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Pain Management Interventions for Hip Fracture

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Title: 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.
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