DOCSLIB.ORG

ELECTRICAL NERVE STIMULATION for the TREATMENT of PAIN Provided By

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
ELECTRICAL NERVE STIMULATION for the TREATMENT of PAIN Provided By WA Health Technology Assessment - HTA HEALTH TECHNOLOGY ASSESSMENT UPDATED HTA FINAL REPORT ELECTRICAL NERVE STIMULATION FOR THE TREATMENT OF PAIN UPDATED DATE: FRIDAY, NOVEMBER 13, 2009 Health Technology Assessment Program 676 Woodland Square Loop SE P.O. Box 42712 Olympia, WA 98504-2712 http://www.hta.hca.wa.gov Updated FINAL: ENS: 11-13-09 1 of 104 WA Health Technology Assessment - HTA ELECTRICAL NERVE STIMULATION FOR THE TREATMENT OF PAIN Provided by: Spectrum Research, Inc. Prepared by: Jocelyn M. Weiss, PhD, MPH Andrea C. Skelly, PhD, MPH Nora Henrikson, PhD, MPH Lisa Kercher, PhD, MPH Joseph R. Dettori, PhD, MPH With assistance from: Erika D. Ecker, BS This technology assessment report is based on research conducted by a contracted technology assessment center, with updates as contracted by the Washington State Health Care Authority. This report is an independent assessment of the technology question(s) described based on accepted methodological principles. The findings and conclusions contained herein are those of the investigators and authors who are responsible for the content. These findings and conclusions may not necessarily represent the views of the HCA/Agency and thus, no statement in this report shall be construed as an official position or policy of the HCA/Agency. The information in this assessment is intended to assist health care decision makers, clinicians, patients and policy makers in making sound evidence-based decisions that may improve the quality and cost- effectiveness of health care services. Information in this report is not a substitute for sound clinical judgment. Those making decisions regarding the provision of health care services should consider this report in a manner similar to any other medical reference, integrating the information with all other pertinent information to make decisions within the context of individual patient circumstances and resource availability. Updated FINAL: ENS: 11-13-09 2 of 104 WA Health Technology Assessment - HTA TABLE OF CONTENTS EXECUTIVE SUMMARY 7 RATIONALE FOR THE APPRAISAL 21 1. BACKGROUND 1.1 The Conditions: Acute and Chronic Pain 22 1.2 The Technology and its Comparators 22 1.3 Clinical Guidelines 25 1.4 Previous Health Technology Assessments 27 1.5 Medicare and Private Insurer Coverage Policies 28 1.6 WASHINGTON STATE DATA 31 2. THE EVIDENCE 2.1 Systematic Literature Review 32 2.2 Methods 33 2.3 Quality of Literature Available 37 2.4 Outcome Measures 41 3. RESULTS 3.1 Key Question 1: What is the evidence of efficacy and effectiveness of TENS for the treatment of acute and chronic pain? 44 3.2 Key Question 2: What is the evidence of about the safetly profile for TENS? 80 3.3 Key Question 3: Is there evidence of differential efficacy or safety issues with the use of TENS? What is the evidence of cost implications and cost effectiveness of TENS? 81 4. SUMMARY AND IMPLICATIONS 4.1 Summary with respect to efficacy and effectiveness of transcutaneous electrical nerve stimulation (TENS) in the treatment of acute and chronic pain 85 4.2 Summary with respect to the safety of TENS 89 4.3 Summary with respect to economic studies 90 BIBLIOGRAPHY 96 Updated FINAL: ENS: 11-13-09 3 of 104 WA Health Technology Assessment - HTA LIST OF TABLES Table 1. Overall Strength of Evidence (SoE) Criteria 13 Table 2. Summary of Evidence for each Key Question 1 14 Table 3. Summary of Evidence for each Key Question 2 19 Table 4. Summary of Evidence for each Key Question 3 20 Table 5. Overview of previous technology assessments of electrical nerve stimulation for pain management. 27 Table 6. Overview of payer technology assessments and policies for electrical nerve stimulation 29 Table 7. Inclusion and Exclusion Criteria for this Assessment 32 Table 8. Definition of the different levels of evidence for articles on therapy 35 Table 9. Assessment checklist for HTAs, systematic reviews, and meta-analyses 36 Table 10. Study quality assessment: Cochrane reviews of acute pain, labor pain, primary dysmenorrhea 38 Table 11. Study quality assessment: Cochrane reviews of chronic pain, chronic LBP, osteoarthritis of the knee and rheumatoid arthritis in the hand 39 Table 12. Study quality assessment: Cochrane reviews of cancer pain, chronic headache, neck disorders, and post-stroke shoulder pain 39 Table 13. Study quality assessment: New studies on acute pain (labor, primary dysmenorrhea) 40 Table 14. Study quality assessment: New studies on chronic pain 41 Table 15. TENS vs. sham TENS or control for labor pain: Pain- and satisfaction-related outcomes, with TENS applied either to the back or acupuncture points 49 Table 16. TENS vs. sham TENS: Labor and delivery outcomes, with TENS applied either to the back or acupuncture points 50 Table 17. TENS to the back vs. pharmacologic relief for treatment of labor pain 51 Table 18. Comparisons between TENS and placebo TENS, indicating for which analyses TENS was favored for treatment of osteoarthritis of the knee (pain relief measured by VAS 68 and patient-reported improvement) Table 19. Costing study, Chabal 1998 82 Table 20. Effectiveness measures used for cost simulation: Chabal 1998 83 Table 21. Overall results for cost simulations from Chabal 1998 83 Updated FINAL: ENS: 11-13-09 4 of 104 WA Health Technology Assessment - HTA LIST OF FIGURES Figure 1. Algorithm for article selection 33 Figure 2. Search results 34 Figure 3. Risk ratios for pain reduction of at least 50% and patient rating of excellent/good comparing TENS with sham TENS post-treatment based on three studies (one study 45 per comparison) Figure 4. Mean difference in pain intensity betwen TENS and placebo measured during a procedure, immediately post-treatment, or after 2 days of treatment 46 Figure 5. Mean difference in pain intensity for comparisons of TENS vs. control and high vs. low amplitude TENS, measured either during a procedure or post-treatment using a 47 numerical rating scale or visual analogue scale. Figure 6. HFTENS vs. placebo for dysmenorrhea: Pain relief (overall experience), adverse effects, and additional analgesic requirement (no. of women) 53 Figure 7. Weighted mean differences of pain relief (reduction in VAS score) , analgesic requirements (no. of pills), and lost hours from work/school for HFTENS compared to 54 placebo Figure 8. Positive overall experience with pain relief for LFTENS compared to placebo TENS and placebo pill for dysmenorrhea (Odds ratios, 95% CI) 55 Figure 9. Weighted mean differences of pain relief (reduction in VAS score), analgesic requirement (no. of pills), and lost hours from work/school for LFTENS compared to 56 placebo Figure 10. LFTENS vs. ibuprofen and naproxen: Pain relief, use of analgesics, and adverse events (Odds Ratio, 95% CI) 57 Figure 11. Proportion of studies of active TENS versus sham TENS for which an overall positive effect of TENS for relieving chronic pain (at different times post-treatment) was 59 described Figure 12. Evidence for analgesic efficacy after active HFTENS compared with sham TENS for the treatment of chronic pain over time 60 Figure 13. Mean difference in pain relief and pain intensity measured by VAS and pain improvement and pain frequency measured categorically in comparisons of conventional TENS +/ ALTENS vs. placebo at the end of 4 weeks treatment in a 62 study of 125 patients with chronic low back pain Figure 14. Mean differences in pain intensity and activity pain (measured by VAS) at the end of two weeks treatment in two studies of chronic low back pain 63 Figure 15. Mean differences in VAS pain relief experienced between TENS/ALTENS, TENS alone, ALTENS alone, HFTENS, high burst TENS and placebo 66 Figure 16. Comparison of pain improvement between TENS and placebo groups (reported categorically) immediately following treatment and during follow-up (Peto Odds 67 Ratio, 95% CI) Figure 17. Weighted mean difference in resting pain improvement and grip pain improvement comparing ALTENS to placebo after 3 weeks of treatment 71 Figure 18. Single treatment TENS vs. placebo for neck pain: standardized mean difference of % change in pain intensity and % change in trigger point tenderness 73 Figure 19. Multiple treatment TENS vs. placebo for neck pain: standardized mean difference of % change in pain intensity (1 study, n=20) (standardized mean difference, 95% CI) 74 Updated FINAL: ENS: 11-13-09 5 of 104 WA Health Technology Assessment - HTA Figure 20. Diadynamic (interferential) current therapy vs. placebo: Pain intensity and patient- rated improvement (number of patients reporting no pain/improved) after 5 days 75 treatment (RR, 95% CI) Figure 21. Reduction in VAS pain intensity from baseline: electrical stimulation vs. control and TENS vs. control (standard mean difference, 95% CI) 77 Figure 22. New reports of shoulder pain following treatment with ENS and TENS compared to control (Peto Odds Ratio, 95% CI; 2 studies) 78 Figure 23. Improvement in passive humeral lateral rotation (PHLR): ENS, TENS 79 and FES compared to control (Mean difference, 95% CI; 3 studies) Updated FINAL: ENS: 11-13-09 6 of 104 WA Health Technology Assessment - HTA EXECUTIVE SUMMARY INTRODUCTION According to the Centers for Disease Control and Prevention (CDC), pain is one of the most common causes of disability in the United States. The CDC’s National Center for Health Statistics reported in 2006 that one in four U.S. adults report a day-long bout of pain in the past month, and one in 10 say the pain lasted at least a year1. Low back pain, headache, and joint pain, aching or stiffness are among the most common complaints. Data from the 1999–2002 National Health and Nutrition Examination Survey (NHANES) revealed back pain to be the most commonly reported of all types, with more than 25% of adults reporting low back pain in the prior 3 months, with pain most commonly reported among adults 45 years of age and over.
Load more

Recommended publications
  • Use of Electroanalgesia and Laser Therapies As Alternatives to Opioids for Acute and Chronic Pain Management[Version 1; Peer
    F1000Research 2017, 6(F1000 Faculty Rev):2161 Last updated: 04 AUG 2020 REVIEW Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management [version 1; peer review: 2 approved] Paul F. White1-3, Ofelia Loani Elvir-Lazo 3, Lidia Galeas4, Xuezhao Cao3,5 1P.O. Box 548, Gualala, CA 95445, USA 2The White Mountain Institute, The Sea Ranch, CA, USA 3Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 95445, USA 4Orlando Family Medicine, Orlando, FL, USA 5First Hospital of China Medical University, Shenyang, China v1 First published: 21 Dec 2017, 6(F1000 Faculty Rev):2161 Open Peer Review https://doi.org/10.12688/f1000research.12324.1 Latest published: 21 Dec 2017, 6(F1000 Faculty Rev):2161 https://doi.org/10.12688/f1000research.12324.1 Reviewer Status Abstract Invited Reviewers The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported 1 2 that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer version 1 experiencing joint pain. The use of epidural local analgesia for 21 Dec 2017 perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients Faculty Reviews are review articles written by the undergoing abdominal surgery. In a retrospective study involving prestigious Members of Faculty Opinions. The over 390,000 outpatients more than 66 years of age who underwent articles are commissioned and peer reviewed minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% before publication to ensure that the final, more likely to continue using opioids 1 year after surgery.
    [Show full text]
  • Lower Back Pain in Athletes EXPERT CONSULTANTS: Timothy Hosea, MD, Monica Arnold, DO
    SPORTS TIP Lower Back Pain in Athletes EXPERT CONSULTANTS: Timothy Hosea, MD, Monica Arnold, DO How common is low back pain? What structures of the back Low back pain is a very common can cause pain? problem in industrialized countries, Low back pain can come from all the affecting over 70 percent of the working spinal structures. The bony elements population. Back pain is also common of the spine can develop stress fractures, in such sports as football, soccer, or in the older athlete, arthritic changes golf, rowing, and gymnastics. which may pinch the nerve roots. The annulus has a large number of pain What are the structures fibers, and any injury to this structure, of the back? such as a sprain, bulging disc, or disc The spine is composed of three regions herniation will result in pain. Finally, the from your neck to the lower back. surrounding muscles and ligaments may The cervical region corresponds also suffer an injury, leading to pain. to your neck, the thoracic region is the mid-back (or back of the chest), How is the lower back injured? and the lumbar area is the lower back. Injuries to the lower back can be the The lumbar area provides the most result of improper conditioning and motion and works the hardest in warm-up, repetitive loading patterns, supporting your weight, and enables excessive sudden loads, and twisting you to bend, twist, and lift. activities. Proper body mechanics and flexibility are essential for all activities. Each area of the spine is composed To prevent injury, it is important to learn of stacked bony vertebral bodies with the proper technique in any sporting interposed cushioning pads called discs.
    [Show full text]
  • Guidline for the Evidence-Informed Primary Care Management of Low Back Pain
    Guideline for the Evidence-Informed Primary Care Management of Low Back Pain 2nd Edition These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Guideline Disease/Condition(s) Targeted Specifications Acute and sub-acute low back pain Chronic low back pain Acute and sub-acute sciatica/radiculopathy Chronic sciatica/radiculopathy Category Prevention Diagnosis Evaluation Management Treatment Intended Users Primary health care providers, for example: family physicians, osteopathic physicians, chiro- practors, physical therapists, occupational therapists, nurses, pharmacists, psychologists. Purpose To help Alberta clinicians make evidence-informed decisions about care of patients with non- specific low back pain. Objectives • To increase the use of evidence-informed conservative approaches to the prevention, assessment, diagnosis, and treatment in primary care patients with low back pain • To promote appropriate specialist referrals and use of diagnostic tests in patients with low back pain • To encourage patients to engage in appropriate self-care activities Target Population Adult patients 18 years or older in primary care settings. Exclusions: pregnant women; patients under the age of 18 years; diagnosis or treatment of specific causes of low back pain such as: inpatient treatments (surgical treatments); referred pain (from abdomen, kidney, ovary, pelvis,
    [Show full text]
  • Anesthetic Or Corticosteroid Injections for Low Back Pain
    Anesthetic or Corticosteroid Injections for Low Back Pain Examples Trigger point injections. Sometimes, putting pressure on a certain spot in the back (called a trigger point) can cause pain at that spot or extending to another area of the body, such as the hip or leg. To try to relieve pain, a local anesthetic, either alone or combined with a corticosteroid, is injected into the area of the back that triggers pain (trigger point injection). Facet joint injections. A local anesthetic or corticosteroid is injected into a facet joint, which is one of the points where one vertebra connects to another. Epidural injections. A corticosteroid is injected into the spinal canal where it bathes the sheath that surrounds the spinal cord and nerve roots. These injections can be done by an orthopedist, an anesthesiologist, a neurologist, a physiatrist, a pain management specialist, or a rheumatologist. How It Works Local anesthesia is believed to break the cycle of pain that can cause you to become less physically active. Muscles that are not being exercised are more easily injured. Then the irritated and injured muscles can cause more pain and spasm and can disrupt sleep. This pain, spasm, and fatigue, in turn, can lead to less and less activity. Steroids reduce inflammation. So a corticosteroid injected into the spinal canal can help relieve pressure on nerves and nerve roots. Why It Is Used Injections may be tried if you have symptoms of nerve root compression or facet inflammation and you do not respond to nonsurgical therapy after 6 weeks. How Well It Works Research has not shown that local injections are effective in controlling low back pain that does not spread down the leg.footnote1 Side Effects All medicines have side effects.
    [Show full text]
  • VHA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of POSTOPERATIVE PAIN
    VHA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTOPERATIVE PAIN Veterans Health Administration Department of Defense Prepared by: THE MANAGEMENT OF POSTOPERATIVE PAIN Working Group with support from: The Office of Performance and Quality, VHA, Washington, DC & Quality Management Directorate, United States Army MEDCOM VERSION 1.2 JULY 2001/ UPDATE MAY 2002 VHA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POSTOPERATIVE PAIN TABLE OF CONTENTS Version 1.2 Version 1.2 VHA/DoD Clinical Practice Guideline for the Management of Postoperative Pain TABLE OF CONTENTS INTRODUCTION A. ALGORITHM & ANNOTATIONS • Preoperative Pain Management.....................................................................................................1 • Postoperative Pain Management ...................................................................................................2 B. PAIN ASSESSMENT C. SITE-SPECIFIC PAIN MANAGEMENT • Summary Table: Site-Specific Pain Management Interventions ................................................1 • Head and Neck Surgery..................................................................................................................3 - Ophthalmic Surgery - Craniotomies Surgery - Radical Neck Surgery - Oral-maxillofacial • Thorax (Non-cardiac) Surgery.......................................................................................................9 - Thoracotomy - Mastectomy - Thoracoscopy • Thorax (Cardiac) Surgery............................................................................................................16
    [Show full text]
  • Mechanical Low Back Pain Joshua Scott Will, DO; ​David C
    Mechanical Low Back Pain Joshua Scott Will, DO; David C. Bury, DO; and John A. Miller, DPT Martin Army Community Hospital, Fort Benning, Georgia Low back pain is usually nonspecific or mechanical. Mechanical low back pain arises intrinsically from the spine, interverte- bral disks, or surrounding soft tissues. Clinical clues, or red flags, may help identify cases of nonmechanical low back pain and prompt further evaluation or imaging. Red flags include progressive motor or sensory loss, new urinary retention or overflow incontinence, history of cancer, recent invasive spinal procedure, and significant trauma relative to age. Imaging on initial presentation should be reserved for when there is suspicion for cauda equina syndrome, malignancy, fracture, or infection. Plain radiography of the lumbar spine is appropriate to assess for fracture and bony abnormality, whereas magnetic resonance imaging is better for identifying the source of neurologic or soft tissue abnormalities. There are multiple treatment modalities for mechanical low back pain, but strong evidence of benefit is often lacking. Moderate evidence supports the use of nonsteroidal anti-inflammatory drugs, opioids, and topiramate in the short-term treatment of mechanical low back pain. There is little or no evidence of benefit for acetamin- ophen, antidepressants (except duloxetine), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation in the treatment of chronic low back pain. There is strong evidence for short-term effectiveness and moderate-quality evidence for long-term effectiveness of yoga in the treatment of chronic low back pain. Various spinal manipulative techniques (osteopathic manipulative treatment, spinal manipulative therapy) have shown mixed benefits in the acute and chronic setting.
    [Show full text]
  • Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy
    Y Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines 1 G Evidence-Based Clinical Guidelines for Multidisciplinary ETHODOLO Spine Care M NE I DEL I U /G ON Diagnosis and Treatment of I NTRODUCT Lumbar Disc I Herniation with Radiculopathy NASS Evidence-Based Clinical Guidelines Committee D. Scott Kreiner, MD Paul Dougherty, II, DC Committee Chair, Natural History Chair Robert Fernand, MD Gary Ghiselli, MD Steven Hwang, MD Amgad S. Hanna, MD Diagnosis/Imaging Chair Tim Lamer, MD Anthony J. Lisi, DC John Easa, MD Daniel J. Mazanec, MD Medical/Interventional Treatment Chair Richard J. Meagher, MD Robert C. Nucci, MD Daniel K .Resnick, MD Rakesh D. Patel, MD Surgical Treatment Chair Jonathan N. Sembrano, MD Anil K. Sharma, MD Jamie Baisden, MD Jeffrey T. Summers, MD Shay Bess, MD Christopher K. Taleghani, MD Charles H. Cho, MD, MBA William L. Tontz, Jr., MD Michael J. DePalma, MD John F. Toton, MD This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physi- cian and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. I NTRODUCT 2 Lumbar Disc Herniation with Radiculopathy | NASS Clinical Guidelines I ON Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating /G authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy.
    [Show full text]
  • Acutepain Evdoc 5.20
    Treating acute pain without overusing opioids Evidence-based pain management approaches Principal Consultants: Brian Bateman M.D., M.Sc. and Julie Lauffenburger, PharmD, Ph.D. Series Editors: Jerry Avorn, M.D. (principal editor), Jing Luo, M.D., M.P.H., Michael Fischer, M.D., M.S., Ellen Dancel, PharmD, M.P.H. Medical Writers: Jenny Cai, Stephen Braun Alosa Health is a nonprofit organization which is not affiliated with any pharmaceutical company. None of the authors accepts any personal compensation from any pharmaceutical manufacturer. These are general recommendations only; specific clinical decisions should be made by the treating clinician based on an individual patient’s clinical condition. © 2019 Alosa Health. All rights reserved. For more information, see AlosaHealth.org. ii | Treating acute pain without overusing opioids Alosa Health Treating acute pain without overusing opioids Accreditation: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Harvard Medical School and Alosa Health. The Harvard Medical School is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: The Harvard Medical School designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Overview: The primary goal of this educational program is to address the need for safe, effective pain relief among older adults across a range of settings. Achieving functional goals while avoiding harm from side effects, addiction, or potential overdose is challenging in this patient population due to such issues as altered pharmacodynamics/pharmacokinetics with age; polypharmacy; potential cognitive deficits; and heightened risk of falls and organ-specific vulnerabilities.
    [Show full text]
  • Pain Management Injection Therapies for Low-Back Pain: Topic Refinement
    Final Topic Refinement Document Pain Management Injection Therapies for Low back Pain – Project ID ESIB0813 Date: 9/19/14 Topic: Pain Management Injection Therapies for Low-back Pain Evidence-based Practice Center: Pacific Northwest Evidence-based Practice Center Agency for Healthcare Research and Quality Task Order Officer: Kim Wittenberg Partner: Centers for Medicare and Medicaid Services 1 Final Topic Refinement Document Pain Management Injection Therapies for Low back Pain – Project ID ESIB0813 Final Topic Refinement Document Key Questions Key Question 1. In patients with low back pain, what characteristics predict responsiveness to injection therapies on outcomes related to pain, function, and quality of life? Key Question 2. In patients with low back pain, what is the effectiveness of epidural corticosteroid injections, facet joint corticosteroid injections, medial branch blocks, and sacroiliac joint corticosteroid injections versus epidural nonsteroid injection, nonepidural injection, no injection, surgery or non-surgical therapies on outcomes related to pain, function and quality of life? Key Question 2a. How does effectiveness vary according to the medication used (corticosteroid, local anesthetic, or both), the dose or frequency of injections, the number of levels treated, or degree of provider experience? Key Question 2b. In patients undergoing epidural corticosteroid injection, how does effectiveness vary according to use of imaging guidance or route of administration (interlaminar, transforaminal, caudal, or other)? Key Question 3. In randomized trials of low back pain injection therapies, what is the response rate to different types of control therapies (e.g., epidural nonsteroid injection, nonepidural injection, no injection, surgery, or non-surgical therapies)? Key Question 3a. How do response rates vary according to the specific comparator evaluated (e.g., saline epidural, epidural with local anesthetic, nonepidural injection, no injection, surgery, non-surgical therapies)? Key Question 4.
    [Show full text]
  • Acute Low Back Pain
    Acute low back pain Key reviewers: Mr Chris Hoffman, Orthopaedic Surgeon, Mana Orthopaedics, Wellington Dr John MacVicar, Medical Director, Southern Rehab, Christchurch Key concepts: ■ Acute low back pain is common and most patients will recover fully within three months ■ Serious causes are rare and can be excluded with careful history and examination ■ Radiological studies are not required for acute low back pain in the absence of red flags ■ An exact diagnosis is often not possible, nor needed for management ■ Patients’ beliefs and attitudes warrant as much attention as the anatomical and pathological aspects of their condition ■ Fear about pain is a major determinant of disability and possible chronicity ■ Management should include reassurance, education and helping the patient stay active ■ Adequate analgesia is important to allow the patient www.bpac.org.nz keyword: lowbackpain to stay active 6 | BPJ | Issue 21 Acute low back pain is common and often relapsing Red Flags: ▪ Trauma Low back pain is discomfort, muscle tension or stiffness ▪ Unrelenting pain, or pain worse at night localised to the area around the lumbar spine. Back pain (supine) may radiate to the groin, buttocks or legs as referred somatic pain and may be associated with lumbar radicular ▪ Age <20 years, or new back pain age >50 pain such as sciatica. years ▪ History of cancer In any given year approximately one third of adults will ▪ Systemic symptoms suffer from low back pain and one third of these will seek help from a health practitioner.1 Most people with low ▪ IV drug use back pain self-treat with over-the-counter medications and ▪ Immunosuppression or steroids lifestyle changes.2 ▪ Widespread or progressive neurological deficit Low back pain is described as acute if present for less than six weeks, sub-acute between six weeks and three Serious causes of acute low back pain are rare months, and chronic if it continues for longer than three and include:6 months.
    [Show full text]
  • Pain Monograph 5/5/06 2:42 PM Page 59
    Pain Monograph 5/5/06 2:42 PM Page 59 Section IV: Management of Acute Pain and Chronic Noncancer Pain Pain Monograph 5/5/06 2:42 PM Page 61 Section IV: Management of Acute Pain and Chronic Noncancer Pain A . A C U T E P A I N Table 32. Examples of This section reviews the general approach to the treatment of acute pain, including treatment Multimodal Therapy goals, therapeutic strategies, and elements of pain management. It also provides an overview Combination of Agents Example (i.e., summary tables) of the treatment of some Systemic NSAIDa plus PO Ibuprofen plus PO common types of acute pain. systemic opioid hydromorphone Systemic NSAID plus IV ketorolac plus epidural epidural opioid and local fentanyl and bupivacaine anesthetic Systemic NSAID plus local IV ketorolac plus lidocaine infiltration of anesthetic plus infiltration of surgical site systemic opioid plus IV PCA morphine Regional block plus systemic Intraoperative anesthetic 1. Treatment Goals NSAID plus epidural opioid plus IV ketorolac plus As addressed in Section I.C.1, acute pain is a and local anesthetic postoperative fentanyl and bupivacaine epidural complex multidimensional experience that usu- Source: Reference 6. ally occurs in response to tissue trauma. Whereas aNSAIDs need to be used with care in surgical patients due to responses to acute pain may be adaptive, they the risk of bleeding (“anti-platelet” effect). can have adverse physiologic and psychological IV: intravenous; NSAID: nonsteroidal anti-inflammatory drugs; consequences (e.g., reduced tidal volume, exces- PCA: patient-controlled analgesia; PO: per os (oral). sive stress response, progression to chronic pain, inability to comply with rehabilitation, patient suffering and dissatisfaction).
    [Show full text]
  • Guidelines for Prescribing Controlled Substances for Pain
    GUIDELINES FOR PRESCRIBI NG CONTROLLED SUBSTANCE S FOR PAIN MEDICAL BOARD OF CALIFORNIA NOVEMBER 2014 Edmund G. Brown Jr., Governor David Serrano Sewell, J.D., President, Medical Board of California Kimberly Kirchmeyer, Executive Director, Medical Board of California Guidelines for Prescribing Controlled Substances for Pain Table of Contents PREAMBLE ..................................................................................................................... 1 UNDERSTANDING PAIN ................................................................................................ 2 Pain ............................................................................................................................. 2 Acute and Chronic Pain ............................................................................................... 3 Nociceptive and Neuropathic Pain ............................................................................... 3 Cancer and Non-Cancer Pain ...................................................................................... 3 Tolerance, Dependence and Addiction ........................................................................ 4 Pain as an Illness......................................................................................................... 4 SPECIAL PATIENT POPULATIONS............................................................................... 4 Acute Pain ................................................................................................................... 4 Emergency
    [Show full text]