The Management of Acute Pain for Musculoskeletal Conditions: The Challenges of Opioids and Opportunities for the Future

Detroit Interventional Pain Assessment Scale: A Pain Score and Method for Measuring and Evaluating Post-Operative Pain Management-A Prospective Study

Background and Objectives: Orthopedic surgeons commonly prescribe opioids, surpassing all medical specialties. Our objective was to develop a pain management scale that captures medication use, patient-reported pain scores, and helps orthopedic surgeons evaluate their post-operative prescribing practice. Materials and Methods: An IRB-approved prospective study followed 502 post-operative orthopedic surgery patients over a six-month period. All patients were surveyed in an orthopedic clinic at a Level 1 US Trauma Center, during a routine follow-up. Patient pain satisfaction was assessed using the validated Interventional Pain Assessment (IPA) scale, which uses three categories: 0 (no pain), 1 (tolerable pain), and 2 (intolerable pain). Daily narcotic use was translated to morphine milligram equivalents (MMEs) using the Michigan Automated Prescription System (MAPS) narcotics registry. When patient pain satisfaction and narcotic usage were combined, this scale was called the Detroit Interventional Pain Assessment (DIPA) scale. Results: The five classes based on common prescription and usage of narcotics in this cohort include the following: A (no pain medication), B (over-the-counter medication), C (occasional use of short-acting narcotics 1-30 MMEs), D (consistent/regular use of short-acting narcotics 31-79 MMEs), and E (long-duration or stronger short-acting narcotics 80+ MMEs). Patients were most satisfied with their pain management at six weeks (80.5%) and three months (75.65%), and least satisfied at two weeks (62.5%) and six months (60.9%). Additional information displayed on the DIPA graph revealed there was a significant decrease in the percentage of patients on narcotics at two weeks (65.2%) to six months (32.6%) at p < 0.001. Conclusions: The DIPA pain scale shows the relationship between patient pain perception and opioid prescription/usage, while also tracking prescriber tendencies. Providers were able to visualize their post-operative pain management progression at each designated clinic visit with corresponding alphabetical daily MME categories. In this study, results suggest that surgeons were not effective at managing the pain of patients at two weeks post-operative, which is attributed to an inadequate number of pain pills prescribed upon discharge. Overall, the DIPA graph signaled that better pain management interventions are necessitated in periods with lower efficiency scores.

Use of Wearable Sensor Device and Mobile Application for Objective Assessment of Pain in Post-surgical Patients: A Preliminary Study

Effective post-operative pain management requires an accurate and frequent assessment of the pain experienced by the patients. The current gold-standard of pain assessment is through patient self-evaluation (e.g., numeric rating scale, NRS) which is subjective, prone to recall-bias, and does not provide comprehensive information of the pain intensity and its trends. We conducted a study to explore the potential of wearable biosensors and machine learning-based analysis of physiological parameters to estimate the pain intensity. The results from our study of post-operative knee surgery patients monitored over a period of 30 days demonstrate the feasibility of the system in ambulatory setting, with a substantial agreement (Cohen's Kappa = 0.70, 95% CI 0.68-0.72) between the pain intensity estimation and the patient reported numerical rating scale. Therefore, the wearable biosensors coupled with the machine learning-derived pain estimation are capable of remotely assessing the pain intensity.

Efficacy of surgeon-directed suprascapular and axillary nerve blocks in shoulder arthroscopy: a 3-arm prospective randomized controlled trial

Background

The use of regional anesthesia in shoulder arthroscopy improves perioperative pain control, thereby reducing the need for opioids and their recognized side effects. Occasionally one type of block is not suitable for a patient's anatomy or comorbidities or requires a specially trained anesthetist to safely perform. The primary aim of this study is to compare the efficacy of 3 different nerve blocks for pain management in patients undergoing shoulder arthroscopy.

Methods

A 3-arm, blinded, randomized controlled trial in patients undergoing elective, unilateral shoulder arthroscopic procedures between August 2018 and November 2020 was conducted at a single center. One hundred and thirty participants were randomized into 1 of 3 regional anesthesia techniques. The first group received an ultrasound-guided interscalene block performed by an anesthetist (US + ISB). The second group received an ultrasound-guided suprascapular nerve block and an axillary nerve block by an anesthetist (US + SSANB). The final group received a suprascapular nerve block without ultrasound and an axillary nerve block under arthroscopic guidance by an orthopedic surgeon (A + SSANB). Intraoperative pain response, analgesia requirements, and side effects were recorded. Visual analogue pain scores and opioid doses were recorded in the Post Anaesthesia Care Unit (PACU) and daily for 8 days following the procedure.

Results

Twelve patients withdrew from the study after randomization, leaving 39 participants in US + ISB, 40 in US + SSANB, and 39 in A + SSANB. The US + ISB group required significantly lower intraoperative opioid doses than US + SSANB and A + SSANB (P < .001) and postoperatively in PACU (P < .001). After discharge from hospital, there were no differences between all groups in daily analgesia requirements (P = .063). There was significantly more nerve complications with 6 patient-reported complications in the US + ISB group (P = .02). There were no reported differences in satisfaction rates between groups (P = .41); however, the A + SSANB group was more likely to report a wish to not have a regional anesthetic again (P = .04).

Conclusion

The US + ISB group required lower opioid doses perioperatively; however, there was no difference between groups after discharge from PACU. The analgesia requirements between the US + SSANB and A + SSANB were similar intraoperatively and postoperatively. A surgeon-administered SSANB may be a viable alternative when an experienced regional anesthetist is not available.

Opioid Prescribing for Osteoarthritis: Cross-Sectional Survey among Primary Care Physicians, Rheumatologists, and Orthopaedic Surgeons

Opioids are often prescribed for osteoarthritis (OA) pain, despite recommendations to limit use due to minimal benefits and associated harms. This study aimed to assess physicians' practice patterns and perceptions regarding opioids by specialty one year following the Centers for Disease Control and Prevention (CDC) published guidance on opioid prescribing. The 139/153 (90.8%) physicians who reported prescribing opioids in the previous year reported decreased prescribing for mild OA (51.3%, 26.5% and 33.3% of primary care physicians, rheumatologists, and orthopaedic surgeons, respectively), moderate OA (50.0%, 47.1% and 48.1%) and severe OA (43.6%, 41.2% and 44.4%). Prescribing changes were attributed to the CDC guidelines for 58.9% of primary care physicians, 59.1% of rheumatologists, and 73.3% of orthopaedic surgeons. Strong opioids were mostly reserved as third-line treatment. Although treatment effectiveness post-CDC guidelines was not assessed, perceptions of efficacy and quality of life with opioids significantly differed across specialties, whereas perceptions of safety, convenience/acceptability and costs did not. Physicians generally agreed on the barriers to opioid prescribing, with fear of addiction and drug abuse being the most important. Across specialties, physicians reported decreased opioid prescribing for OA, irrespective of OA severity, and in most cases attributed changes in prescribing to the CDC guideline.

Prevalence, Prevention, and Treatment of Work-Related Musculoskeletal Disorders Among Microsurgeons

BACKGROUND

 While work related musculoskeletal disorders have been well recognized among all surgeons, and microsurgeons in particular; their prevention and treatment are presently unknown. Our study aims to define the impact of musculoskeletal ailments on microsurgeons and investigate trends in microsurgeon musculoskeletal injury treatment.

METHODS

 An electronic survey was sent to all members of the American Society of Reconstructive Microsurgery. The survey solicited surgeon demographics, microsurgical volume, equipment usage, history of musculoskeletal injury, impact of injury, and interventions / treatment modalities used to address / prevent these issues.

RESULTS

 Of the 883 microsurgeons surveyed, 203 responded (23% response rate). The average age was 45 years (IQR 39-52 years). Most microsurgeons were male (80.8%). Musculoskeletal injury or symptoms related to microsurgery were reported by 137 respondents (67.0%). Fifty surgeons (37.9%) reported that their musculoskeletal injury had adversely affected their practice. Formal medical intervention was sought by 53 respondents (26.1%), with 17 surgeons (8.4%) undergoing surgical intervention. Self-treated was used by 127 microsurgeons (62.6%) for musculoskeletal ailments. Preventative treatments such as strength training, stretching, yoga, massages, and diet were the most beneficial, each with utilization scores of 4 out of 5.

CONCLUSION

 A majority of microsurgeons experience musculoskeletal injury, and some even require surgery to treat their musculoskeletal pathology. Prophylactic practices such as strength training, stretching, yoga, massages, and diet maintenance, are the superior treatment for musculoskeletal injury. Microsurgeons should incorporate training routines in their lives as injury prophylaxis to improve their career longevity and patient care.

Low-intensity LASER and LED (photobiomodulation therapy) for pain control of the most common musculoskeletal conditions

Pain is the most common reason for physician consultations and the number one reason for missed work or school days is musculoskeletal pain. Pain management is utilized for easing the suffering and improving the Quality of Life of those living with chronic pain. Over the past several decades, physicians have become increasingly willing to prescribe opioids to manage pain. However, the opioid use can cause side effects as poor coordination, sedation, mood swings, depression, and anxiety combined with a dependence on the drugs. In the rehabilitation setting, patients benefit most when their health providers utilize a multimodal approach combining different types of therapies and when patients take on a significant role in optimal management of their own pain. The use of light as a therapeutic alternative form of medicine to manage pain and inflammation has been proposed to fill this void. Photobiomodulation therapy applied in the form of low-intensity Light Amplification by Stimulated Emission of Radiation (LASER) and light-emitting diode (LED) has been shown to reduce inflammation and swelling, promote healing, and reduce pain for an array of musculoskeletal conditions. There is evidence that photobiomodulation therapy reduces pain intensity in non-specific knee pain, osteoarthritis, pain post-total hip arthroplasty, fibromyalgia, temporomandibular diseases, neck pain, and low back pain. Therefore, the purpose of this paper was to present the up-to-dated evidence about the effects of low-intensity LASER and LED (photobiomodulation therapy) on pain control of the most common musculoskeletal conditions. We observed that the photobiomodulation therapy offers a non-invasive, safe, drug-free, and side-effect-free method for pain relief of both acute and chronic musculoskeletal conditions as well as fibromyalgia.

Effect of Music Therapy on Pain, Anxiety, and Use of Opioids Among Patients Underwent Orthopedic Surgery: A Systematic Review and Meta-Analysis

Background of the topic revealed that orthopedic surgery is one of the most painful surgeries in which music therapy is found to be effective for reducing pain and anxiety. This study aimed to examine the effect of music therapy on pain, anxiety, and the use of opioids among patients who underwent orthopedic surgery. Methods include a comprehensive search was conducted in PubMed/MEDLINE, Embase, Ovid, Clinical Key, and Google Scholar for relevant randomized controlled trials (RCTs) and quasi-experimental studies published until December 2020 in the English language regarding music therapy in comparison to standard care on pain, anxiety, and opioid use among postoperative orthopedic patients. Results of the study included 13 studies, having a total of 778 patients included in a systematic review comprising ten RCTs and three quasi-experimental studies. Meta-analysis was performed on ten RCTs. The results showed a significant difference between the two groups regarding the use of music therapy in reducing the pain [standard mean difference (SMD) = -0.27; p = 0.002] and anxiety (SMD = -0.40; p = 0.0009). No statistically significant difference was found in the use of opioids and physiological variables between the two groups. Conclusion of the current evidence demonstrated that music therapy significantly reduces pain and anxiety among postoperative orthopedic patients. Researchers recommended using it in the routine care of orthopedic patients for managing their subjective feelings like pain and anxiety. Musical intervention timing, duration, and type of music can be changed according to specific clinical settings and medical teams.

Chronic pain with neuropathic characteristics after surgery for major trauma to the lower limb: prevalence, predictors, and association with pain severity, disability, and quality of life in the UK WHiST trial

AIMS

To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

METHODS

Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care.

RESULTS

The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain.

CONCLUSION

Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047-1054.