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Review
. 2019 May;33(5):e158-e182.
doi: 10.1097/BOT.0000000000001430.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

Joseph R Hsu  1 , Hassan Mir  2 , Meghan K Wally  1 , Rachel B Seymour  1 ; Orthopaedic Trauma Association Musculoskeletal Pain Task Force
Collaborators, Affiliations
Review

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

Joseph R Hsu et al. J Orthop Trauma. 2019 May.

Abstract

Purpose: We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

Methods: A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

Results: We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

Conclusions: Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

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Conflict of interest statement

D. Ring reports royalties from Skeletal Dynamics and Wright Medical, Deputy Editor for Clinical Orthopaedics and Related Research and Journal of Orthopaedic Trauma, and expert testimony. K. R. Archer reports APTA, Palladian Health, Pacira, and NeuroPoint Alliance, Inc. C. Mamczak reports consulting from Smith & Nephew, speakers bureau for Smith & Nephew and AO North America, publishing royalties for Springer-Verlag and Lippincott, and Journal Review for Journal of Orthopaedic Trauma. T. Higgins reports consulting from DePuy Synthes and Imagen and stock ownership in SMV Holdings, OrthoGrid, and NT nPhase. B. Attum reports consulting for Synthes and research support from Arthrex. E. Harvey reports Editor in Chief of Canadian Journal of Surgery, Orthopaedic Trauma Association Basic Science Focus Forum Supplement, Editorial Board of OTA International, CMO of Greybox Solutions, Co-Founder Head of Medical Innovation for NXTSens Inc, Co-Founder CMO Chairman of Board of Directors of MY01 Inc., and Medical Device Advisor for Wavelite Inc. E. Harvey receives institutional support from J & J (Depuy Synthes) and Stryker and is a board/committee member of the Orthopaedic Trauma Association, Canadian Orthopaedic Association, and CIHR-IAB. J. Lowe reports consulting for Stryker. The remaining authors report no conflict of interest.

Comment in

References

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