Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery

Publication Date: July 14, 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)
312070

b) Limited evidence suggests no significant difference in patient pain and function outcomes between auricular or other acupuncture and sham. (L)
312070

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)
312070

Compression

Limited evidence suggests no significant differences in pain or function with compression. (L)
312070

Cryotherapy

Limited evidence suggests no significant difference in patient pain, function and opioid use between cryo-compression and control/ice/circulating water. (L)
312070

Early Mobilization

Limited evidence suggests no difference in patient pain, function and opioid use between earlier mobilization and standard treatment. (L)
312070

Massage

Massage may be used with standard treatment for improved pain outcomes. (M)
312070

Neuromuscular Electrical Stimulations

Neuromuscular electrical stimulation should be used with standard treatment to improve function, but no significant difference is seen in pain. (S)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

Guided Relaxation Therapy

There is no significant difference in pain and opioid use outcomes between guided relaxation therapy and standard treatment. (M)
312070

Music Therapy

Music therapy might be used with standard treatment to decrease postoperative pain and opioid use. (L)
312070

Patient Education

Limited evidence suggests patient education can be used to improve patient function and earlier cessation of opioid use. (L)
312070

Virtual Reality

Limited evidence suggests no difference in patient outcomes between use of virtual reality and standard treatment. (L)
312070

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)
312070

Opioid Combo/NSAID

Limited evidence suggests opioid/NSAID combination treatment may be used over NSAIDs to improve pain. (L)
312070

Fentanyl Patch vs Morphine

Limited evidence suggests no significant difference in patient outcomes between fentanyl patch and morphine. (L)
312070

Tramadol vs NSAID

Limited evidence suggests no significant difference in patient outcomes between tramadol and NSAIDs. (L)
312070

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)
312070

Oral Acetaminophen

There is no significant difference in pain intensity and opioid use between oral acetaminophen and intravenous acetaminophen. (S)
312070

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)
312070

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)
312070

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)
312070

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)
312070

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)
312070

Oral Relaxants

There is no significant difference in patient outcomes, pain intensity or opioid use between oral relaxants and placebo given postoperatively. (M)
312070

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)
312070

Recommendation Grading

Disclaimer

Overview

Title

Pharmacologic, Physical, and Cognitive Pain Alleviation for Musculoskeletal Extremity/Pelvis Surgery

Authoring Organization

Publication Month/Year

July 14, 2021

Last Updated Month/Year

July 14, 2023

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

Data Supplement, Data Supplement

Methodology

Number of Source Documents
227
Literature Search Start Date
November 18, 2019
Literature Search End Date
June 2, 2020