Pain Management Interventions for Hip Fracture

1
Pain Management Interventions forHip Fracture

• Prepared for
• Agency for Healthcare Research and Quality (AHRQ)
• www.ahrq.gov

2
Outline of Material

• Introduction to pain management during treatment
  for hip fracture.
• Systematic review methods.
• The clinical questions addressed by the
  comparative effectiveness review (CER).
• Results of studies and evidence-based conclusions
  about effectiveness and harms of pain management
  interventions.
• Gaps in knowledge and future research needs.
• What to discuss with patients and their
  caregivers.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
3
Health Impact in the United States ofHip
Fracture From Low-Impact Injury

• The incidence of hip fracture increases with age.
• At age 50, the rates are 22.5 per 100,000 for men
  and 23.9 per 100,000 for women.
• At age 80, the rates are 632.2 per 100,000 for
  men and 1,289.3 per 100,000 for women.
• Mortality rates in the 1st year postfracture are
  high.
• 25 for women 37 for men.
• Return to prefracture level of function is poor.
• 2550 of patients have not returned home by 1
  year postfracture.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
4
Consequences of Pain From Hip Fracture

• Pain following hip fracture has been associated
  with
• Delirium
• Depression
• Sleep disturbance
• Altered response to treatment for comorbidities
• Inadequately managed pain is associated with
• Delayed ambulation
• Cardiovascular and pulmonary complications
• Delayed transition to less-intensive care
  settings
• Aggravation of comorbidities and mortality risk

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
5
Implementation of Hip FracturePain Management (1)

• May be used preoperatively, intraoperatively, and
  postoperatively.
• May be pharmacological or nonpharmacological.
• May combine approaches that disrupt pain in more
  than one component of pain pathways. This is
  called multimodal pain management.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
6
Implementation of Hip FracturePain Management (2)

• Pain management is guided by
• The prior medical status of the patient
• Fracture characteristics
• Requirements of the treatment plan
• The patient population with pain due to hip
  fracture is predominantly elderly women who have
  significant and/or multiple comorbidities.
• Over age 80 1,289 per 100,000 women versus 632
  per 100,000 men.
• Comorbidities can affect both perception of pain
  and response to pain treatments (both benefits
  and harms).

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
7
Implementation of Hip FracturePain Management (3)

• Usual care Current guidelines recommend systemic
  analgesia, primarily with nonsteroidal
  anti-inflammatory drugs (NSAIDs) and opioids, as
  the 1st-line approach for management of moderate
  to severe pain in elderly patients in general.
• Complications of opioids include
• Alterations in mental status
• Nausea and vomiting
• Respiratory depression
• Tolerance
• Which alternative or adjunctive methods are safe
  and effective options that can be used within the
  clinical circumstances of older adults with hip
  fracture?

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
8
Agency for Healthcare Research and Quality (AHRQ)
Comparative Effectiveness Review (CER) Development

• Topics are nominated through a public process,
  which includes submissions from health care
  professionals, professional organizations, the
  private sector, policymakers, members of the
  public, and others.
• A systematic review of all relevant clinical
  studies is conducted by independent researchers,
  funded by AHRQ, to synthesize the evidence in a
  report summarizing what is known and not known
  about the select clinical issue. The research
  questions and the results of the report are
  subject to expert input, peer review, and public
  comment.
• The results of these reviews are summarized into
  Clinician Guides and Consumer Guides for use in
  decisionmaking and in discussions with patients.
  The Guides and the full report, with references
  for included and excluded studies, are available
  at www.effectivehealthcare.ahrq.gov.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
9
Rating the Strength of Evidence From the CER

• The strength of evidence was classified into four
  broad categories

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
10
Clinical Questions Addressed by the CER (1)

• In older adults, what is the effectiveness of
  pain management interventions for controlling
  acute (up to 30 days postfracture) and chronic
  pain (up to 1 year postfracture), compared to
  usual care or other interventions?
• What is the effect of pain management
  interventions on outcomes other than pain (up to
  1 year postfracture), compared to usual care or
  other interventions?
• For example mortality, mental status

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
11
Clinical Questions Addressed by the CER (2)

• What are the nature and frequency of adverse
  effects associated with pain management
  interventions, up to 1 year postfracture?
• Myocardial infarction, renal failure, and stroke
• How do patient subpopulation characteristics
  affect effectiveness and safety?

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
12
Pain Management Interventions Includedin This
CER (1)

• Systemic Analgesia
• Both narcotic (opioids) and non-narcotic (NSAIDs,
  acetaminophen) medications are typical in usual
  care.
• Nerve Blocks (regional blocks)
• Injection of anesthetics into nerve bundles
  prevents the generation and conduction of nerve
  impulses to the spinal cord and brain.
• Traction
• A traditional approach for the population of
  patients with hip fracture.
• Preoperative skin or skeletal traction.
• Goal is to stabilize the fractured leg, to reduce
  pain, and to improve fracture reduction.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
13
Pain Management Interventions Examined in this
CER (2)

• Anesthesia
• Neuraxial spinal and epidural
• Injection of an anesthetic into the epidural or
  subarachnoid space in the spinal column
• Transcutaneous Electrical Neurostimulation (TENS)
  
• Applies electrical energy to peripheral nerves,
  to reduce the perception of pain
• Uses varying amplitudes and frequencies,
  depending on indication
• Rehabilitation
• Part of standard postoperative care
• Goal is to increase mobility and reduce pain by
  improving muscle strength and range of motion
• Participation can be limited by delirium and
  degree of pain experienced by the patient

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
14
Pain Management Interventions Examined in this
CER (3)

• Complementary and Alternative Medicine (CAM)
• Systems, practices, and products that are not
  part of conventional medicine, such as
• Acupressure applying pressure at body sites away
  from the pain locale.
• Jacobson relaxation technique alternating
  between contracting and relaxing muscles.
• Multimodal Pain Management
• The use of multiple strategies as part of the
  clinical pathway.
• Intent is to decrease pain to a greater extent
  than with one intervention alone.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
15
Clinically Significant Outcomes of Interest

• Acute and Chronic Pain Intensity
• Overall pain
• Pain on movement
• Pain at rest
• Most research has focused on acute pain, the
  emotional and sensory response to injury, which
  lasts for the duration of injury and healing.
• For hip fracture studies, the duration for acute
  pain is defined as occurring up to 30 days
  postfracture.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
16
Measuring Pain in Clinical Studies (1)

• The patients self-report of pain is the standard
  for evaluating the character and intensity of
  pain.
• There is no consensus about the exact cutoff for
  determining a clinically significant reduction in
  pain.
• Two methods commonly used to assess the intensity
  of pain
• Visual analog scale (VAS)
• On a 10-cm line, where the far left is no pain
  and the far right end is the worst pain ever,
  point to how your pain feels.
• Numerical scale
• For example, On a scale of 010, where 0 is no
  pain and 10 is the worst pain possible, how would
  you rate your pain?
• Numerical scales show a linear correlation with
  VAS results.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.gov
/hippain.cfm.
17
Measuring Pain in Clinical Studies (2)

• For the evidence presented here, pain
  measurements were evaluated as differences
  between intervention and comparator VAS means as
  measured after treatment.
• Test intervention VAS mean - control intervention
  VAS mean VAS mean difference.
• The values are reported as centimeters (cm)
  difference.
• For example, a mean difference of -1.0 expresses
  an additional 1-cm shift of the indicated point
  on the VAS toward less pain, achieved by the
  test intervention when compared with the control
  intervention.
• Absolute change from baseline for test and
  control interventions is not reported here.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
18
Other Clinically Significant Outcomes and Adverse
Events

• The evidence about these outcomes and events was
  evaluated
• Clinically significant outcomes
• 30-day mortality rate
• Mental status (delirium)
• Quality of life
• Serious Adverse Events
• Stroke
• Myocardial infarction
• Renal failure

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
19
Summary of Study Characteristics Evaluated in the
Effectiveness Review PICOTS

• Population Elderly patients experiencing pain
  from nonpathological, low-impact injury hip
  fractures.
• Interventions Pain management methods, including
  systemic analgesia, neuraxial anesthesia, nerve
  blocks, traction, TENS, rehabilitation,
  complementary and alternative methods, and
  multimodal approaches.
• Comparators usual care (non-narcotic and
  opioid), and/or other interventions.
• Outcomes pain intensity, mental status, 30-day
  mortality, serious adverse events (stroke,
  myocardial infarction, renal failure).
• The evidence about only these key outcomes was
  scored for strength of evidence.
• Timing acute care, within 30 days of fracture.
• Setting acute care.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
20
Controlled Trials of Pain Interventions Examined
in the Effectiveness Review
Intraop intraoperative postop postoperative
preop preoperative.
Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
21
Controlled Trials Reporting Effectiveness for
Acute Pain

• Of the 71 controlled trials of pain management
  interventions reviewed, only 37 directly measured
  effects on pain. Others measured secondary
  outcomes (e.g., mental status).

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
22
Effectiveness of Systemic Analgesics forAcute
Pain Trials, Results, and Conclusions

• No studies compared effectiveness, benefits, and
  harms of the systemic analgesics commonly used in
  pain management (non-narcotic and opioid) for
  elderly patients with hip fractures.
• The evidence is insufficient to make any
  conclusions about the effectiveness or safety of
  these interventions or other systemic analgesics
  in elderly patients with hip fractures.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
23
Effectiveness of Anesthesia on Acute Pain
Trials, Results, and Conclusions

• The evidence is insufficient to understand the
  effectiveness against acute pain of differing
  doses, modes of administration, and the addition
  of opioids to the anesthetic injection.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
24
Effectiveness of Nerve Block on Acute Pain
(Overall Pain) Trials and Results
Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
Centimeters difference Meta-estimate.
25
Effectiveness of Nerve Block onAcute Pain
Conclusions

• In general, nerve blocks provide greater relief
  from the acute pain of hip fracture than usual
  care alone.
• Strength of Evidence Moderate
• Nerve blocks used intraoperatively may be as
  effective as epidural and spinal anesthesia for
  relief of acute pain.
• Strength of Evidence Low

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
26
Effectiveness of Skin Traction on Acute Pain
Trials, Results, and Conclusions

• Meta-analysis indicates that skin traction does
  not provide more relief from acute pain than
  standard care.
• The difference between treated and control
  groups for reported intensity of pain is neither
  clinically important nor statistically
  significant.
• Strength of Evidence Low
• In one trial, skeletal traction exhibited no
  statistically significant difference in pain
  relief when compared with skin traction.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
27
Effectiveness of TENS on Acute Pain Trials,
Results, and Conclusions

• The meta-estimate indicates that TENS may relieve
  pain more than a sham control with standard care
  in both preoperative and postoperative use.
• However, the evidence is insufficient to form a
  conclusion about potential benefits to assist in
  decisionmaking.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
28
Effectiveness of Complementary and Alternative
Medicine Techniques for Acute Pain Trials,
Results, and Conclusions

• Acupressure and the Jacobson relaxation technique
  may contribute to pain reduction over that from
  standard care alone, but the evidence is
  insufficient to permit a conclusion about the
  extent of potential benefits.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
29
Effectiveness of Rehabilitation on Acute Pain
Trials, Results, and Conclusions

• Stretching and strengthening exercises reduced
  acute pain (back pain) more than standard care
  alone, but the evidence is insufficient to permit
  a conclusion about benefits.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
30
Evidence About Effectiveness for Other Outcomes

• Clinically important outcomes that may show
  differences between pain-control methods include
• Mortality rate (at 30 days)
• Mental status (delirium)
• Health-related quality of life

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
31
Effectiveness of Pain Management Interventions on
Other Important Outcomes

• The evidence is insufficient to estimate the
  effect on mortality rate, mental status, or
  health-related quality of life of these
  interventions

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
32
Effectiveness of Anesthesia on Other Important
Outcomes

• Continuous and single-dose modes of spinal
  anesthesia do not differ in effects on the 30-day
  mortality rate or mental status.
• For all other comparisons of doses, modes of
  administration, and the addition of opioids to
  the injection, the evidence is insufficient to
  determine an estimate of the effect.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
33
Effectiveness of Nerve Block on Other Important
Outcomes

• In all studies, nerve blocks were compared with
  standard care alone.
• Nerve blocks do not affect 30-day mortality
  rates.
• Nerve blocks do reduce the incidence of delirium.
• NNT (number needed to be treated to have one
  additional patient benefit, when compared with
  usual care,) from randomized controlled trial
  (RCT) data 9.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
34
Summary of Benefits (1)

• Nerve Blocks
• Reduce the intensity of acute pain.
• Strength of Evidence Moderate
• Can be as effective as spinal anesthesia for
  relief of acute pain.
• Strength of Evidence Low
• Reduce the likelihood of delirium (NNT 9).
• Strength of Evidence Moderate
• Do not affect mortality rates.
• Strength of Evidence Low

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
35
Summary of Benefits (2)

• Spinal Anesthesia
• Continuous versus single-dose modes do not differ
  in effect on mortality rates or incidence of
  delirium.
• Strength of Evidence Low
• The evidence is insufficient to understand the
  effectiveness and benefits of differing doses,
  modes of administration, and the addition of
  opioids to the anesthetic injection.
• Skin traction
• Does not reduce the intensity of acute pain.
• Strength of Evidence Low

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
36
Summary of Benefits (3)

• Rehabilitation, Acupressure, Jacobson Relaxation
  Technique, and TENS
• The current evidence indicates that these
  modalities show some promise for pain relief, but
  the data are too limited to permit conclusions
  about the benefits or harms.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
37
Adverse Events Influenced by Pain Management
Interventions

• Evidence about clinically significant, serious
  adverse events influenced by pain interventions
  was examined for the effectiveness review.
• These events are
• Stroke
• Myocardial infarction
• Renal failure

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
38
Studies Reporting Evidence AboutAdverse Events
Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No. 30.
Available at http//effectivehealthcare.ahrq.go
v/hippain.cfm.
39
Adverse Events Influenced by Pain Management
Interventions

• Overall, adverse event rates were similar in both
  treated and control groups, but studies were not
  powered to identify statistically significant
  differences.
• Myocardial infarction, stroke, and renal failure
  were either rarely reported or no significant
  differences were found between groups.
• The evidence is insufficient to understand the
  association of pain management interventions with
  clinically significant, serious adverse events
  that occur in elderly patients with hip fracture.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
40
Influence of Subpopulation Characteristics on
Effectiveness and Safety (1)

• Response to pain management may be affected by
  patient subpopulation characteristics, including
• Age
• Sex
• Comorbidities
• Prefracture functional status

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
41
Influence of Subpopulation Characteristics on
Effectiveness and Safety (2)

• Only two studies of nerve blocks were performed
  with consideration of subpopulation
  characteristics.
• One study in individuals with Preopexisting heart
  disease.
• One study in individuals who were independent
  before their hip fracture.
• No other studies were designed to determine
  effects of patient characteristics on outcomes.
• The evidence is insufficient to understand the
  influences of subpopulation characteristics on
  effectiveness, benefits, or adverse events.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
42
Conclusions About Benefits and Adverse Events

• Overall, there is limited evidence about the
  comparative effectiveness, benefits, and harms of
  pain management interventions used for elderly
  patients with hip fracture.
• Evidence of moderate strength supports the
  findings that nerve blocks reduce pain and the
  incidence of delirium when compared with usual
  care alone.
• Evidence of low strength supports the finding
  that preoperative traction does not improve
  relief from acute pain.
• For all modalities, including those most commonly
  used (acetaminophen, NSAIDs, and opioids), the
  evidence is inadequate to estimate harms and the
  incidence of common adverse events in elderly
  patients with hip fracture.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
43
Knowledge Gaps and Future Research Needs (1)

• Few studies of pain management interventions have
  been performed that specifically address
  effectiveness, benefits, and harms in elderly
  patients with hip fracture.
• There are no studies that compare the
  effectiveness and safety of the systemic opioid
  and NSAID analgesics that are used for elderly
  patients with hip fracture.
• There is no evidence about the effectiveness of
  multimodal approaches for acute pain relief, and
  the evidence is insufficient to understand the
  influence of the pain-relief approach on adverse
  events.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
44
Knowledge Gaps and Future Research Needs (2)

• How rehabilitation techniques may affect either
  acute or chronic pain is unexplored.
• Knowledge is very limited about the benefits and
  adverse events associated with pain management
  approaches in the long term (beyond 30 days).
• Applicability of current studies is limited, as
  patients in institutional settings and those with
  cognitive impairment were rarely represented.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
45
Knowledge Gaps and Future Research Needs (3)

• To improve evidence quality and reduce bias,
  future research should use blinded outcome
  assessors, validated and standardized
  outcome-assessment tools, adequate concealment of
  allocation to an intervention (where applicable),
  and appropriate handling of missing data.
• Multicenter research studies are needed that are
  large enough for statistical analysis of
  subgroups (by age, gender, comorbidities, or
  prefracture functional status) and for detection
  of adverse effects.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.
46
What To Discuss With Your Patients and Their
Caregivers

• Managing pain during the period from injury
  through rehabilitation is important for advancing
  return to function and quality of life.
• There are options for pain management that may be
  suitable for patients with a variety of
  comorbidities.
• There is limited evidence about the benefits and
  harms of pain-control interventions when they are
  used for elderly patients with hip fractures.

Abou-Setta AM, Beaupre LA, Jones CA, et al. AHRQ
Comparative Effectiveness Review No.
30. Available at http//effectivehealthcare.ahrq
.gov/hippain.cfm.