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

A qualitative analysis of the use of intraoperative acupuncture for patients with nosocomephobia

BACKGROUND

Nosocomephobia, a type of posttraumatic stress disorder (PTSD), is a diagnosis of an extreme fear of hospitals that can hinder current/future medical care. There is little research on how nosocomephobia affects elective surgery or how acupuncture can help patients cope.

METHODS

Using the transactional model of stress/coping, this qualitative case study examined the role of acupuncture in nosocomephobia patients' elective surgery appraisal processes. Two patients were interviewed about their nosocomephobia and prior hospital experiences. Six reviewers coded interview transcripts line-by-line using Dedoose software. Reviewers labeled meaningful words, phrases and sentences and produced over 600 codes. Reviewers discussed/identified themes by grouping similar codes and resolving discrepancies. A thematic analysis was then used to develop final themes. Pseudonyms were assigned to protect patient privacy. Sophie had avascular necrosis in both hips and suffered PTSD from a previous traumatic event. Intraoperative acupuncture calmed her hospital anxiety, allowing her to have both hips replaced. Olivia had experienced PTSD and hospital phobia since she was 12 years old. Acupuncture reduced her anxiety surrounding a necessary knee arthrotomy and osteochondral allograft.

RESULTS

Thematic analysis showed how nosocomephobia impacted patients' views of surgery and distinguished between their unique fear rationale. The transactional model of stress/coping illustrated patients' appraisal process from surgery (stressor) to coping (acupuncture) to reappraisal (mental state).

CONCLUSION

Procedural visits can be stressful due to already heightened anxiety. Although no definitive conclusions can be drawn from this small, uncontrolled case series, acupuncture may represent a safe, noninvasive way for nosocomephobia patients to manage preoperative anxiety.

Non-Opioid Analgesia Protocols After Total Hip Arthroplasty and Total Knee Arthroplasty: An Updated Scoping Review and Meta-Analysis

BACKGROUND

Despite their effectiveness in postoperative analgesia regimens for total knee arthroplasty (TKA) and total hip arthroplasty (THA), opioid medications are accompanied by well-known side effects and a risk of long-term dependence. These drawbacks have prompted the exploration of opioid-free analgesia protocols. The purpose of this study was to summarize the nature and extent of evidence available on opioid-free analgesia protocols in THA and TKA management.

METHODS

A scoping review of all Medline, Embase, and CENTRAL-indexed studies published between March 2019 and May 2023 was conducted, focusing on opioid-free analgesia regimens following THA and TKA. All included studies were assessed for potential risk of bias. Meta-analyses of pooled opioid-free percentages and pain scores were conducted using odds ratio and standardized mean difference, respectively, in a random-effects model.

RESULTS

A total of 23 studies (15 TKAs and eight THAs) were included. Among both TKA and THA, rescue opioids were the most commonly reported postoperative intervention. The most commonly investigated nonopioid analgesic modality was local anesthetics/nerve blocks with 52.2% (12 of 23) of the studies, followed by multimodal combinations (21.7%) and intravenous corticosteroids (13.0%). Only two of the 10 included TKA randomized controlled studies demonstrated statistically significant increases in the postoperative opioid-free rates. Of the six included THA randomized controlled trials, four demonstrated statistically significant increases in patients completing the postoperative period opioid-free. Our meta-analysis demonstrated a statistically significant impact of nerve blocks following TKA on the opioid-free rate and postoperative pain scores. Among the included THA studies, all studies in which patients received postoperative intravenous corticosteroids demonstrated significant increases in opioid-free percentage.

CONCLUSIONS

Despite some nonopioid analgesics demonstrating promise, rescue opioids remained the most frequently employed postoperative pain medication. The optimized opioid-free analgesic regimen likely requires a multimodal approach, especially using both local anesthetics/nerve blocks and intravenous corticosteroids. Further investigation and reporting of opioid-free episodes of care are needed.

Open-Label Randomized Clinical Trial to Assess the Effects of Preoperative Acupuncture in High Anxiety Patients Undergoing Total Knee or Hip Arthroplasty

Background: Preoperative state anxiety is a known predisposing factor for enhanced postoperative pain and hindered recovery following total knee or hip replacement. Acupuncture administered preoperatively has been associated with reduced anxiety in surgical studies, yet evidence of its efficacy in the orthopedic surgical setting is limited. Objective: This study investigated the effects of preoperative acupuncture on preoperative anxiety and pain and compared acute postoperative pain between acupuncture and control patient groups. Design: Parallel-arm, open-label, randomized controlled trial. Setting: Bone and Joint Institute, Hartford Hospital, Hartford, CT. Participants: Sixty middle-aged and elderly men and women with clinically validated preoperative anxiety undergoing elective total hip or knee replacement. Intervention: One-to-one randomization to preoperative acupuncture (n = 30) or no acupuncture treatment (n = 30) on the day of surgery. Coprimary outcomes: Anxiety before and after preoperative acupuncture using the visual analog scale and postsurgical pain using the numeric pain scale. Secondary outcomes: Incidence of acupuncture-related complications, pain before and after acupuncture, nausea and vomiting incidence, opioid consumption, anxiolytics and antiemetics use, and patient satisfaction. Results: Patients reported lower anxiety and pain preoperatively following acupuncture compared with before treatment (both p < 0.001). Postoperatively, the acupuncture group reported lower pain in the first 3 h than the control group, although this difference was not statistically significant. No significant differences in postoperative complications or patient satisfaction were observed between the study groups. Most patients were satisfied with the acupuncture treatment and reported a likelihood of considering preoperative acupuncture for future surgeries. Conclusions: These preliminary findings support that preoperative acupuncture is a safe and effective means to reduce perioperative anxiety and pain in patients undergoing total hip or knee replacement surgery. Additional studies should be conducted to best determine the value of preoperative acupuncture in total hip or knee patients presenting with surgically related anxiety. Clinical Trial Registration: ClinicalTrials.gov (10/31/2023, NCT06099223).

Acupuncture as a Complementary Treatment Modality in the Post-Anesthesia Care Setting: A Feasibility Study

Introduction: Postoperative pain management and postoperative nausea and vomiting are a persistent challenge for both health care providers and patients. Acupuncture is an effective and safe modality for the management of pain and nausea, and has the potential to play a key role in postoperative pain management. This study explores the utility and feasibility of acupuncture in the immediate postoperative setting. Methods: In a retrospective case-control study, 22 patients who underwent elective surgeries and received acupuncture in the post-anesthesia care unit (PACU) were compared with 88 case controls. Indications for acupuncture therapy included persistent pain, nausea, or anxiety. Patient satisfaction and symptom improvement after acupuncture were assessed. PACU nurses and patients were queried on their perspectives on using this therapy. Demographic data, perioperative opioid consumption, pain score in the PACU, incidence of postoperative nausea, PACU length of stay, and unintended hospital admission were assessed. The groups with/without acupuncture were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate. Results: A total of 78.9% of patients receiving acupuncture felt improvement in their symptoms. 94.7% of recovery nurses who cared for patients who received acupuncture felt that it was helpful and 78.9% did not believe it was disruptive. Patients who opted for acupuncture had a statistically significant higher overall median (interquartile range) pain score in the PACU (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0], p = 0. 03). There was no difference between total perioperative opioid consumption between groups (p = 0.94). Conclusions: Most patients who received acupuncture therapy in the PACU were satisfied with their therapy and would recommend it to future patients undergoing surgery. Most recovery nurses felt it was helpful, was not disruptive, and would like to see it utilized in the PACU.

Hotspots and Trends in Research on Treating Pain with Electroacupuncture: A Bibliometric and Visualization Analysis from 1994 to 2022

Purpose

Electroacupuncture is widely used to pain management. A bibliometric analysis was conducted to identify the hotspots and trends in research on electroacupuncture for pain.

Methods

We retrieved studies published from 1994-2022 on the topic of pain relief by electroacupuncture from the Web of Science Core Collection database. We comprehensively analysed the data with VOSviewer, CiteSpace, and bibliometrix. Seven aspects of the data were analysed separately: annual publication outputs, countries, institutions, authors, journals, keywords and references.

Results

A total of 2030 papers were analysed, and the number of worldwide publications continuously increased over the period of interest. The most productive country and institution in this field were China and KyungHee University. Evidence-Based Complementary and Alternative Medicine was the most productive journal, and Pain was the most co-cited journal. Han Jisheng, Fang Jianqiao, and Lao Lixing were the most representative authors. Based on keywords and references, three active areas of research on EA for pain were mechanisms, randomized controlled trials, and perioperative applications. Three emerging trends were functional magnetic resonance imaging (fMRI), systematic reviews, and knee osteoarthritis.

Conclusion

This study comprehensively analysed the research published over the past 28 years on electroacupuncture for pain treatment, using bibliometrics and science mapping analysis. This work presents the current status and landscape of the field and may serve as a valuable resource for researchers. Chronic pain, fMRI-based mechanistic research, and the perioperative application of electroacupuncture are among the likely foci of future research in this area.

Acupuncture Effect on Analgesic Consumption and Cortisol Levels Following Total Knee Arthroplasty: A Randomized Controlled Trial

Objective

Pain following total knee arthroplasty (TKA) is common. Various modalities of treating orthopedic postoperative pain (POP) exist; however, the optimal management of POP remains unclear. The purpose of this study was to examine acupuncture's effect on postoperative analgesic consumption and cortisol levels in patients undergoing TKA.

Materials and Methods

In this randomized controlled trial, 80 patients scheduled for elective TKA surgery were recruited and randomly assigned to 2 groups: (1) an intervention group, receiving acupuncture treatment on days 1 and 2 in addition to standard POP management (n = 40) and a control group, who received standard POP management only (n = 40).

Results

There was no statistical difference between the groups in analgesic consumption on days 1 and 3 postoperatively. On day 5 postoperatively, lower analgesic consumption was seen in the intervention group, compared to the control group. However, this difference was not statistically significant (1.4 versus 2.3, respectively; P = 0.215). There was no statistical difference between the groups in cortisol levels on day 1 postoperatively. In contrast, on day 2 postoperatively, cortisol level was significantly lower in the intervention group, compared to the control group (296 nmol/L versus 400 nmol/L, respectively; P < 0.05).

Conclusions

The findings suggest that acupuncture may have some effect on patients' analgesic consumption short-term after TKA. Further studies with larger samples are required for establishing these results.This trial was registered at ClinicalTrials.gov (Registration #: NCT03415204).