NEW YORK (Reuters Health) – Electrotherapy and acupuncture are associated with reduced and delayed opioid use after total knee arthroplasty, although more-robust evidence for these and other nonpharmacologic interventions is needed, researchers say.
“Opioid addiction is a national crisis. As surgery is thought to be a gateway to opioid misuse, opioid-sparing approaches for pain management following surgery are a top priority,” Dr. Tina Hernandez-Boussard of Stanford University, in California, told Reuters Health.
To investigate, Dr. Hernandez-Boussard and colleagues analyzed randomized clinical trials, published from 1946 through April 2016, comparing nonpharmacologic interventions with other treatments, in combination with standard care.
From 5,509 studies, the researchers selected 39 trials involving 2,391 patients who underwent total knee arthroplasty. The studies focused on five common pain interventions: continuous passive motion (CPM), preoperative exercise, cryotherapy, electrotherapy and acupuncture.
As reported in JAMA Surgery, online August 16, the studies showed methodological heterogeneity and bias (due mainly to improper or absent masking). For the interventions overall, the quality of the evidence on pain improvement was of low or very low certainty.
A meta-analysis of two electrotherapy studies, involving 99 patients, showed moderate-certainty evidence that this treatment reduces opioid consumption by about 3.5 mg per hour.
Analysis of seven cryotherapy studies, involving 468 patients, showed a very low-certainty reduction in opioid consumption of about one-tenth of a milligram per hour. However, a subgroup analysis of three studies showed a significant reduction in use of non-steroidal anti-inflammatory drugs of about two tablets per day. There was also very low-certainty evidence that cryotherapy improved pain (mean difference, 0.51, on the visual analog scale).
Moderate-certainty evidence suggested that acupuncture significantly increases the time to a first use of patient-controlled analgesia by close to an hour. Low-certainty evidence showed that acupuncture improved pain (mean difference, 1.14, on a visual analog scale at two days post-surgery).
Low- or very low-certainty evidence showed that CPM did not improve pain or reduce opioid consumption at one or two weeks post-surgery. “The CPM results are particularly notable,” the authors state, because the intervention is commonly used after total knee arthroscopy.
Preoperative exercise was similarly ineffective in reducing pain; there were no data on preoperative exercise and opioid consumption.
“As prescription opioid use is under national scrutiny,” Dr. Hernandez-Boussard said by email, “it is important to identify drug-free pain management therapies that may reduce opioid use and, therefore, help curb this national epidemic.”
“Strong, unbiased evidence is needed to further support the results from this meta-analysis,” she added. “In particular, further evidence supporting the association between acupuncture and electrotherapy and reduced or delayed opioid consumption is critical to inform appropriate postoperative pain management.”
Dr. Vernon Williams, director of the Kerlan-Jobe Center for Sports Neurology and Pain Medicine at Kerlan-Jobe Orthopaedic Clinic in Los Angeles, told Reuters Health, “In my experience, electrical stimulation and acupuncture can be useful and effective components of multidisciplinary pain management and can reduce pain, improve function, and decrease the amount of opioid pain medications needed.”
“While icing the knee (cryotherapy) may not have achieved statistical significance in terms of reducing opioid use, it can provide additional benefit in terms of pain control in many patients and is generally safe and inexpensive,” he said by email. “Ice . . . has a long history of successful use in reducing pain.”
“While we’ve been repeatedly made aware of the opioid problem, there haven’t been as many efforts to provide effective alternatives for people who have significant pain,” he observed. “(Now) we can begin to discuss options with patients that are supported by evidence of efficacy.”
“There are other aspects of multidisciplinary pain management that don’t involve medications,” he continued. “Cognitive therapy, biofeedback, and even mindfulness meditation may be useful in reducing pain, decreasing opioid use, and improving function.”
“Increasingly, we’re learning of other interventional procedures that significantly reduce pain through neuromodulation. Applying focused cold therapies (cryoablation) to specific nerves can be extremely effective in reducing pain by temporarily eliminating the nerve’s ability to send pain signals,” he noted. “That can give patients a 6- to 8-month ‘runway’ for healing and participation in physical therapy during the postoperative period, reducing the need for opioid medications.”
“Other forms of neuromodulation involve focused radiofrequency stimulation of nerves that can also temporarily reduce pain signals,” he said. “Finally . . . focused ultrasound and magnetic stimulation of nerves in the brain and spinal cord are powerful options in reducing moderate-to-severe pain without opioid medications.”
“All of these options can reduce (the) dose of opioid needed to control pain, reduce the duration of exposure to opioids, or even replace opioids in the menu of treatment options,” Dr. Williams concluded.
SOURCE: http://bit.ly/2x5YJgI
JAMA Surg 2017.
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