Evidence map for acute low back pain interventions depicting the overall evidence landscape for the 2021 update to the low back pain clinical practice guideline. (peto or dersimonian or der simonian or fixed effect).tw,sh. The strength of the evidence may be downgraded based on the limitations described above. Its one of the most common reasons/types of pain for hospitalization, It can indicate a serious condition or injury, https://www.emed.theclinics.com/article/S0733-8627(04)00146-4/pdf#relatedArticles, https://nightingale.edu/blog/nursing-care-plan/, https://milnepublishing.geneseo.edu/nursingcare/chapter/management-of-pain-and-physical-symptoms/, https://health.ucdavis.edu/livinghealthy/topic/pain-management/acute-pain-verses-chronic-pain.html, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5540572/https://nursingcecentral.com/lessons/nursing-interventions-for-acute-pain-management/, https://nursingcecentral.com/lessons/nursing-interventions-for-acute-pain-management/. Topical NSAIDs are recommended for nonlow back, musculoskeletal injuries. (((back or spine or spinal or vertebral or leg or musculoskeletal or neuropathic or nociceptive or radicular) adj1 pain) or headache or arthritis or fibromyalgia or osteoarthritis or neuralgia or neuropath*).ti,ab,kw. The fair-quality category is broad, and studies with this rating vary in their strengths and weaknesses. For patients with acute pain being considered for opioid therapy, what is the effectiveness of instruments for predicting risk of opioid misuse, opioid use disorder, or overdose? There is no convincing evidence that antiepileptics have a role in the treatment of acute neuropathic pain or the prevention of chronic pain.52 The use of gabapentinoids has been studied as a strategy to decrease the use of opioids in the perioperative period with mixed results.5355 Although national guidelines recommend gabapentinoids as part of a multimodal treatment plan for patients undergoing major surgeries,56 concerns about sedation and addiction limit their use.57, Medical-grade cannabis is effective for the treatment of chronic pain58,59; however, neither marijuana nor cannabidiol has evidence of benefit for acute pain.60,61, Other proposed adjunctive medications with low evidence of benefit for the management of acute pain include benzodiazepines, corticosteroids, and antidepressants.41,62,63, Opioids activate mu opioid receptors in the central nervous system and are potent analgesics.64 Up to 6.5% of patients who are opioid-naive and prescribed opioids for surgery are still taking opioids one year later, and 0.6% of patients prescribed an opioid medication will develop an opioid use disorder.65 Unused opioids prescribed for acute pain may be diverted for recreational use by others, contributing to the opioid crisis.65,66, Opioids are effective for acute pain but carry substantial risks, such as neurologic and GI adverse effects. 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The key decisional dilemma in acute pain management involves selection of interventions to provide adequate pain relief, in order to improve quality of life, improve function, and facilitate recovery, while minimizing adverse effects and avoiding overprescribing of opioids.8 Evidence also suggests that adequate acute pain treatment may mitigate factors that promote the transition to chronic pain.3,9,10 However, shortcomings in acute pain care have been documented.11,12 In addition to the underlying cause of pain, patient factors that impact acute pain management include age, sex, race/ethnicity, pain severity, comorbidities (including mental health and substance use), genetic factors, pregnancy, or breastfeeding status.13-16 Timing of presentation and clinical setting can also influence acute pain management. 5600 Fishers Lane Chronic pain lasts more than three months requires long-term care & treatment conditions such as arthritis, cancer, and fibromyalgia are tied to chronic pain. We will classify the magnitude of effects for continuous measures of pain and function using the same system as in prior and in-progress AHRQ reviews on pain,45-49 and where possible, will focus on the proportion of patients meeting thresholds for clinically important differences (e.g., >30% improvement in pain). ), Intermediate outcomes (e.g., range of motion, physical strength, etc. A complete assessment at least once per shift or according to your institutional policies. Determine if there are other symptoms, ask about the characteristics of their pain (PQRSTU questions), and perform a physical examination as needed. An additional overview of Cochrane reviews reported that the relative risk of any adverse event from a single dose of ibuprofen, 200 mg, is 0.9 (95% CI, 0.7 to 1.02). For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations. Peer reviewers do not participate in writing or editing of the final report or other products. Opioid prescribing quadrupled from 1999 to 2010; concurrently, the number of opioid analgesics deaths and opioid use disorder cases similarly rose sharply.17 In 2017, an estimated 47,600 Americans died from opioid overdose (approximately 17,000 from prescription opioids).18 Until recently, policy efforts have focused on opioids for chronic pain, but attention has increasingly shifted to use for acute pain. Articles were eligi Nursing Care Plan 3 For some patients a small improvement in pain or function using a treatment with low cost or no serious harms may be important. Systematic reviews will be included as evidence if they are a strong match to a Key Question, PICOTS, and methods, and are assessed as being at low risk of bias, based on assessment using the AMSTAR-2 quality tool, on factors such as the methods used to conduct searches, select studies, abstract data, assess risk of bias, and synthesize data.40,41 If systematic reviews are included, we will update findings with new primary studies identified in our searches. Patient uses pharmacological and nonpharmacological pain-relief strategies. Patients undergoing end-of-life care, terminally ill (e.g., hospice) patients; those under supervised palliative care; those with pain due to metastatic or advanced cancer, Vertebral augmentation procedures (vertebroplasty and kyphoplasty) for pain due to vertebral compression fracture, Piriformis injection (local anesthetic, corticosteroid, and/or botulinum toxin) for piriformis syndrome, Sphenopalatine block for trigeminal neuralgia or headache, Cooled radiofrequency denervation for degenerative back or hip pain and pulsed radiofrequency denervation for degenerative back pain, Intradiscal and facet joint platelet rich plasma for presumed discogenic back pain, Intradiscal stem cells for presumed discogenic back pain, Intradiscal methylene blue for presumed discogenic back pain, Intradiscal ozone for radicular low back pain or non-radicular, presumed discogenic back pain, Peripheral nerve stimulation for ulnar, median, or radial neuropathy, Orthopedic intra-articular and soft tissue injections, Other interventional procedures and conditions not listed as included, Harms (e.g., bleeding, infection, other complications), adverse events, unintended consequences, Non-validated instruments for outcomes (e.g., pain, function, HRQOL, depression, etc. Plans for treating acute pain should always be unique to the patient. Muscle relaxants are not recommended for older adults. The final report does not necessarily represent the views of individual reviewers. The goals of acute pain management are to relieve suffering, facilitate function, enhance recovery, and satisfy patients. Acute pain is the most common reason for visiting an emergency department, 3 and surgical . The draft Key Questions and scope were developed by the Evidence-based Practice Center with input from the Agency for Healthcare Research and Quality (AHRQ) and CMS and was revised based on input from a Technical Expert Panel (TEP) prior to finalization. The opioid epidemic has increased physician and community awareness of the harms of opioid medications; however, severe acute pain may necessitate short-term use of opioids with attention to minimizing risk, including in patients on medication-assisted therapy for opioid use disorder. Bodies of evidence consisting of RCTs are initially considered as high strength while bodies of comparative observational studies begin as low-strength evidence. EPC core team members must disclose any financial conflicts of interest greater than $1,000 and any other relevant business or professional conflicts of interest. Acute pain is ubiquitous following surgery.5 Pain is the most common reason for emergency department visits and is commonly encountered in primary care, other outpatient, and inpatient settings.2,6,7. LowWe have limited confidence that the estimate of effect lies close to the true effect for this outcome. Nonnarcotic Methods of Pain Management | NEJM Treatments for Acute Pain: A Systematic Review The Inter-Agency Task Force report suggested that a number of interventional procedures be considered for acute or chronic pain, including epidural steroidal infections, facet joint nerve block and denervation procedures, cryoneuroablation, radiofrequency ablation, peripheral nerve injections, sympathetic nerve blocks, neuromodulation, intrathecal medication pumps, vertebral augmentation procedures, trigger point injections, joint injections, and regenerative adult autologous stem cell therapy.16 The Task Force did not specifically make recommendations for use of these procedures in Medicare populations, in whom optimal management of pain must consider factors such as medical comorbidities, polypharmacy, presence of disability, falls risk, and cognitive issues.18 Therefore, a systematic review focusing on the benefits and harms of selected interventional therapies of uncertain utility in this population is warranted. Randomized and nonrandomized trials will be evaluated using criteria and methods developed by the Cochrane Back Review Group,43 cohort studies will be evaluated using criteria developed by the U.S. Preventive Services Task Force,44 and studies of diagnostic accuracy will be assessed using QUADAS-2.45 Systematic reviews will be assessed using the AMSTAR-2 quality rating instrument on factors such as the methods used to conduct searches, select studies, abstract data, assess risk of bias, and synthesize data.41 These criteria and methods will be used in conjunction with the approach recommended in the chapter, Assessing the Risk of Bias of Individual Studies When Comparing Medical Interventions in the Methods Guide for Effectiveness and Comparative Effectiveness Reviews developed by the Agency for Healthcare Research and Quality.40 Studies will be given an overall rating of "good," "fair," or "poor. Relatively selective COX-2 inhibitors (e.g., meloxicam, nabumetone) inhibit the activity of COX-2 enzymes at low doses (e.g., meloxicam, 7.5 mg) but are less selective at higher doses (e.g., meloxicam, 15 mg). Divergent and conflicting opinions are common and perceived as healthy scientific discourse that fosters a thoughtful, relevant systematic review. Any systemic opioid, including agonists, partial agonists, and mixed mechanism opioids. Accurately capture current data, highlight possible requirements or dangers, and base findings on evidence-based methods. Key Question 1: What are the effectiveness and harms of selected interventional procedures (vertebral augmentation procedures, piriformis injection, sphenopalatine block, occipital nerve stimulation, cooled or pulsed radiofrequency ablation, intradiscal and facet joint platelet rich plasma, intradiscal methylene blue, intradiscal ozone, and peripheral nerve stimulation) versus placebo, a sham procedure, or no interventional procedure for Medicare beneficiaries with pain? If multiple systematic reviews are relevant and low risk of bias, we will select the most relevant, recent, and highest-quality review or reviews; if more than one is included for a particular topic we will evaluate areas of consistency and inconsistency across the reviews.42. age, gender); (2) patient medical and psychiatric comorbidities; (3) the type of treatment used; (4) the frequency of therapy; (5) the duration of therapy? Technical Experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. Nonopioids including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, as ordered. Nociceptive pain caused by tissue damage, such as fractured bones usually throbbing or sharp. NSAIDs, acetaminophen, or a combination is an effective initial treatment approach for acute pain syndromes. HighWe are very confident that the estimate of effect lies close to the true effect for this outcome. Meta-analyses will be conducted to summarize data and obtain more precise estimates on outcomes for which studies are homogeneous enough to provide a meaningful combined estimate.46 The decision to conduct quantitative synthesis will depend on presence of at least two studies, completeness of reported outcomes and a lack of heterogeneity among the reported results. Occipital nerve stimulator. Management should include a review of treatment expectations and a plan for the time course of prescriptions. Nursing Care Plan (NCP) for Acute Pain Demonstrate the use of appropriate diversional activities and relaxation skills. Diclofenac gel has shown superiority among topical NSAIDs (NNT = 2). (buprenorphine or codeine or fentanyl or hydrocodone or hydromorphone or methadone or morphine or oxycodone or oxymorphone or tapentadol or tramadol).ti,ab,kw,sh,hw. For subquestion F, we will include studies that evaluate the performance of a risk prediction instrument against a reference standard for opioid misuse, opioid use disorder, or overdose. Hand Searching: Reference lists of included articles will also be reviewed for includable literature. We will not exclude studies rated poor quality a priori, but poor-quality studies will be considered less reliable than higher-quality studies when synthesizing the evidence, particularly if discrepancies between studies are present. High:We are very confident that the estimate of effect lies close to the true effect for this outcome. Should Muscle Relaxants Be Used as Adjuvants in Patients With Acute Low Back Pain? If any pertinent new literature is identified for inclusion in the report, it will be incorporated before the final submission of the report. (sensitivity or specificity or accuracy).ti,ab,kf.&/li>. Process for Selecting Studies: Pre-established criteria will be used to determine eligibility for inclusion and exclusion of abstracts in accordance with the AHRQ Methods Guide, based on the Key Questions and PICOTS.40 To ensure accuracy, all excluded abstracts will be dual reviewed to confirm exclusion. See permissionsforcopyrightquestions and/or permission requests. Adjunctive medications are a broad category of medications that do not primarily treat pain but can augment analgesics. variable effect sizes on emotional stress resulting from pain during medical interventions have . Copyright 2023 American Academy of Family Physicians. Publication Date Range: Electronic searches for evidence were conducted in August 2019, and were conducted back to the inception of each database. A moderate effect is defined for pain as a mean difference of 10 to 20 points on a 0- to 100-point VAS, for function as a mean difference of 10 to 20 points on the ODI or 2 to 5 points on the RDQ, and for any outcome as an SMD of 0.5 to 0.8. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. Psychotherapy for the Treatment of Acute Musculoskeletal Pain: A Review Therefore study questions, design, and methodological approaches do not necessarily represent the views of individual technical and content experts. What is the comparative effectiveness of nonpharmacologic treatments (e.g. Concerns include the effectiveness of nonopioid treatment alternatives, potential undertreatment of acute pain, and other unintended consequences.37,38 A draft Agency for Healthcare Research and Quality (AHRQ) Technical Brief (Treatment for Acute Pain: Evidence Map) identified a number of acute pain conditions for which evidence (from systematic reviews and original research) to inform treatment decisions is available, however it also noted that few reviews were sufficiently rigorous and comprehensive and that an up-to-date comprehensive systematic review would provide valuable information.39. Demonstrate pain relief by maintaining stable vital signs and avoiding muscle tension and restlessness. There is ongoing controversy about the role of vertebral augmentation procedures, due to conflicting trial results. Acute pain serves as . It usually occurs in response to tissue injury and results from activating peripheral pain receptors and their specific A-delta and C-sensory nerve fibers (nociceptors). A low daily dosage of aspirin (75 mg to 81 mg) inhibits COX-1dependent platelet function, producing its antithrombotic effect. age, race, ethnicity, gender); (2) patient medical and psychiatric comorbidities; (3) the type of nonopioid medication; (4) dose of medication; (5) duration of treatment? The EPC will complete a disposition of all peer review comments. Statements in the report should not be construed as endorsement by either the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. It serves as a warning of a disease or threat to the body. Pain assessment is critical to optimal pain management interventions. A myriad of interventional procedures and techniques are available for pain. INTRODUCTION. Factors that may affect applicability, which we have identified a priori include (1) patient factors (e.g., age and disability status, medical and psychiatric comorbidities, symptom severity, duration and underlying pain condition); (2) technical factors (e.g., medications used [for procedures that involve medications], intensity or dose, number of treatments, frequency of treatments, duration of treatment, use of imaging guidance, technique utilized, and clinical background of person performing the procedure [e.g., anesthesia pain medicine, interventional radiology, or other]); (3) comparators (e.g., sham procedure, no treatment, or usual care); (4) outcomes (e.g., use of nonstandardized or unvalidated outcomes); and (5) settings (e.g., country). The acute pain service (APS) is a specialized, multi-disciplinary inpatient team consulted to assist with management of severe pain. Improving the Quality of Care Through Pain Assessment and Management Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
