Key Clinical Issue
What are the comparative effectiveness, benefits, and adverse events associated with interventions for acute-pain management, as compared to usual care, in elderly patients with hip fractures from low-impact injury?
A note about this Clinician Guide
This topic was nominated through a public process. The research questions and the results of the report were subject to expert input, peer review, and public comment.
The results of this review are summarized here for use in your decisionmaking and in discussions with patients.
Background Information
For patients with hip fractures, adequate pain management from the preoperative period through rehabilitation contributes to avoiding complications (e.g., mental status changes, cardiopulmonary consequences), restoring ambulation, and transitioning to less-intensive care settings. For example, treatment of moderate to severe pain may require opioids, which present complications that include habituation, alterations in mental status, nausea and vomiting, constipation, and respiratory depression. Individual variation in narcotic tolerance is a clinical issue. Alternative or adjunctive methods that are safe and effective in the older adult population are of interest.
Conclusions
Clinical Bottom Line
Effectiveness of Pain Management Interventions
Systemic Analgesics and Multimodal Approaches:
Studies comparing specific regimens of systemic analgesics or comparing multimodal approaches with standard care were limited, and evidence is insufficient to permit conclusions.[evidence insufficient]
Spinal and Epidural Anesthesia:
The evidence is insufficient to understand the effectiveness, benefits, or adverse events from differing doses, modes of administration, and the addition of opioids to the anesthetic injection. [evidence insufficient]
Continuous versus single-dose modes of spinal anesthesia do not differ for either 30-day mortality rates or changes in mental status. [evidence low]
Nerve Blocks:
Reduce the intensity of acute pain (3-in-1, fascia iliaca, femoral, psoas compartment, and combined obturator+femoral blocks). [evidence medium]
Reduce the incidence of delirium (NNT = 9).* [evidence medium]
Do not affect mortality rates (pre- and postoperative use). [evidence low]
Skin Traction:
Does not reduce intensity of acute pain. [evidence low]
Rehabilitation,† Acupressure, Relaxation Therapy, and TENS‡:
The current evidence indicates that these modalities show some promise for pain relief, but the data are too limited to draw conclusions about the benefits or harms. [evidence insufficient]
Adverse Events
*NNT = number needed to treat
†Strengthening and stretching exercises
‡TENS = transcutaneous electrical nerve stimulation
Strength of Evidence
High: [evidence high]
There are consistent results from good-quality studies. Further research is very unlikely to change the conclusions.
Moderate: [evidence medium]
Findings are supported, but further research could change the conclusions.
Low: [evidence low]
There are very few studies, or existing studies are flawed.
Insufficient: [evidence insufficient]
Research is either unavailable or does not permit estimation of a treatment effect.
Timing of Use of Pain Management Interventions
This table summarizes the various treatment options examined in the systematic review upon which this guide is based, including the numbers of studies, and the timings of the interventions studied relative to surgery.
Intervention | Number of Studies | Timing Used in Studies |
---|---|---|
Systemic Analgesia | 3 | Pre- and postoperative |
Anesthesia | 30 | Intraoperative |
Nerve Blocks | 32 | Pre-, intra-, and postoperative |
Traction | 11 | Preoperative |
Transcutaneous Electrical Neurostimulation (TENS) |
2 | Pre- and postoperative |
Acupressure; Relaxation Techniques |
2 | Preoperative |
Rehabilitation | 1 | Postoperative |
Multimodal Pain Management |
2 | Pre- and postoperative |
Gaps in Knowledge
- 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.
- How rehabilitation techniques may affect either acute or chronic pain is unexplored.
- Studies did not report how nerve blocks with both sensory and motor effects may affect rehabilitation, ambulation, or mobility.
- 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.
What To Discuss With Your Patients or Their Caregivers
Clinicians who wish to engage in shared decisionmaking can communicate the critical evidence on effectiveness, benefits, and adverse events to patients and their caregivers, while exploring their values and preferences and encouraging them to be involved in their own care.
- Managing pain during the period from injury through rehabilitation is important for advancing return to function and improvement in 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 adverse events of pain-control interventions when they are used for elderly patients with hip fractures.
Resource for Patients
Managing Pain From a Broken Hip, A Guide for Adults and Their Caregivers, is a free companion to this clinician guide. It covers:
- The importance of pain management during treatment for and recovery from a broken hip.
- A description of the options that are available for patients with a broken hip.
- The evidence about benefits and risks of the various pain-control interventions that may be used for an elderly patient with a broken hip.
Source
The information in this summary is based on Pain Management Interventions for Hip Fracture, Comparative Effectiveness Review No. 30, prepared by the University of Alberta Evidencebased Practice Center under Contract No. for the Agency for Healthcare Research and Quality, April 2011.
This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Diane Markesich, Ph.D., Thomas Workman, Ph.D., Michael Heggeness, M.D., and Michael Fordis, M.D.