Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery
Publication Date: July 13, 2021
Last Updated: March 14, 2022
Acupuncture
a) Limited evidence suggests that acupuncture may be used with standard treatment for lower pain scores. However, there were no significant differences in function. (L)
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b) Limited evidence suggests no significant difference in patient pain and function outcomes between auricular or other acupuncture and sham. (L)
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Acupressure
Limited evidence suggests that auricular acupressure may be used with standard treatment for opioid reduction and improved function. However, there was no difference in pain. (L)
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Compression
Limited evidence suggests no significant differences in pain or function with compression. (L)
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Cryotherapy
Limited evidence suggests no significant difference in patient pain, function and opioid use between cryo-compression and control/ice/circulating water. (L)
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Early Mobilization
Limited evidence suggests no difference in patient pain, function and opioid use between earlier mobilization and standard treatment. (L)
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Massage
Massage may be used with standard treatment for improved pain outcomes. (M)
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Neuromuscular Electrical Stimulations
Neuromuscular electrical stimulation should be used with standard treatment to improve function, but no significant difference is seen in pain. (S)
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Transcutaneous Electrical Nerve Stimulation
Moderate evidence supports no significant difference in functional outcomes, pain or opioid use between transcutaneous electrical nerve stimulation and standard treatment or sham. (M)
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Peri-op Injections
Moderate evidence suggests no difference in patient outcomes between local and regional anesthesia for patients undergoing total knee and hip arthroplasty. (M)
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Peri-op Injections Total Shoulder Arthroplasty
Strong evidence supports the use of continuous regional anesthesia over local anesthesia in total shoulder arthroplasty to reduce pain and opioid use in the first 24hrs after surgery. (M)
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Peri-op Injections Total Shoulder Arthroplasty
Strong evidence supports the use of continuous regional anesthesia over local anesthesia in total shoulder arthroplasty to reduce pain and opioid use in the first 24hrs after surgery. (S)
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Cognitive/Behavioral Treatment
Limited evidence suggests no difference in patient function or pain outcomes between cognitive behavioral therapy and standard treatment for patients undergoing total knee arthroplasty. (L)
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Guided Relaxation Therapy
There is no significant difference in pain and opioid use outcomes between guided relaxation therapy and standard treatment. (M)
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Music Therapy
Music therapy might be used with standard treatment to decrease postoperative pain and opioid use. (L)
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Patient Education
Limited evidence suggests patient education can be used to improve patient function and earlier cessation of opioid use. (L)
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Virtual Reality
Limited evidence suggests no difference in patient outcomes between use of virtual reality and standard treatment. (L)
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Intra-Articular Opioids vs NSAIDs
Limited evidence suggesting there is no difference in patient outcomes between intra-articular opioids and NSAIDs administered intraoperatively for post-operative pain control. (L)
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Opioid Combo/NSAID
Limited evidence suggests opioid/NSAID combination treatment may be used over NSAIDs to improve pain. (L)
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Fentanyl Patch vs Morphine
Limited evidence suggests no significant difference in patient outcomes between fentanyl patch and morphine. (L)
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Tramadol vs NSAID
Limited evidence suggests no significant difference in patient outcomes between tramadol and NSAIDs. (L)
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Cox-2
Cox2 agents should be used to limit patient opioid consumption, improve pain and function. However, there is no difference in adverse events. (S)
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Oral Acetaminophen
There is no significant difference in pain intensity and opioid use between oral acetaminophen and intravenous acetaminophen. (S)
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Acetaminophen/NSAID Combination Treatment
Acetaminophen/NSAID combination treatments may be used over NSAIDs for reduction in pain. However, no significant difference in reduction of opioid use. (L)
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Gabapentin
a) There is no significant difference in patient outcome between multi-dose gabapentin and placebo. However, additional concerns for adverse events such as sedation and respiratory depression should be recognized with its use. (S)
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b) There is no significant difference in patient outcome between single-dose gabapentin and placebo. However, additional concerns for adverse events such as sedation and respiratory depression should be recognized with its use. (S)
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Pregabalin
Moderate evidence suggests single or multi-dose pregabalin could be used to improve patient pain and opioid consumption outcomes. However, additional concerns for adverse events such as dizziness and sedation should be recognized with its use. (M)
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Ketamine
Strong evidence supports the use of intravenous ketamine in the perioperative period to reduce opioid use in the first 24hrs after hip and knee arthroplasty. (S)
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Oral Relaxants
There is no significant difference in patient outcomes, pain intensity or opioid use between oral relaxants and placebo given postoperatively. (M)
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Anti-Depressants
In the absence of reliable evidence, it is the opinion of the workgroup that a recommendation for or against the use of duloxetine cannot be made given the limited evidence and safety concerns. (C)
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Recommendation Grading
Overview
Title
Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery
Authoring Organization
American Academy of Orthopaedic Surgeons
Publication Month/Year
July 13, 2021
Last Updated Month/Year
September 4, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Target Patient Population
Musculoskeletal Extremity/Pelvis Surgery patients with Pain
Target Provider Population
Orthopedic Surgeons, Pain Specialists, Gynecologists
Inclusion Criteria
Male, Female, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Occupational therapist, physical therapist, physician, nurse, nurse practitioner, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D009141 - Musculoskeletal System, D010388 - Pelvis
Keywords
Clinical Practice Guideline, Cognitive Pain Alleviation, Musculoskeletal Extremity, Pelvis Surgery, orthopaedic surgery
Source Citation
American Academy of Orthopaedic Surgeons Evidence- Based Clinical Practice Guideline for Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery https://www.aaos.org/painalleviationcpg Published 07/19/21
Supplemental Methodology Resources
Methodology
Number of Source Documents
227
Literature Search Start Date
November 17, 2019
Literature Search End Date
June 1, 2020