Ahmed M. Abou-Setta, MD, PhD; Lauren A. Beaupre, PT, PhD; Saifee Rashiq, MB, MSc; Donna M. Dryden, PhD; Michele P. Hamm, MSc; Cheryl A. Sadowski, BSc(Pharm), PharmD; Matthew R.G. Menon, MD, MHSc; Sumit R. Majumdar, MD, MPH; Donna M. Wilson, RN, PhD; Mohammad Karkhaneh, MD; Shima S. Mousavi, MD; Kai Wong, MSc; Lisa Tjosvold, MLIS; C. Allyson Jones, PT, PhD
Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative Effectiveness of Pain Management Interventions for Hip Fracture: A Systematic Review. Ann Intern Med. 2011;155:234-245. doi: 10.7326/0003-4819-155-4-201108160-00346
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Published: Ann Intern Med. 2011;155(4):234-245.
Pain management is integral to the management of hip fracture.
To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain after hip fracture.
25 electronic databases (January 1990 to December 2010), gray literature, trial registries, and reference lists, with no language restrictions.
Multiple reviewers independently and in duplicate screened 9357 citations to identify randomized, controlled trials (RCTs); nonrandomized, controlled trials (non-RCTs); and cohort studies of pain management techniques in older adults after acute hip fracture.
Independent, duplicate data extraction and quality assessment were conducted, with discrepancies resolved by consensus or a third reviewer. Data extracted included study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes.
83 unique studies (64 RCTs, 5 non-RCTs, and 14 cohort studies) were included that addressed nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multimodal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2). Overall, moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium. Low-level evidence suggests that preoperative traction does not reduce acute pain. Evidence was insufficient on the benefits and harms of most interventions, including spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy regimens, in managing acute pain.
No studies evaluated outcomes of chronic pain or exclusively examined participants from nursing homes or with cognitive impairment. Systemic analgesics (narcotics, nonsteroidal anti-inflammatory drugs) were understudied during the search period.
Nerve blockade seems to be effective in reducing acute pain after hip fracture. Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture.
Agency for Healthcare Research and Quality.
Multiple pain management strategies are available for patients after hip fracture.
This systematic review found moderate-level evidence that nerve blockades reduced acute pain and delirium after hip fracture and low-level evidence that preoperative traction did not affect pain. Benefits and harms of such interventions as spinal anesthesia, systemic analgesia, multimodal pain management, acupressure, relaxation therapy, transcutaneous electrical neurostimulation, and physical therapy were unclear.
No or few studies evaluated outcomes of chronic pain or systemic analgesics.
Nerve blockade reduces acute pain after hip fracture, but the comparative effectiveness of multiple alternative pain management strategies is not known.
ADL = activity of daily living; KQ = key question; LOS = length of stay.
* Body of evidence rated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.
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Appendix Table 4.
NA = not applicable; SMD = standardized mean difference.
MD = mean difference; NA = not applicable.
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