/ejp.1735.
7.  Santi C, Haag T, Cooke C, Schatman ME, Tinnirello A. Two-centre retrospective analysis on selective sensory denervation of the shoulder joint by means of cooled radiofrequency in chronic shoulder pain. J Pain Res2024;17:3139–3150. doi:10.2147/JPR.S463583.
8. National Institute for Health and Care Excellence (NICE). Radiofrequency denervation for osteoarthritic knee pain.Interventional Procedures Guidance IPG767. London: NICE; 2023.
9. Royal College of Anaesthetists. RCoA Quality Improvement Compendium. London: RCoA; 2021.
10.Faculty of Pain Medicine, Royal College of Anaesthetists. Core Standards for Pain Management Services in the UK. 2nd ed. London: FPM; 2022.
11. Faculty of Pain Medicine. Procedural Guidance for Interventional Pain Management. London: FPM; 2023.