Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Improving Pain Self-Efficacy in Orthopedic Surgery Patients Through Video-Based Education: A Quality Improvement Project

BACKGROUND

Effective pain management following discharge is critical for postoperative recovery, with pain self-efficacy serving as a crucial component in this process. Patient education plays a key role in enhancing self-efficacy. Among various educational modalities, a growing body of evidence supports the efficacy of video-based methods.

LOCAL PROBLEM

A lack of evidence-based pain education programs for patients undergoing elective orthopedic surgery was identified at an urban academic hospital on the East Coast of the United States. This quality improvement project aimed to develop and assess a video-based pain education program, focusing on pain self-efficacy and self-reported preparedness among adult patients prescribed opioids for postsurgical pain.

METHODS

This project adopted a pretest-posttest design, utilizing the knowledge-to-action framework. Data collection spanned 3 months. Among the 69 patients screened for eligibility, 13 participants were included in the analysis. The primary intervention consisted of a 15-minute educational video covering essential pain management aspects. Following the intervention, pain self-efficacy and self-reported preparedness were evaluated using the Pain Self-Efficacy Questionnaire and a five-point Likert scale, respectively.

RESULTS

Median (IQR) scores on the Pain Self-Efficacy Questionnaire increased significantly from 20 (16) to 32 (14) (p < .01). Mean (SD) scores for patients' self-reported preparedness also increased from 21.92 (6.53) to 31.85 (2.41) (p < .01). All participants reported being satisfied or very satisfied with the educational intervention.

CONCLUSION

Video-based education is a time-efficient and cost-effective approach. Healthcare providers can consider integrating video education to enhance pain self-efficacy in the postoperative phase, thus enhancing postsurgical pain outcomes and overall recovery experience.

Acupuncture Provides Short-term Functional Improvements and Pain Relief for Patients after Knee Replacement Surgery: A Systematic Review and Meta-analysis

The impact of acupuncture on knee function and pain intensity following knee replacement remains controversial. Therefore, we categorized the post-surgery recovery period into three phases: short-term (≤ 2 weeks), intermediate term (2 weeks ~3 months) and long-term (> 3 months), and then assessed the effectiveness of acupuncture in improving function and alleviating pain at different stages following knee replacement. This meta-analysis included randomized controlled trials that compared acupuncture intervention with either no-treatment or a sham group after knee replacement. Six databases were searched from inception to December 31, 2023, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and two Chinese databases (Chinese National Knowledge Infrastructure, and WanFang Data). A total of 23 studies comprised of 1,464 participants were included. Significant improvement of active range of motion was observed on Day 7 and week 2 after operation. Lower pain intensity at rest was noted in patients receiving acupuncture in short-term periods after operation (12 h, Day 1, Day 2, Day 5, and Week 2). A reduction in pain intensity during movement with acupuncture was observed on postoperative Day 1 and Day 7. Auricular acupuncture did not show not significant effectiveness in improving range of motion and pain intensity. For conventional acupuncture, the combination of distal and local point selection was found to be the most effective. Early application of acupuncture, in conjunction with physical therapy, starting before postoperative Day 1 or day 2 was recommended. Further high-quality researches are warranted to validate the findings in this meta-analysis. REGISTRATION ID: The study was registered on PROSPERO (CRD42024503479). PERSPECTIVE: This article demonstrates that acupuncture have short-term effects (≤ 2 weeks) on improving active range of motion, and reducing pain rest and during movement following knee replacement surgery. The findings support the early application of acupuncture in hospital settings after knee replacement.

Effects of contralateral versus ipsilateral electroacupuncture for analgesia and rehabilitation after unilateral total knee arthroplasty: a randomized controlled trial

PURPOSE

Total knee arthroplasty (TKA) is a treatment for advanced knee osteoarthritis. Since postoperative pain affects rehabilitation, this study aimed to determine whether electroacupuncture (EA) contralateral to the surgical site is more effective than ipsilateral EA or sham EA in terms of relieving postoperative pain and promoting post-TKA rehabilitation.

METHODS

In this parallel, single-blind randomized controlled trial, 114 patients undergoing unilateral TKA were assigned to the contralateral EA (EA on the contralateral side + sham EA on the ipsilateral), ipsilateral EA (EA on the ipsilateral + sham EA on the contralateral side), or sham EA (sham EA on both sides) groups (n = 38 each). Treatment was performed once daily on postoperative days 1-3. The visual analog scale (VAS) scores, additional opioid doses via patient-controlled analgesia (PCA) pump, Hospital for Special Surgery (HSS) knee scores, active/passive range of motion (AROM/PROM), swelling around the knee joint, and Hamilton anxiety scale (HAMA) scores were used for postoperative evaluation.

RESULTS

At 3 days postoperatively, the VAS scores, HSS scores, AROM/PROM, swelling around the knee, and HAMA scores in the contralateral EA and ipsilateral EA groups were significantly improved compared with baseline. In addition, VAS scores, HSS scores, PROM and swelling around the knee were significantly better in the contralateral and ipsilateral EA groups than in the sham EA group, but similar in the two true EA groups. Furthermore, PCA additional dose release was significantly higher in the sham EA group than in the two true EA groups (which did not significantly differ). At 10 days postoperatively, the HSS scores, AROM/PROM, and HAMA scores were better in the contralateral and ipsilateral EA groups than in the sham EA group, but similar in the two true EA groups.

CONCLUSION

Contralateral EA is more effective than sham EA for treating postoperative pain following TKA, but has an analgesic effect similar to that of ipsilateral EA.

TRIAL REGISTRATION NUMBER

ChiCTR1800020297 (Chinese Clinical Trial Registry).

Virtual Reality as a Pain Control Adjunct in Orthopedics: A Narrative Review

Orthopedic surgeons typically prescribe opioids for postoperative pain management as they are effective in managing pain. However, opioid use can lead to issues such as overdose, prescription excess, inadequate pain management, and addiction. Virtual reality (VR) therapy is an alternative route for postoperative pain management that has grown in popularity over the years. VR therapy involves immersing patients in a virtual 3D experience that is anticipated to alleviate pain. In this review article, we summarized the findings of numerous PubMed studies on the effectiveness of VR therapy for postoperative pain control. VR therapy is beneficial for reducing anxiety, pain, and opioid use after surgical procedures across various specialties. Further studies should explore VR therapy in orthopedic procedures.

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Multimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

Patients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates.

CONCLUSIONS

Adding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

Pain Control Associated With Gabapentinoid Prescription After Elective Total Knee Arthroplasty

BACKGROUND

Gabapentinoid (GABA) prescribing has substantially increased as a nonopioid analgesics for surgical conditions. We examined the effectiveness of GABA use for postoperative pain control among patients receiving total knee arthroplasty (TKA).

METHODS

This retrospective cohort study using 2016 to 2019 data from a 20% national sample of Medicare enrollees included patients aged 66 and over years who received an elective TKA, were discharged to home, received home health care, and had both admission and discharge assessments of pain (n = 35,186). Study outcomes were pain score difference between admission and discharge and less-than-daily pain interfering with activity at discharge. Opioid and GABA prescriptions after surgery and receipt of nerve block within 3 days of surgery were also assessed.

RESULTS

There were 30% of patients who had a pain score decrease of 3 to 4 levels and 55.8% had pain score decreases of 1 to 2 levels. In multivariable analyses, receiving a nerve block was significantly associated with pain score reduction. A GABA prescription increased the magnitude of pain score reduction among those receiving a nerve block. Results from inverse probability weighted analysis with propensity score showed that coprescribing of GABA and low-dose opioid was associated with significantly lower pain scores.

CONCLUSIONS

Post-TKA opioid use was not associated with pain score reduction. Receiving a nerve block was associated with a modest pain score reduction. Co-prescribing GABA with low-dose opioid or receiving a nerve block was associated with increasing magnitudes of pain reduction. Further research should identify alternatives to opioid use for managing postoperative TKA pain.

Efficacy of Diosmin in Reducing Lower-Extremity Swelling and Pain After Total Knee Arthroplasty: A Randomized, Controlled Multicenter Trial

BACKGROUND

Many patients experience lower-extremity swelling following total knee arthroplasty (TKA), which impedes recovery. Diosmin is a semisynthetic flavonoid that is often utilized to treat swelling and pain caused by chronic venous insufficiency. We aimed to evaluate the efficacy and safety of diosmin in reducing lower-extremity swelling and pain as well as in improving functional outcomes following TKA.

METHODS

This study was designed as a randomized, controlled multicenter trial and conducted in 13 university-affiliated tertiary hospitals. A total of 330 patients undergoing TKA were randomized to either receive or not receive diosmin postoperatively. The diosmin group received 0.9 g of diosmin twice per day for 14 consecutive days starting on the day after surgery, whereas the control group received neither diosmin nor a placebo postoperatively. The primary outcome was lower-extremity swelling 1, 2, 3, and 14 days postoperatively. The secondary outcomes were postoperative pain assessed with use of a visual analogue scale, Hospital for Special Surgery score, range of knee motion, levels of the inflammatory biomarkers C-reactive protein and interleukin-6, and complications.

RESULTS

At all postoperative time points, diosmin was associated with significantly less swelling of the calf, thigh, and upper pole of the patella as well as with significantly lower pain scores during motion. However, no significant differences in postoperative pain scores at rest, Hospital for Special Surgery scores, range of motion, levels of inflammatory biomarkers, or complication rates were found between the diosmin and control groups.

CONCLUSIONS

The use of diosmin after TKA reduced lower-extremity swelling and pain during motion and was not associated with an increased incidence of short-term complications involving the outcomes studied. However, further studies are needed to continue exploring the efficacy and safety of diosmin use in TKA.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials

Objective

This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context.

Methods

We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value.

Results

We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively.

Conclusion

For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions.

Systematic review registration

https://www.crd.york.ac.uk/, identifier (CRD42023492859).

Opioid reduction and enhanced recovery in orthopaedic surgery (OREOS): a protocol for a feasibility randomised controlled trial in patients undergoing total knee arthroplasty

BACKGROUND

Knee arthritis is a leading cause of limited function and long-term disability in older adults. Despite a technically successful total knee arthroplasty (TKA), around 20% of patients continue to have persisting pain with reduced function, and low quality of life. Many of them continue using opioids for pain control, which puts them at risk for potential long-term adverse effects such as dependence, overdose and risk of falls. Although persisting pain and opioid use after TKA have been recognised to be important issues, individual strategies to decrease their burden have limitations and multi-component interventions, despite their potential, have not been well studied. In this study, we propose a multi-component pathway including personalized pain management, facilitated by a pain management coordinator. The objectives of this pilot trial are to evaluate feasibility (recruitment, retention, and adherence), along with opioid-free pain control at 8 weeks after TKA.

METHODS

This is a protocol for a multicentre pilot randomised controlled trial using a 2-arm parallel group design. Adult participants undergoing unilateral total knee arthroplasty will be considered for inclusion and randomised to control and intervention groups. Participants in the intervention group will receive support from a pain management coordinator who will facilitate a multicomponent pain management pathway including (1) preoperative education on pain and opioid use, (2) preoperative risk identification and mitigation, (3) personalized post-discharge analgesic prescriptions and (4) continued support for pain control and recovery up to 8 weeks post-op. Participants in the control group will undergo usual care. The primary outcomes of this pilot trial are to assess the feasibility of participant recruitment, retention, and adherence to the interventions, and key secondary outcomes are persisting pain and opioid use.

DISCUSSION

The results of this trial will determine the feasibility of conducting a definitive trial for the implementation of a multicomponent pain pathway to improve pain control and reduce harms using a coordinated approach, while keeping an emphasis on patient centred care and shared decision making.

TRIAL REGISTRATION

Prospectively registered in Clinicaltrials.gov (NCT04968132).

Effectiveness of Cold Therapy for Pain and Anxiety Associated with Chest Tube Removal: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

To assess the effectiveness of cold therapy for pain and anxiety associated with chest tube removal.

DESIGN

A Systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

Articles were searched from Cochrane Library, PubMed, Embase, CINAHL, ProQuest, Airiti Library, China National Knowledge Infrastructure, and the National Digital Library of Theses and Dissertations in Taiwan.

REVIEW/ANALYSIS METHODS

Eight electronic databases were searched from inception to August 20, 2022. The Cochrane Risk of Bias 2.0 tool was used to assess the quality of the included studies. Using a random-effects model, we calculated Hedges' g and its associated confidence interval to evaluate the effects of cold therapy. Cochrane's Q test and an I2 test were used to detect heterogeneity, and moderator and meta-regression analyses were conducted to explore possible sources of heterogeneity. Publication bias was assessed using a funnel plot, Egger's test, and trim-and-fill analysis.

RESULTS

We examined 24 trials involving 1,821 patients. Cold therapy significantly reduced pain during and after chest tube removal as well as anxiety after chest tube removal (Hedges' g: -1.28, -1.27, and -1.80, respectively). Additionally, the effect size of cold therapy for reducing anxiety after chest tube removal was significantly and positively associated with that of cold therapy for reducing pain after chest tube removal.

CONCLUSIONS

Cold therapy can reduce pain and anxiety associated with chest tube removal.

Novel lumbar plexus block versus femoral nerve block for analgesia and motor recovery after total knee arthroplasty

This study aimed to compare the postoperative analgesic efficacy and motor recovery of a novel lumbar plexus block (LPB) with that of a femoral nerve block (FNB) after total knee arthroplasty (TKA). Forty patients who underwent TKA were randomised equally into an lumbar plexus and sciatic nerve (LS) group (receiving novel LPB) and an femoral and sciatic nerves (FS) group (receiving FNB). The assessed variables were the onset time of pain, time to the first analgesic request, pain scores, motor block at 6, 12, and 24 h after TKA, and the number of patients receiving successful blockade for each branch of the lumbar plexus. In the LS group, the femoral, lateral femoral cutaneous, genitofemoral, iliohypogastric, ilioinguinal, and obturator nerves were blocked in 18, 20, 16, 18, 15, and 19 patients. Compared to the FS group, the LS group had a significantly shorter onset time of pain and time to the first analgesic request, a significantly larger total postoperative dose of sufentanil, significantly higher numeric rating scale scores for both rest and dynamic pain at 6, 12, and 24 h, and faster motor recovery. Novel ultrasound-guided LPB has a high blocking success rate and provides inferior postoperative analgesia, but faster motor recovery after TKA than FNB.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Personalized checkpoint acupuncture can reduce postoperative pain after abdominal surgery-a STRICTA-conform pilot study

BACKGROUND

Optimal pain management is one of the core elements of Enhanced Recovery After Surgery (ERAS®) protocols and remains a challenge. Acupuncture (AC) is an effective treatment for various pain conditions. Systematic and personalized allocation of acupoints may be decisive for efficacy.

METHODS

Based on the predominant pressure sensitivity of six gastrointestinal (GI) checkpoints (G1-G6), we devised a method to detect personalized patterns of pain and a corresponding set of acupoints. We performed a single AC treatment with semi-permanent needles and assessed the visual analogue scale (VAS) score, pain threshold based on pressure algometry (PA), and temperature changes on abdominal skin areas before and 5 min after AC.

RESULTS

Between April and June 2021, thirty-eight patients were prospectively included in this pilot study. The mean reduction in subjective pain sensation as assessed by VAS was 86%, paralleled by an augmentation of the pain threshold as measured by PA by 64%. A small but significant increase in the skin temperature was observed above the abdominal surface. These effects were independent of the type of surgery.

CONCLUSION

Checkpoint acupuncture may be a complementary tool for postoperative pain management. Further investigations are needed to explore this analgesic effect.

Characteristics of Early Interventions for Pain and Function Following Lower Extremity Joint Replacement: Systematic Review

Occupational therapy is beneficial among adults with chronic pain; however, occupational therapy interventions addressing earlier phases of pain have not been clearly explicated. This systematic review characterized acute and subacute interventions billable by occupational therapy after hip or knee replacement to improve pain and function. Seven articles met inclusion criteria. Six articles had a low risk of bias. Three intervention types were found: task-oriented exercise, water-based, and modalities. Only task-oriented interventions improved both pain and function one-year after surgery. There are long-term benefits to early task-oriented exercise. Further research is needed to contextualize occupational therapy's role in early pain interventions.

The Influence of Tourniquet and Adductor Canal Block Use on Pain and Opioid Consumption after Total Knee Arthroplasty

Reducing pain and opioid consumption after total knee arthroplasty (TKA) is an important perioperative consideration. Though commonly used, the combined influence of tourniquets and adductor canal blocks (ACBs) on pain and opioid consumption is unknown. This study evaluated inpatient opioid consumption and pain between patients with TKA based on tourniquet and/or ACB use. Pain and opioid consumption were highest when a tourniquet, but no ACB was used, and lowest when an ACB, but no tourniquet was used - though absolute differences in pain scores were not clinically significant. Tourniquet and ACB use should be considered as part of TKA opioid-sparing protocols.

Investigation of the Effects of Acupuncture on Post-Operative Chest Pain after Open Heart Surgery

Background

Coronary artery bypass grafting (CABG) accounts for more than half of all adult cardiac surgeries worldwide. Post-operative chest pain is a common CABG complication and can cause significant discomfort.

Objectives

Because taking large amounts of analgesics can have many side effects, we evaluated whether acupuncture effectively reduces pain and the use of analgesics by CABG patients.

Methods

In this clinical trial, 30 patients who had recently undergone CABG were randomly allocated to two groups. For both groups, exercise therapy and routine analgesics were recommended. The intervention group underwent bilateral acupuncture in distinct acupoints, including the HT3, HT4, HT5, HT6, HT7, PC3, PC5, PC6, and PC7 for 10 daily sessions constantly. Visual analog scale (VAS) and analgesic use were evaluated in both groups at baseline and after completing the 10-day treatment.

Results

Our analysis revealed significant decreases in the mean VAS scores in both the intervention and the control group, and that the reduction was more significant in the acupuncture group (p < 0.001). Moreover, analgesic use was significantly lower in the acupuncture group when compared with the control group (p < 0.001).

Conclusion

Our findings highlight acupuncture as an alternative method of controlling CABG-associated post-operative chest pain and reducing the use of analgesics, which might have many side effects.

Transcutaneous electrical acupoint stimulation in adult patients receiving gastrectomy/colorectal resection: A randomized controlled trial

BACKGROUND

Acupuncture promotes the recovery of gastrointestinal function and provides analgesia after major abdominal surgery. The effects of transcutaneous electrical acupoint stimulation (TEAS) remain unclear.

AIM

To explore the potential effects of TEAS on the recovery of gastrointestinal function after gastrectomy and colorectal resection.

METHODS

Patients scheduled for gastrectomy or colorectal resection were randomized at a 2:3:3:2 ratio to receive: (1) TEAS at maximum tolerable current for 30 min immediately prior to anesthesia induction and for the entire duration of surgery, plus two 30-min daily sessions for 3 consecutive days after surgery (perioperative TEAS group); (2) Preoperative and intraoperative TEAS only; (3) Preoperative and postoperative TEAS only; or (4) Sham stimulation. The primary outcome was the time from the end of surgery to the first bowel sound.

RESULTS

In total, 441 patients were randomized; 405 patients (58.4 ± 10.2 years of age; 247 males) received the planned surgery. The time to the first bowel sounds did not differ among the four groups (P = 0.90; log-rank test). On postoperative day 1, the rest pain scores differed significantly among the four groups (P = 0.04; Kruskal-Wallis test). Post hoc comparison using the Bonferroni test showed lower pain scores in the perioperative TEAS group (1.4 ± 1.2) than in the sham stimulation group (1.7 ± 1.1; P = 0.04). Surgical complications did not differ among the four groups.

CONCLUSION

TEAS provided analgesic effects in adult patients undergoing major abdominal surgery, and it can be added to clinical practice as a means of accelerating postoperative rehabilitation of these patients.

Analgesic Effect of Passive Range-of-Motion Exercise on the Healthy Side for Pain after Total Knee Arthroplasty: A Prospective Randomized Trial

Background

Exercise can reduce the pain threshold momentarily and induce analgesia, which is called exercise-induced hypoalgesia (EIH). Exercise therapy for inducing EIH may be an effective treatment option for pain. We aimed at investigating whether continuous passive motion (CPM) on both healthy and affected sides could induce EIH and reduce pain in the operated knee in patients after unilateral total knee arthroplasty (TKA). Patients and Methods. In this prospective randomized controlled trial, participants were randomly assigned to two groups: a bilateral group that received bilateral exercise on the operated and healthy sides and a unilateral group that received exercise therapy only on the affected side. We enrolled 40 patients aged ≥60 years who were scheduled to undergo unilateral TKA. Visual analogue scale (VAS) scores and range of motion (ROM) on the operated side were measured immediately before and after CPM on postoperative days 2, 4, 7, and 14. The primary outcome was the difference in the VAS scores before and after CPM on postoperative day 14. The secondary outcome was the difference in the ROM before and after CPM on postoperative day 14.

Results

Comparison of VAS scores before and after CPM showed no significant intergroup differences on all measurement dates. However, there was a significant difference in values on day 14 (P < 0.05). Both groups showed an increase in ROM after CPM, with significant increments observed on days 2 and 4 in the bilateral group and on day 14 in the unilateral group. There was no significant difference in values on postoperative day 14.

Conclusion

Post-TKA pain was reduced by performing the same exercise on the healthy knee during CPM therapy. This could be due to EIH, and the results indicated that EIH can also influence postoperative pain immediately after surgery.

Efficacy of combining intravenous and topical dexamethasone against postoperative pain and function recovery after total knee arthroplasty: A prospective, double-blind, randomized controlled trial

BACKGROUND

Dexamethasone is a corticosteroid with powerful anti-inflammatory effects. This study aimed to explore whether combining intravenous and topical dexamethasone could improve postoperative pain, swelling, and function recovery after total knee arthroplasty (TKA).

METHODS

In this prospective, double-blind, randomized controlled study, 90 patients undergoing primary unilateral TKA were randomized into a dexamethasone group, which received dexamethasone (10 mg) by periarticular infiltration during surgery, as well as intravenous dexamethasone (10 mg) before tourniquet release and at 12 h postoperatively; or a control group, which received equal volumes of isotonic saline instead of dexamethasone. The primary outcome was postoperative pain, as assessed on the visual analogue scale (VAS). Secondary outcomes were postoperative consumption of morphine hydrochloride for rescue analgesia, postoperative swelling ratio of the thigh, knee, and tibia; functional recovery in terms of total range of motion (ROM) of knee and daily ambulation distance; postoperative inflammation biomarkers levels of C-reactive protein and interleukin-6; and postoperative complications.

RESULTS

Resting VAS scores at postoperative 6, 12, and 24 h, and VAS scores during motion at postoperative 2, 6, 12, and 24 h were significantly lower in the dexamethasone group. The dexamethasone group also showed significantly less morphine consumption during the first 24 h after surgery and cumulatively during hospitalization, milder limb swelling at 24 and 48 h postoperatively, greater flexion and total ROM on postoperative day 1, and longer ambulation distance on postoperative days 1 and 2, and lower levels of inflammatory biomarkers on postoperative days 1 and 2. The dexamethasone group had significantly lower incidence of postoperative nausea and vomiting.

CONCLUSION

Compared with placebo, the combination of intravenous and topical dexamethasone can reduce pain, swelling, and inflammation after TKA, it also can improve functional recovery and reduce the incidence of postoperative nausea and vomiting.

Oral Dexamethasone Following Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Intravenous dexamethasone has been shown to reduce pain in total joint arthroplasty. This double-blind, randomized, placebo-controlled trial investigated the postoperative effects and safety of oral dexamethasone as a potential augment to multimodal pain management in outpatient knee arthroplasty.

METHODS

The authors prospectively randomized 109 consecutive patients undergoing primary total knee arthroplasty. Patients were assigned to Group A (57 patients) received 4 mg of dexamethasone by mouth twice per day starting postoperative day (POD) one for four days and Group B received placebo capsules. All healthcare professionals and patients were blinded to group allocation. The primary outcome was defined as postoperative pain scores. Secondary outcomes included 90-day postoperative complications, nausea and vomiting, daily opioid usage, assistance for ambulation, difficulty sleeping, and early patient reported outcomes. Demographics were similar between groups.

RESULTS

The patients who received dexamethasone had statistically significant decrease in VAS scores when averaging POD 1 to 4 (P=0.01). The average VAS scores among individual days were significantly lower with dexamethasone on POD 2, 3, and 4. While taking dexamethasone, morning and mid-day VAS scores were significantly lower. There was no difference between the groups with opioid use, nausea or vomiting, 90-day complications, ability to walk with/without assistance, difficulty sleeping, and early patient reported outcomes.

CONCLUSION

This double-blind, randomized, placebo-controlled trial demonstrated that oral dexamethasone following primary total knee arthroplasty can reduce postoperative pain. This may be a beneficial option in ambulatory surgery where intravenous limitations exist, but larger series are needed to further evaluate the safety profile in this population.

Preoperative Opioid and Benzodiazepine Use: Influence on Abdominal Surgical Outcomes

BACKGROUND

Preoperative opioid use has shown association with worse outcomes after surgery. However, little is known about the effect of preoperative benzodiazepines with and without opioids. The aim of this study was to determine the influence of preoperative substance use on outcomes after abdominal surgery.

STUDY DESIGN

Patients undergoing abdominal operations including ventral hernia, colectomy, hysterectomy, cholecystectomy, appendectomy, nephrectomy, and hiatal hernia were identified in an opioid surgical steward program by a regional NSQIP consortium between 2019 and 2021. American College of Surgeons NSQIP data were linked with custom substance use variables created by the collaborative. Univariable and multivariable analyses were performed for 30-day outcomes.

RESULTS

Of 4,439 patients, 64% (n = 2,847) were women, with a median age of 56 years. The most common operations performed were hysterectomy (22%), ventral hernia repair (22%), and colectomy (21%). Preoperative opioid use was present in 11% of patients (n = 472), 10% (n = 449) were on benzodiazepines, and 2.3% (n = 104) were on both. Serious morbidity was significantly (p < 0.001) increased in patients on preoperative opioids (16% vs 7.9%) and benzodiazepines (14% vs 8.3%) compared with their naïve counterpart and this effect was amplified in patients on both substances (20% vs 7.5%). Multivariable regression analyses reveal that preoperative substance use is an independent risk factor (p < 0.01) for overall morbidity and serious morbidity.

CONCLUSIONS

Preoperative opioid and benzodiazepine use are independent risk factors that contribute to postoperative morbidity. This influence on surgical outcomes is exacerbated when patients are on both substances.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting

OBJECTIVES

The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR.

DESIGN

In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models.

SETTING

The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance.

PARTICIPANTS

Overall, 9122 patients undergoing KR between 2015 and 2018 were identified.

PRIMARY AND SECONDARY OUTCOME MEASURES

Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated.

RESULTS

Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)).

CONCLUSION

The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.

Uncemented Tibial Fixation Has Comparable Prognostic Outcomes and Safety Versus Cemented Fixation in Cruciate-Retaining Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cemented and uncemented fixation are the primary methods of tibial prosthesis fixation in total knee arthroplasty. However, the optimal fixation method remains controversial. This article explored whether uncemented tibial fixation has better clinical and radiological outcomes, fewer complications, and revision rates compared to cemented tibial fixation.

METHODS

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2022 to identify randomized controlled trials (RCTs) that compared uncemented total knee arthroplasty (TKA) and cemented TKA. The outcome assessment consisted of clinical and radiological outcomes, complications (aseptic loosening, infection, and thrombosis), and revision rate. Subgroup analysis was used to explore the effects of different fixation methods on knee scores in younger patients.

RESULTS

Nine RCTs were finally analyzed with 686 uncemented knees and 678 cemented knees. The mean follow-up time was 12.6 years. The pooled data revealed significant advantages of uncemented fixations over cemented fixations in terms of the Knee Society Knee Score (KSKS) (p = 0.01) and the Knee Society Score-Pain (KSS-Pain) (p = 0.02). Cemented fixations showed significant advantages in maximum total point motion (MTPM) (p < 0.0001). There was no significant difference between uncemented fixation and cemented fixation regarding functional outcomes, range of motion, complications, and revision rates. When comparing among young people (<65 years), the differences in KSKS became statistically insignificant. No significant difference was shown in aseptic loosening and the revision rate among young patients.

CONCLUSIONS

The current evidence shows better knee score, less pain, comparable complications and revision rates for uncemented tibial prosthesis fixation, compared to cemented, in cruciate-retaining total knee arthroplasty.

Electroacupuncture alleviates pain after total knee arthroplasty through regulating neuroplasticity: A resting-state functional magnetic resonance imaging study

INTRODUCTION

We aimed to evaluate the efficacy of electroacupuncture in relieving acute pain after total knee arthroplasty (TKA) and related mechanism.

METHODS

In this randomized, single-blind, and sham-acupuncture controlled study. Forty patients with postoperative acute pain were recruited and randomly divided electroacupuncture group (n = 20) and sham-acupuncture group (n = 20) from November 2020 to October 2021. All patients received electroacupuncture or sham-acupuncture for 5 days after TKA. Their brain regions were scanned with resting-state functional magnetic resonance imaging before and after intervention. Pain was scaled. Another 40 matched healthy controls underwent scanning once. The amplitude of low-frequency fluctuation (ALFF) values was compared. Pearson's correlation analysis was utilized to explore the correlation of ALFF with clinical variables in patients after intervention.

RESULTS

Compared with the HCs, patients with acute pain following TKA had significantly decreased ALFF value in right middle frontal gyrus, right supplementary motor area, bilateral precuneus, right calcarine fissure and surrounding cortex, and left triangular part of inferior frontal gyrus (false discovery rate corrected p < .05). Patients had higher ALFF value in bilateral precuneus, right cuneus, right angular gyrus, bilateral middle occipital gyrus, and left middle temporal gyrus after electroacupuncture (AlphaSim corrected p < .01). Correlation analysis revealed that the change (postoperative day 7 to postoperative day 3) of ALFF in bilateral precuneus were negatively correlated with the change of NRS scores (r = -0.706; p = .002; 95% CI = -0.890 to -0.323) in EA group.

CONCLUSIONS

The functional activities of related brain regions decreased in patients with acute pain after TKA. The enhancement of the functional activity of precuneus may be the neurobiological mechanism of electroacupuncture in treating pain following TKA.

Recent trends in acupuncture for chronic pain: A bibliometric analysis and review of the literature

BACKGROUND

Acupuncture has been increasingly used in patients with chronic pain, yet no bibliometric analysis of acupuncture studies for chronic pain exists.

OBJECTIVES

To investigate the characteristics, hotspots and frontiers of global scientific output in acupuncture research for chronic pain over the past decade.

METHODS

We retrieved publications on acupuncture for chronic pain published from 2011 to 2022 from the Science Citation Index Expanded (SCI-expanded) of the Web of Science Core Collection (WoSCC). The co-occurrence relationships of journals/countries/institutions/authors/keywords were performed using VOSviewer V6.1.2, and CiteSpace V1.6.18 analyzed the clustering and burst analysis of keywords and co-cited references.

RESULTS

A total of 1616 articles were retrieved. The results showed that the number of annual publications on acupuncture for chronic pain has increased over time, with the main types of literature being original articles (1091 articles, 67.5 %) and review articles (351 articles, 21.7 %). China had the most publications (598 articles, 37 %), with Beijing University of Traditional Chinese Medicine (93 articles, 5.8 %) and Evidence-based Complementary and Alternative Medicine ranked first (169 articles, 10.45 %) as the most prolific affiliate and journal, respectively. Liang FR was the most productive author (43 articles), and the article published by Vickers Andrew J in 2012 had the highest number of citations (625 citations). Recently, "acupuncture" and "pain" appeared most frequently. The hot topics in acupuncture for chronic pain based on keywords clustering analysis were experimental design, hot diseases, interventions, and mechanism studies. According to burst analysis, the main research frontiers were functional connectivity (FC), depression, and risk.

CONCLUSION

This study provides an in-depth perspective on acupuncture for chronic pain studies, revealing pivotal points, research hotspots, and research trends. Valuable ideas are provided for future research activities.

A systematic review of patient-centered interventions for improving pain outcomes and reducing opioid-related risks in acute care settings

Objectives

This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006).

Data Sources

A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines.

Study Selection

Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes.

Data Extraction

A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool.

Data Synthesis

Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies.

Conclusion

Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma.

Level of Evidence

Therapeutic level III.

[Reflexology in patient rehabilitation with postoperative pain. (Literature review)]

Postoperative pain is a pressing medical problem, as it significantly reduces the quality of life of patients after surgical treatment. Chronic postoperative pain further disables patients and impairs their functional activity. Being a widespread interdisciplinary problem, postoperative pain requires the integration of various pain management methods in complex multimodal pain management in the acute period and treatment programs for its chronicity. The paper examines the possibilities of reflexology methods for the relief of acute and treatment of chronic postoperative pain. Integration of reflex effects from the first days after surgery makes it possible to more effectively and safely solve the problems of acute and chronic postoperative pain.

Management of Opioid-induced Constipation in Older Adults

Opioid-induced constipation (OIC) is a common condition in older adults who may not be responsive to traditional laxative therapy. OIC is defined as new or worsening constipation symptoms that occur with initiation of or altering the dose of opioid analgesia. For adult patients with OIC and noncancer pain, we recommend considering nonpharmacologic interventions (eg, dietary measures, increased physical activity, and biofeedback training) and over-the-counter laxatives, followed by prescription opioid receptor antagonists (methylnaltrexone, naloxegol, and naldemedine) if traditional over-the-counter laxatives fail. Other options may include lubiprostone, linaclotide, plecanatide, and prucalopride; however, these are not indicated for OIC specifically or studied in older adults. Because of the complex nature of absorption, distribution, metabolism, and excretion in the aging population, all agents used to treat OIC must be evaluated individually and reevaluated as patients continue to age. This review will serve as a guide to managing OIC in older adults.

Opioid Free Anesthesia in Thoracic Surgery: A Systematic Review and Meta Analysis

Introduction: Recent studies showed that balanced opioid-free anesthesia is feasible and desirable in several surgical settings. However, in thoracic surgery, scientific evidence is still lacking. Thus, we conducted the first systematic review and meta-analysis of opioid-free anesthesia in this field. Methods: The primary outcome was the occurrence of any complication. Secondary outcomes were the length of hospital stay, recovery room length of stay, postoperative pain at 24 and 48 h, and morphine equivalent consumption at 48 h. Results: Out of 375 potentially relevant articles, 6 studies (1 randomized controlled trial and 5 observational cohort studies) counting a total of 904 patients were included. Opioid-free anesthesia compared to opioid-based anesthesia, was associated with a lower rate of any complication (74 of 175 [42%] vs. 200 of 294 [68%]; RR = 0.76; 95% CI, 0.65−0.89; p < 0.001; I2 = 0%), lower 48 h morphine equivalent consumption (MD −14.5 [−29.17/−0.22]; p = 0.05; I2 = 95%) and lower pain at 48 h (MD −1.95 [−3.6/0.3]; p = 0.02, I = 98%). Conclusions: Opioid-free anesthesia in thoracic surgery is associated with lower postoperative complications, and less opioid demand with better postoperative analgesia at 48 h compared to opioid-based anesthesia.

Signs of Inequitable Access: Users of Private Physiotherapy Services Do Not Reflect the Urban Population in Winnipeg, Manitoba

Purpose: Both private and public funding cover outpatient physiotherapy (PT) in Canada. Knowledge is lacking in who does and does not access PT services, which limits the ability to identify health/access inequities created by current financing structures. This study characterizes the individuals accessing private PT in Winnipeg to better understand whether inequities exist, given the very limited publicly financed PT. Methods: Patients attending PT in 32 private businesses, sampled for geographic variation, completed a survey online or on paper. We compared the sample's demographic characteristics with Winnipeg population data using chi-square goodness-of-fit tests. Results: In total, 665 adults accessing PT participated. Respondents were older and had higher levels of income and education compared to Winnipeg census data (p < 0.001). Our sample included higher proportions of female and White individuals, and lower proportions of Indigenous persons, newcomers, and people from visible minorities (p < 0.001). Conclusions: There are signs that inequities exist in access to PT in Winnipeg; the cohort who access private PT services does not reflect the wider population, which suggests that some segments of the population are not receiving care.

Use of Acupuncture for Adult Health Conditions, 2013 to 2021: A Systematic Review

IMPORTANCE

Acupuncture is a popular treatment that has been advocated for dozens of adult health conditions and has a vast evidence base.

OBJECTIVE

To map the systematic reviews, conclusions, and certainty or quality of evidence for outcomes of acupuncture as a treatment for adult health conditions.

EVIDENCE REVIEW

Computerized search of PubMed and 4 other databases from 2013 to 2021. Systematic reviews of acupuncture (whole body, auricular, or electroacupuncture) for adult health conditions that formally rated the certainty, quality, or strength of evidence for conclusions. Studies of acupressure, fire acupuncture, laser acupuncture, or traditional Chinese medicine without mention of acupuncture were excluded. Health condition, number of included studies, type of acupuncture, type of comparison group, conclusions, and certainty or quality of evidence. Reviews with at least 1 conclusion rated as high-certainty evidence, reviews with at least 1 conclusion rated as moderate-certainty evidence, and reviews with all conclusions rated as low- or very low-certainty evidence; full list of all conclusions and certainty of evidence.

FINDINGS

A total of 434 systematic reviews of acupuncture for adult health conditions were found; of these, 127 reviews used a formal method to rate certainty or quality of evidence of their conclusions, and 82 reviews were mapped, covering 56 health conditions. Across these, there were 4 conclusions that were rated as high-certainty evidence, and 31 conclusions that were rated as moderate-certainty evidence. All remaining conclusions (>60) were rated as low- or very low-certainty evidence. Approximately 10% of conclusions rated as high or moderate-certainty were that acupuncture was no better than the comparator treatment, and approximately 75% of high- or moderate-certainty evidence conclusions were about acupuncture compared with a sham or no treatment.

CONCLUSIONS AND RELEVANCE

Despite a vast number of randomized trials, systematic reviews of acupuncture for adult health conditions have rated only a minority of conclusions as high- or moderate-certainty evidence, and most of these were about comparisons with sham treatment or had conclusions of no benefit of acupuncture. Conclusions with moderate or high-certainty evidence that acupuncture is superior to other active therapies were rare.

Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019

IMPORTANCE

Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain.

OBJECTIVES

To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference.

DESIGN, SETTING, AND PARTICIPANTS

A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022.

EXPOSURES

Calendar year (2011-2019) was the primary exposure.

MAIN OUTCOMES AND MEASURES

The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type.

RESULTS

Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals.

CONCLUSIONS AND RELEVANCE

Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.

Acupuncture for pain control after degenerative lumbar spine surgery

Background

Wound pain after surgery for lumbar spine disease may interfere with patients’ recovery. Acupuncture is commonly used for pain management, but its efficacy for postoperative pain control is unclear. This study aimed to evaluate the effectiveness of acupuncture for adjuvant pain control after surgery for degenerative lumbar spine disease.

Methods

We retrospectively reviewed the records of consecutive patients who received surgery for degenerative lumbar spine disease at our institution from 2013 to 2014. Surgical procedures included open laminectomy, discectomy, and trans-pedicle screw instrumentation with posterior-lateral fusion. Patients were grouped by pain control methods, including routine analgesia, patient-controlled analgesia (PCA), and acupuncture. The routine analgesia group received oral acetaminophen/non-steroidal anti-inflammatory drugs with meperidine as needed for immediate pain control. The PCA group received a basal dose of morphine and subsequent user-demand doses. The acupuncture group received acupuncture every other day after surgery.

Results

Ninety-six patients were included, of whom 37 received acupuncture, 27 received PCA, and 32 received routine analgesics for pain control. Visual analog scale (VAS) pain scores in all 3 groups decreased significantly, and to the same degree, from the first postoperative day to the second day. No significant differences were found in VAS scores over the next 6 postoperative days; however, the scores of patients treated with PCA were slightly but still significantly higher (p = 0.026) on postoperative day 4 than scores of patients treated with acupuncture and traditional analgesia, a difference likely due to PCA being discontinued on postoperative day 3. No major complications were noted in the acupuncture group, but 2 patients dropped out because of fear of needle insertion.

Conclusions

Acupuncture may be as effective as traditional analgesia and PCA for adjuvant pain control after surgery for degenerative lumbar spine disease.

Characteristics of Zusanli Dorsal Root Ganglion Neurons in Rats and Their Receptor Mechanisms in Response to Adenosine

Neural systems play important roles in the functions of acupuncture. But the unclear structure and mechanism of acupoints hinder acupuncture standardization and cause the acupuncture effects to be varying or even paradoxical. It has been broadly assumed that the efficacy of acupuncture depends on the biological signals triggered at acupoints and passed up along neural systems. However, as the first station to transmit such signals, the characters of the dorsal root ganglia (DRG) neurons innervating acupoints are still not well elucidated. We adopted Zusanli (ST36) as a representative acupoint and found most DRG neurons innervating ST36 acupoint are middle-size neurons with a single spike firing pattern. This suggests that proprioceptive neurons take on greater possibility than small size nociceptive neurons do to mediate the acupuncture signals. Moreover, we found that adenosine injected into ST36 acupoints could dose- and acupoint-dependently mimic the analgesic effect of acupuncture. However, adenosine could not elicit action potentials in the acutely isolated ST36 DRG neurons, but it inhibited I_D currents and increased the areas of overshoots. Further, we found that 4 types of adenosine receptors were all expressed by ST36 DRG neurons, and A1, A2b, and A3 receptors were the principal reactors to adenosine. PERSPECTIVE: This study provides the major characteristics of ST36 DRG neurons, which will help to analyze the neural pathway of acupuncture signals. At the same time, these findings could provide a new possible therapy for pain relief, such as injecting adenosine or corresponding agonists into acupoints.

Perioperative medicine role in painful knee prosthesis prevention

Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.

Patient Experience and Perspective on Medical Cannabis as an Alternative for Musculoskeletal Pain Management

Introduction:

The current rate of opioid prescription is disquieting because of their high abuse potential, adverse effects, and thousands of overdose deaths. This situation imposes urgency in seeking alternatives for adequate pain management. From this perspective, this study aimed to evaluate the experience and the perceived analgesic efficacy of medical cannabis in managing the pain associated with musculoskeletal conditions.

Methods:

A 28-question survey was distributed to patients at a major medical cannabis center in Puerto Rico for 2 months. Demographics, medical history, cannabis usage, cannabis use perspective, and analgesic efficacy were assessed in the questionnaire.

Results:

One hundred eighty-four patients completed our survey. The majority (67%) were males, and the participants' average age was 38 years. This study showed an average pain reduction score of 4.02 points on the Numeric Rating Scale among all the participants. Those with musculoskeletal conditions reported a notable average pain reduction score of 4.47 points. In addition, 89% of the participants considered medical cannabis to be more effective than narcotics for adequate pain management.

Conclusions:

This study demonstrated that the use of medical cannabis among patients with musculoskeletal conditions effectively reduced pain levels based on their Numeric Rating Scale reported scores.

Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial

BACKGROUND

Hypnosis decreases perioperative pain and has opioid-sparing potential but has not been rigorously studied in knee arthroplasty. This trial investigates the impact of perioperative hypnosis on inpatient opioid use following total knee arthroplasty.

METHODS

This prospective randomized controlled trial was conducted at a single academic medical center. The hypnosis arm underwent a scripted 10 min hypnosis session prior to surgery and had access to the recorded script. The control arm received hypnosis education only. The primary outcome was opioid use in milligram oral morphine equivalents per 24 hours during hospital admission. A secondary analysis was performed for patients taking opioids preoperatively.

RESULTS

64 primary knee arthroplasty patients were randomized 1:1 to hypnosis (n=31) versus control (n=33) and included in the intent-to-treat analysis. The mean (SD) postoperative opioid use in oral morphine equivalents per 24 hours was 70.5 (48.4) in the hypnosis versus 90.7 (74.4) in the control arm, a difference that was not statistically significant (difference -20.1; 95% CI -51.8 to 11.4; p=0.20). In the subgroup analysis of the opioid-experienced patients, there was a 54% daily reduction in opioid use in the hypnosis group (82.4 (56.2) vs 179.1 (74.5) difference of -96.7; 95% CI -164.4 to -29.0; p=<0.01), equivalent to sparing 65 mg of oxycodone per day.

CONCLUSION

Perioperative hypnosis significantly reduced inpatient opioid use among opioid-experienced patients only. A larger study examining these findings is warranted.

TRIAL REGISTRATION NUMBER

NCT03308071.

Prospective Randomized Study Using Pharmacogenetics to Customize Postoperative Pain Medication Following Hip and Knee Arthroplasty

BACKGROUND

The purpose of this study is to determine whether pharmacogenetic testing could be used to effectively customize postoperative pain medicine following total joint replacement.

METHODS

Buccal swabs were collected preoperatively from 107 patients. Pharmacogenetic testing was performed for genetic variants on a panel of 16 genes, including CYP2D6, CYP2C9, OPRM1, and CYP1A2, which affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and many opioids. Patients were randomized to a control group or custom group and blinded to their group. The control group was prescribed oxycodone, tramadol, and celecoxib for postoperative pain management. If any of those were not normally metabolized, they were not prescribed to the patients in the custom group, who were given an alternative drug (hydromorphone for narcotics, meloxicam for non-steroidal anti-inflammatory drugs). Patients recorded their pain level (0-10 numeric scale) and all medications taken daily for the first 10 days following surgery. Medication was converted to milligram morphine equivalents (MMEs).

RESULTS

Genetic variations to medications in our standard postoperative pain management protocol occurred in 24 of the 107 patients (22.4%). The 10-day MME consumed by patients in the control group with genetic variants was 162.6 mg. Patients with variants who had custom postoperative medication consumed only 86.7 MME in the same timeframe (P = .126). The control group demonstrated a higher 10-day average pain level of 4.2 vs the custom group pain level of only 3.1 (P < .05).

CONCLUSION

With custom postoperative pain prescriptions based on pharmacogenetic testing, patients were able to achieve lower pain levels while reducing the consumption of pain medication.

Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study

BACKGROUND

  AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care.

DESIGN

This was a prospective feasibility single group pilot study at a level 1 trauma center.

METHOD

The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time.

RESULTS

Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%).

CONCLUSIONS

The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.

Effects of the Femoral Nerve Block and Adductor Canal Block on Tourniquet Response and Postoperative Analgesia in Total Knee Arthroplasty

Tourniquet has emerged as an important role in surgical procedures, sixty patients undergoing elective total knee arthroplasty are randomly divided into the nerve block group and adductor duct block group in this paper. The changes of mean arterial pressure (MAP) and heart rate (HR) at different time points during operation, the changes of VAS scores at resting pain and exercise pain, and the changes of quadriceps femur muscle strength at different time points after operation are observed in 2 groups. The experimental results show that compared with adductor duct block, femoral nerve block can better relieve the intraoperative tourniquet reaction without affecting the postoperative analgesic effect and the muscle strength of quadriceps femurs.

Publication Trends in Rehabilitative Effects of Acupuncture: A Visual Analysis of the Literature

Objectives

To conduct a comprehensive analysis of scientific outputs in 2011–2021 regarding the rehabilitative effects of acupuncture on diseases.

Methods

The study was conducted in the form of knowledge graph and data visualization, with data being drawn from the Web of Science Core Collection database.

Results

Articles and reviews were the dominant types; China, Guangzhou University of Chinese Medicine and Medicine ranked was the active country, institution, and journal, respectively, in terms of issued articles. Systematic reviews and the meta-analyses of stroke and pain were extensively carried out in the past decade, whose principal interventions were manual acupuncture, electroacupuncture, scalp acupuncture, and dry needling correspondingly at Baihui (DU20) and Zusanli (ST36). And most frequently utilized rehabilitation assessment criteria were the Fugl-Meyer Assessment Scale and the Barthel Index. More recently, motor function and chronic obstructive pulmonary disease have captured researchers' attention, which might be the futuristic frontier.

Conclusions

This article provided a relatively panoramic picture of the scientific outputs in acupuncture for disease rehabilitation, which may help readers embrace the heated topic and grasp the recent research focus on this field.

Acupuncture therapy as an Evidence-Based Nonpharmacologic Strategy for Comprehensive Acute Pain Care: the Academic Consortium Pain Task Force White Paper Update

Background

A crisis in pain management persists, as does the epidemic of opioid overdose deaths, addiction, and diversion. Pain medicine is meeting these challenges by returning to its origins: the Bonica model of multidisciplinary pain care. The 2018 Academic Consortium White Paper detailed the historical context and magnitude of the pain crisis and the evidence base for nonpharmacologic strategies. More than 50% of chronic opioid use begins in the acute pain care setting. Acupuncture may be able to reduce this risk.

Objective

This article updates the evidence base for acupuncture therapy for acute pain with a review of systematic reviews and meta-analyses on postsurgical/perioperative pain with opioid sparing and acute nonsurgical/trauma pain, including acute pain in the emergency department.

Methods

To update reviews cited in the 2018 White Paper, electronic searches were conducted in PubMed, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials for “acupuncture” and “acupuncture therapy” and “acute pain,” “surgery,” “peri-operative,” “trauma,” “emergency department,” “urgent care,” “review(s) ,” “systematic review,” “meta-analysis,” with additional manual review of titles, links, and reference lists.

Results

There are 22 systematic reviews, 17 with meta-analyses of acupuncture in acute pain settings, and a review for acute pain in the intensive care unit. There are additional studies of acupuncture in acute pain settings.

Conclusion

The majority of reviews found acupuncture therapy to be an efficacious strategy for acute pain, with potential to avoid or reduce opioid reliance. Future multicenter trials are needed to clarify the dosage and generalizability of acupuncture for acute pain in the emergency department. With an extremely low risk profile, acupuncture therapy is an important strategy in comprehensive acute pain care.

Cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty: study protocol for a randomized, sham-controlled clinical trial

Background

Opposing needling is a unique method used in acupuncture therapy to relieve pain, acting on the side contralateral to the pain. Although opposing needling has been used to treat pain in various diseases, it is not clear how opposing needling affects the activity of the central nervous system to relieve acute pain. We herein present the protocol for a randomized sham-controlled clinical trial aiming to explore the cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty (TKA).

Methods

This is a randomized sham-controlled single-blind clinical trial. Patients will be allocated randomly to two parallel groups (A: opposing electroacupuncture group; B: sham opposing electroacupuncture group). The Yinlingquan (SP9), Yanglingquan (GB34), Futu (ST32), and Zusanli (ST36) acupoints will be used as the opposing needling sites in both groups. In group A, the healthy lower limbs will receive electroacupuncture, while in group B, the healthy lower limbs will receive sham electroacupuncture. At 72 h after unilateral TKA, patients in both groups will begin treatment once per day for 3 days. Functional magnetic resonance imaging will be performed on all patients before the intervention, after unilateral TKA, and at the end of the intervention to detect changes in brain activity. Changes in pressure pain thresholds will be used as the main outcome for the improvement of knee joint pain. Secondary outcome indicators will include the visual analogue scale (including pain during rest and activity) and a 4-m walking test. Surface electromyography, additional analgesia use, the self-rating anxiety scale, and the self-rating depression scale will be used as additional outcome indices.

Discussion

The results will reveal the influence of opposing needling on cerebral activity in patients with acute pain after unilateral TKA and the possible relationship between cerebral activity changes and improvement of clinical variables, which may indicate the central mechanism of opposing needling in managing acute pain after unilateral TKA.

Trial registration

Study on the brain central mechanism of opposing needling analgesia after total kneearthroplasty based on multimodal MRI ChiCTR2100042429. Registered on January 21, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06066-6.

Postoperative Pain Therapy with Laser Acupuncture after Cesarean Section under Spinal Anesthesia: A Double-Blinded, Randomized, Placebo-Controlled Trial

Purpose The aim of our prospective, randomized, double blind, placebo-controlled study was to investigate the effect of laser acupuncture on postoperative pain in women undergoing cesarean section. Methods 80 women (mean age 32 ±5 years) scheduled for cesarean section under spinal anesthesia at Saarland University Hospital Medical Center, Homburg (Germany) were enrolled in this trial after giving written consent. Patients were randomized in two groups receiving a course of 3 treatments over 3 days with either active or placebo laser. Each acupuncture session treated Di-4 and Shen-men of both hands and ears. Primary outcome was defined as the pain severity at rest measured by Numeric Rating Scale (NRS) on the first postoperative day. Secondary outcome measures included analgesic consumption, time to mobilisation and length of stay. Treatment occurred on the operation day and on the following two days. Data were collected by a standardized questionnaire. Results No statistical difference between both groups were observed for pain severity at rest on the first postoperative day after cesarean section (Mann-Whitney U-test, p=0,850, verum group: 3.3±2.1 Vs. Placebo group: 3.2±1.9). Secondary outcome measures regarding analgesic consumption showed no difference in NSAID or opioid between treatment and placebo group. Laser acupuncture showed no effect on time to mobilisation and length of stay. Conclusion Our study could not demonstrate significant effects by the application of laser acupuncture on postoperative pain in women undergoing cesarean section.

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements.

OBJECTIVE

To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019.

INTERVENTIONS

In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain.

RESULTS

A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02364167.

Intraoperative Acupuncture as Part of a Multimodal Analgesic Regimen to Reduce Opioid Usage After Total Knee Arthroplasty: A Prospective Cohort Trial

Objective: Given the U.S. opioid crisis, surgeons and anesthesiologists must collaborate to optimize nonopioid analgesics perioperatively. A common surgical procedure, total knee arthroplasty (TKA) is a critical target for opioid reduction and development of enhanced recovery protocols. Auricular therapy can help reduce pain and opioid analgesic use in the perioperative timeperiod, but intraoperative use for TKA has yet to be explored. The aim of the present study was to investigate the effect of integrating intraoperative auricular therapy as part of an opioid-sparing protocol for TKA. Materials and Methods: In this prospective cohort study, 41 patients undergoing primary unilateral TKA under neuraxial anesthesia received a standardized, opioid-free intraoperative protocol including electroauricular acupuncture. The primary outcome was the number of patients able to remain on a low-dose opioid regimen: ≤112.5 oral morphine equivalents. Additional outcomes included patient-reported pain scores, side-effects, and prior experience with acupuncture. Results: Of the 40 patients who completed the study, 26 (65%) maintained a low-dose opioid regimen, with 3 (7%) remaining opioid-free for 30 days. No subjects used opioids beyond 30 days. Mean pain scores were low at rest (Day 0: 3.4, standard deviation [SD] 2.4; Day 1: 2.4, SD 1.8) and moderate with movement (Day 0: 4.8, SD 2.6; Day 1: 5.1, SD 2.1). The most-common side-effects were dry mouth (43.2%), drowsiness (24.3%), and lightheadedness (24.3%). Conclusions: Incorporating intraoperative electroauricular acupuncture into an existing multimodal analgesia regimen is a feasible way to maintain a low-dose opioid regimen after TKA. This research was registered at clinicaltrials.gov as Clinical Trial Number: NCT#04084288.

Gaps in standardized postoperative pain management quality measures: A systematic review

BACKGROUND

The goal of this study was an assessment of availability postoperative pain management quality measures and National Quality Forum-endorsed measures. Postoperative pain is an important clinical timepoint because poor pain control can lead to patient suffering, chronic opiate use, and/or chronic pain. Quality measures can guide best practices, but it is unclear whether there are measures for managing pain after surgery.

METHODS

The National Quality Forum Quality Positioning System, Agency for Healthcare Research and Quality Indicators, and Centers for Medicare and Medicaid Services Measures Inventory Tool databases were searched in November 2019. We conducted a systematic literature review to further identify quality measures in research publications, clinical practice guidelines, and gray literature for the period between March 11, 2015 and March 11, 2020.

RESULTS

Our systematic review yielded 1,328 publications, of which 206 were pertinent. Nineteen pain management quality measures were identified from the quality measure databases, and 5 were endorsed by National Quality Forum. The National Quality Forum measures were not specific to postoperative pain management. Three of the non-endorsed measures were specific to postoperative pain.

CONCLUSION

The dearth of published postoperative pain management quality measures, especially National Quality Forum-endorsed measures, highlights the need for more rigorous evidence and widely endorsed postoperative pain quality measures to guide best practices.

Comparison between acupuncture therapy and gabapentin for chronic pain: a pilot study

BACKGROUND

We examined whether the effect of true electroacupuncture on pain and functionality in chronic pain participants can be differentiated from that of medication (gabapentin) by analyzing quantitative sensory testing (QST).

METHODS

We recruited chronic back and neck pain participants who received six sessions (twice weekly) of true electroacupuncture versus sham electroacupuncture or 3 weeks of gabapentin versus placebo treatment. QST profiles, pain scores, and functionality profile were obtained at baseline (visit 1) and after three sessions (visit 4) or six sessions (visit 7) of acupuncture or 3 weeks of gabapentin or placebo.

RESULTS

A total of 50 participants were analyzed. We found no differences in QST profile changes (p = 0.892), pain reduction (p = 0.222), or functionality (p = 0.254) between the four groups. A major limitation of this pilot study was the limited number of study participants in each group.

CONCLUSION

This pilot study suggests that a large-scale clinical study with an adequate sample size would be warranted to compare acupuncture and medication therapy for chronic pain management.

TRIAL REGISTRATION NUMBER

NCT01678586 (ClinicalTrials.gov).