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The Journal of Surgical Research Aug 2022Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Multiple rib fractures and flail chest are common in trauma patients and may result in significant morbidity and mortality. While rib fractures have historically been treated conservatively, there is increasing interest in the benefits of surgical fixation. However, strong evidence that supports surgical rib fixation and identifies the most appropriate patients for its application is currently sparse.
METHODS
A systematic review and meta-analysis following PRISMA guidelines was performed to identify all peer-reviewed papers that examined surgical compared to conservative management of rib fractures. We undertook a subgroup analysis to determine the specific effects of rib fracture type, age, the timing of fixation and study design on outcomes. The primary outcomes were the length of hospital and ICU stay, and secondary outcomes included mechanical ventilation time, rates of pneumonia, and mortality.
RESULTS
Our search identified 45 papers in the systematic review, and 40 were included in the meta-analysis. There was a statistical benefit of surgical fixation compared to conservative management of rib fractures for length of ICU stay, mechanical ventilation, mortality, pneumonia, and tracheostomy. The subgroup analysis identified surgical fixation was most favorable for patients with flail chest and those who underwent surgical fixation within 72 h. Patients over 60 y had a statistical benefit of conservative management on length of hospital stay and mechanical ventilation.
CONCLUSIONS
Surgical fixation of flail and multiple rib fractures is associated with a reduction in morbidity and mortality outcomes compared to conservative management. However, careful selection of patients is required for the appropriate application of surgical rib fixation.
Topics: Flail Chest; Fracture Fixation, Internal; Humans; Length of Stay; Pneumonia; Retrospective Studies; Rib Fractures; Ribs; Spinal Fractures
PubMed: 35390577
DOI: 10.1016/j.jss.2022.02.055 -
The Journal of Trauma and Acute Care... Mar 2023Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully... (Meta-Analysis)
Meta-Analysis
Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society.
BACKGROUND
Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia.
METHODS
Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used.
RESULTS
Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality.
CONCLUSION
We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia.
LEVEL OF EVIDENCE
Systematic Review/Meta-analysis; Level IV.
Topics: Humans; Aged; Rib Fractures; Ketamine; Pain; Analgesia, Epidural; Thoracic Injuries; Pneumonia; Neck Injuries; Length of Stay
PubMed: 36730672
DOI: 10.1097/TA.0000000000003830 -
Resuscitation Dec 2021Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients. (Meta-Analysis)
Meta-Analysis Review
AIM
Summarise the evidence regarding the safety of mechanical and manual chest compressions for cardiac arrest patients.
METHODS
Two investigators separately screened the articles of EMBASE, PubMed, and Cochrane Central databases. Cohort studies and randomized clinical trials (RCTs) that evaluated the safety of mechanical (LUCAS or AutoPulse) and manual chest compressions in cardiac arrest patients were included. A meta-analysis was performed using a random effects model to calculate the pooled odds ratios (ORs) and their 95% confidence intervals (CIs). The primary outcome was the rate of overall compression-induced injuries. The secondary outcomes included the incidence of life-threatening injuries, skeletal fractures, visceral injuries, and other soft tissue injuries.
RESULTS
The meta-analysis included 11 trials involving 2,818 patients. A significantly higher rate of overall compression-induced injuries was found for mechanical compressions than manual compressions (OR, 1.29; 95% CI, 1.19-1.41), while there was no significant difference between the two groups in respect of the rate of life-threatening injuries. Furthermore, both modalities shared similar incidences of sternal fractures, vertebral fractures, lung, spleen, and kidney injuries. However, compared to mechanical compressions, manual compressions were shown to present a reduced risk of posterior rib fractures, and heart and liver lesions.
CONCLUSIONS
The findings suggested that manual compressions could decrease the risk of compression-induced injuries compared to mechanical compressions in cardiac arrest patients. Interestingly, mechanical compressions have not increased the risk of life-threatening injuries, whereas additional high-quality RCTs are needed to further verify the safety of mechanical chest devices.
TRIAL REGISTRY
INPLASY; Registration number: INPLASY2020110111; URL: https://inplasy.com/.
Topics: Cardiopulmonary Resuscitation; Heart Arrest; Heart Massage; Humans; Out-of-Hospital Cardiac Arrest; Pressure; Randomized Controlled Trials as Topic; Thoracic Injuries; Thorax
PubMed: 34699924
DOI: 10.1016/j.resuscitation.2021.10.028 -
The Cochrane Database of Systematic... Sep 2022Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first... (Review)
Review
BACKGROUND
Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. This is an update of a review first published in 2010 and updated in 2013.
OBJECTIVES
To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.
SEARCH METHODS
We updated our searches in the following databases to May 2022: the Cochrane Central Register of Controlled Trials (CENTRAL) via OvidSP, MEDLINE via OvidSP (from 1966), Embase via embase.com (from 1974), Physiotherapy Evidence Database (PEDro) (from 1929), CINAHL via EBSCO (from 2009), and the Chinese Biomedical Literature Database (CBM) (from 1978).
SELECTION CRITERIA
Randomised controlled trials (RCTs) and quasi-RCTs assessing the efficacy of chest physiotherapy for treating pneumonia in adults.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane.
MAIN RESULTS
We included two new trials in this update (540 participants), for a total of eight RCTs (974 participants). Four RCTs were conducted in the United States, two in Sweden, one in China, and one in the United Kingdom. The studies looked at five types of chest physiotherapy: conventional chest physiotherapy; osteopathic manipulative treatment (OMT, which includes paraspinal inhibition, rib raising, and myofascial release); active cycle of breathing techniques (which includes active breathing control, thoracic expansion exercises, and forced expiration techniques); positive expiratory pressure; and high-frequency chest wall oscillation. We assessed four trials as at unclear risk of bias and four trials as at high risk of bias. Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving mortality, but the certainty of evidence is very low (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.15 to 7.13; 2 trials, 225 participants; I² = 0%). OMT (versus placebo) may have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.43, 95% CI 0.12 to 1.50; 3 trials, 327 participants; I² = 0%). Similarly, high-frequency chest wall oscillation (versus no physiotherapy) may also have little to no effect on improving mortality, but the certainty of evidence is very low (RR 0.75, 95% CI 0.17 to 3.29; 1 trial, 286 participants). Conventional chest physiotherapy (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.93, 95% CI 0.56 to 1.55; 2 trials, 225 participants; I² = 85%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on improving cure rate, but the certainty of evidence is very low (RR 0.60, 95% CI 0.29 to 1.23; 1 trial, 32 participants). OMT (versus placebo) may improve cure rate, but the certainty of evidence is very low (RR 1.59, 95% CI 1.01 to 2.51; 2 trials, 79 participants; I² = 0%). OMT (versus placebo) may have little to no effect on mean duration of hospital stay, but the certainty of evidence is very low (mean difference (MD) -1.08 days, 95% CI -2.39 to 0.23; 3 trials, 333 participants; I² = 50%). Conventional chest physiotherapy (versus no physiotherapy, MD 0.7 days, 95% CI -1.39 to 2.79; 1 trial, 54 participants) and active cycle of breathing techniques (versus no physiotherapy, MD 1.4 days, 95% CI -0.69 to 3.49; 1 trial, 32 participants) may also have little to no effect on duration of hospital stay, but the certainty of evidence is very low. Positive expiratory pressure (versus no physiotherapy) may reduce the mean duration of hospital stay by 1.4 days, but the certainty of evidence is very low (MD -1.4 days, 95% CI -2.77 to -0.03; 1 trial, 98 participants). Positive expiratory pressure (versus no physiotherapy) may reduce the duration of fever by 0.7 days, but the certainty of evidence is very low (MD -0.7 days, 95% CI -1.36 to -0.04; 1 trial, 98 participants). Conventional chest physiotherapy (versus no physiotherapy, MD 0.4 days, 95% CI -1.01 to 1.81; 1 trial, 54 participants) and OMT (versus placebo, MD 0.6 days, 95% CI -1.60 to 2.80; 1 trial, 21 participants) may have little to no effect on duration of fever, but the certainty of evidence is very low. OMT (versus placebo) may have little to no effect on the mean duration of total antibiotic therapy, but the certainty of evidence is very low (MD -1.07 days, 95% CI -2.37 to 0.23; 3 trials, 333 participants; I² = 61%). Active cycle of breathing techniques (versus no physiotherapy) may have little to no effect on duration of total antibiotic therapy, but the certainty of evidence is very low (MD 0.2 days, 95% CI -4.39 to 4.69; 1 trial, 32 participants). High-frequency chest wall oscillation plus fibrobronchoscope alveolar lavage (versus fibrobronchoscope alveolar lavage alone) may reduce the MD of intensive care unit (ICU) stay by 3.8 days (MD -3.8 days, 95% CI -5.00 to -2.60; 1 trial, 286 participants) and the MD of mechanical ventilation by three days (MD -3 days, 95% CI -3.68 to -2.32; 1 trial, 286 participants), but the certainty of evidence is very low. One trial reported transient muscle tenderness emerging after OMT in two participants. In another trial, three serious adverse events led to early withdrawal after OMT. One trial reported no adverse events after positive expiratory pressure treatment. Limitations of this review were the small sample size and unclear or high risk of bias of the included trials.
AUTHORS' CONCLUSIONS
The inclusion of two new trials in this update did not change the main conclusions of the original review. The current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia. Some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays, as well as mechanical ventilation. However, all of these findings are based on very low certainty evidence and need to be further validated.
Topics: Adult; Anti-Bacterial Agents; Humans; Physical Therapy Modalities; Pneumonia; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Therapy
PubMed: 36066373
DOI: 10.1002/14651858.CD006338.pub4 -
The Cochrane Database of Systematic... Mar 2020Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of asthma and can be performed as the Papworth Method, the Buteyko breathing technique, yogic breathing, deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, lower rib cage and abdominal breathing.
OBJECTIVES
To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.
SEARCH METHODS
To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed handsearching of respiratory journals and meeting abstracts. We also consulted trials registers and reference lists of included articles. The most recent literature search was on 4 April 2019.
SELECTION CRITERIA
We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based on the random-effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We assessed heterogeneity by inspecting the forest plots. We applied the Chi test, with a P value of 0.10 indicating statistical significance, and the I statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.
MAIN RESULTS
We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review. Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow-up, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two with asthma education control groups. Meta-analysis was possible for the primary outcome quality of life and the secondary outcomes asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review. Breathing exercises versus inactive control For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta-analysis showed improvement favouring the breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate-certainty evidence), and at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study, 655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta-analysis at up to three months was inconclusive, MD of -0.15 units (95% CI -2.32 to 2.02; 1 study, 115 participants; low-certainty evidence), and was similar over six months (MD -0.08 units, 95% CI -0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire (from four to six months), meta-analysis showed less symptoms with breathing exercises (MD -3.22, 95% CI -6.31 to -0.13; 2 studies, 118 participants; moderate-certainty evidence), but this was not shown at six months (MD 0.63, 95% CI -0.90 to 2.17; 2 studies, 521 participants). Meta-analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD -0.10 L, (95% CI -0.32 to 0.12; 4 studies, 252 participants; very low-certainty evidence). However, for FEV % of predicted, an improvement was observed in favour of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants). Breathing exercises versus asthma education For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI -0.26 to 0.34; 1 study, 183 participants). When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants). Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD -1.24, 95% CI -3.23 to 0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD -3.16, 95% CI -5.35 to -0.97; 1 study, 183 participants).
AUTHORS' CONCLUSIONS
Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions of treatment methods and outcome measurements are required.
Topics: Adult; Asthma; Breathing Exercises; Disease Progression; Health Education; Humans; Hyperventilation; Quality of Life; Randomized Controlled Trials as Topic; Respiratory Function Tests; Yoga
PubMed: 32212422
DOI: 10.1002/14651858.CD001277.pub4 -
The Cochrane Database of Systematic... Feb 2013Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Despite conflicting evidence, chest physiotherapy has been widely used as an adjunctive treatment for adults with pneumonia.
OBJECTIVES
To assess the effectiveness and safety of chest physiotherapy for pneumonia in adults.
SEARCH METHODS
We searched CENTRAL 2012, Issue 11, MEDLINE (1966 to November week 2, 2012), EMBASE (1974 to November 2012), Physiotherapy Evidence Database (PEDro) (1929 to November 2012), CINAHL (2009 to November 2012) and CBM (1978 to November 2012).
SELECTION CRITERIA
Randomised controlled trials (RCTs) assessing the efficacy of chest physiotherapy for treating pneumonia in adults.
DATA COLLECTION AND ANALYSIS
Two authors independently assessed trial eligibility, extracted data and appraised trial quality. Primary outcomes were mortality and cure rate. We used risk ratios (RR) and mean difference (MD) for individual trial results in the data analysis. We performed meta-analysis and measured all outcomes with 95% confidence intervals (CI).
MAIN RESULTS
Six RCTs (434 participants) appraised four types of chest physiotherapy (conventional chest physiotherapy; osteopathic manipulative treatment (which includes paraspinal inhibition, rib raising and myofascial release); active cycle of breathing techniques (which include active breathing control, thoracic expansion exercises and forced expiration techniques); and positive expiratory pressure).None of the physiotherapies (versus no physiotherapy or placebo) improved mortality rates of adults with pneumonia.Conventional chest physiotherapy (versus no physiotherapy), active cycle of breathing techniques (versus no physiotherapy) and osteopathic manipulative treatment (versus placebo) did not increase the cure rate or chest X-ray improvement rate.Osteopathic manipulative treatment (versus placebo) and positive expiratory pressure (versus no physiotherapy) reduced the mean duration of hospital stay by 2.0 days (mean difference (MD) -2.0 days, 95% CI -3.5 to -0.6) and 1.4 days (MD -1.4 days, 95% CI -2.8 to -0.0), respectively. Conventional chest physiotherapy and active cycle of breathing techniques did not.Positive expiratory pressure (versus no physiotherapy) reduced fever duration (MD -0.7 day, 95% CI -1.4 to -0.0). Osteopathic manipulative treatment did not.Osteopathic manipulative treatment (versus placebo) reduced the duration of intravenous (MD -2.1 days, 95% CI -3.4 to -0.9) and total antibiotic treatment (MD -1.9 days, 95% CI -3.1 to -0.7).Limitations of this review are that the studies addressing osteopathic manipulative treatment were small, and that six published studies which appear to meet the inclusion criteria are awaiting classification.
AUTHORS' CONCLUSIONS
Based on current limited evidence, chest physiotherapy might not be recommended as routine additional treatment for pneumonia in adults.
Topics: Adult; Anti-Bacterial Agents; Breathing Exercises; Humans; Manipulation, Osteopathic; Physical Therapy Modalities; Pneumonia; Randomized Controlled Trials as Topic
PubMed: 23450568
DOI: 10.1002/14651858.CD006338.pub3 -
Cureus Jul 2023Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib... (Review)
Review
Chronic alcohol use has been associated with impaired pulmonary function, increased risk of pneumonia and poor outcomes after trauma. With a high incidence of rib fractures in this population, the clinical and physiological factors associated with alcohol dependence may influence how these patients recover from thoracic injuries. Therefore, the aim of the systematic review was to examine the effect of alcohol dependence on rib fracture outcomes. The Embase, PubMed and Web of Science databases were searched for studies examining adult patients with rib fractures, with and without a history of alcohol dependency. The outcomes of interest were mortality, pulmonary complications, intensive care length of stay, ventilator days and hospital length of stay. A meta-analysis was performed to combine the data and compare results. Three studies met the criteria for inclusion in the review and all studies were observational in design. Alcohol dependency was associated with increased mortality (OR 1.44 (95% CI: 1.33-1.56)), pneumonia (OR 2.14 (2.02-2.27)) and ARDS (OR 1.71(1.48-1.98)) as well as longer stays in hospital and intensive care (p<0.05). No difference was found in ventilator days between the two groups. Early intensive care review should be considered to reduce complications in this population alongside prompt management of withdrawal symptoms. However, limited primary research exists on this topic and the quality of current evidence is low. Additional primary research is needed to further understand this correlation and draw meaningful conclusions.
PubMed: 37644941
DOI: 10.7759/cureus.42639 -
European Journal of Trauma and... Oct 2022The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries. (Review)
Review
PURPOSE
The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.
METHODS
A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14 of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant-Murley score, union and complications.
RESULTS
Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56-60.6% versus 29% in patients without clavicle fractures. Vice versa, 14-18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).
CONCLUSION
Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.
Topics: Clavicle; Humans; Length of Stay; Multiple Trauma; Retrospective Studies; Rib Fractures; Thoracic Injuries; Wounds, Nonpenetrating
PubMed: 34075434
DOI: 10.1007/s00068-021-01701-4 -
The Cochrane Database of Systematic... Jun 2015This is a second update of a Cochrane Review originally published in Issue 2, 2009. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This is a second update of a Cochrane Review originally published in Issue 2, 2009. Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological agent, based on delivering low voltage electrical currents to the skin. TENS is used by people to treat a variety of pain conditions.
OBJECTIVES
To assess the analgesic effectiveness of TENS, as a sole treatment, for acute pain in adults.
SEARCH METHODS
We searched the following databases up to 3 December 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; EMBASE; CINAHL; and AMED. We also checked the reference lists of included trials.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) of adults with acute pain (< 12 weeks) if they examined TENS given as a sole treatment and assessed pain with subjective pain scales. Trials were eligible if they compared TENS to placebo TENS, no treatment controls, pharmacological interventions or non-pharmacological interventions. We excluded trials on experimental pain, case reports, clinical observations, letters, abstracts or reviews. Also we excluded trials investigating the effect of TENS on pain during childbirth (labour), primary dysmenorrhoea or dental procedures. Studies where TENS was given with another treatment as part of the formal trial design were excluded. We did not restrict any articles based on language of publication.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility and carried out study selection, data extraction, 'Risk of bias' assessment and analyses of data. We extracted data on the following: types of participants and pain condition, trial design and methods, treatment parameters, adverse effects, and outcome measures. We contacted trial authors for additional information if necessary.
MAIN RESULTS
We included 12 trials in the original review (2009) and included no further trials in the first update (2011). An additional seven new trials met the inclusion criteria in this second update. In total, we included 19 RCTs involving 1346 participants at entry, with 11 trials awaiting classification either because the full text was unavailable or information in the full text failed to clarify eligibility. We excluded most trials because TENS was given in combination with another treatment as part of the formal study design or TENS was not delivered using appropriate TENS technique. The types of acute pain included in this Cochrane Review were procedural pain, e.g. cervical laser treatment, venepuncture, screening flexible sigmoidoscopy and non-procedural pain, e.g. postpartum uterine contractions and rib fractures. We pooled data for pain intensity for six trials (seven comparisons) comparing TENS with placebo but the I(2) statistic suggested substantial heterogeneity. Mean difference (MD) with 95% confidence intervals (CIs) on a visual analogue scale (VAS, 100 mm) was -24.62 mm (95% CI -31.79 to -17.46) in favour of TENS. Data for the proportion of participants achieving ≥ 50% reduction in pain was pooled for four trials (seven comparisons) and relative risk was 3.91 (95% CI 2.42 to 6.32) in favour of TENS over placebo. We pooled data for pain intensity from five trials (seven comparisons) but the I(2) statistic suggested considerable heterogeneity. MD was -19.05 mm (95% CI -27.30 to -10.79) in favour of TENS using a random-effects model. It was not possible to pool other data. There was a high risk of bias associated with inadequate sample sizes in treatment arms and unsuccessful blinding of treatment interventions. Seven trials reported minor adverse effects, such as mild erythema and itching underneath the electrodes and participants disliking TENS sensation.
AUTHORS' CONCLUSIONS
This Cochrane Review update includes seven new trials, in addition to the 12 trials reviewed in the first update in 2011. The analysis provides tentative evidence that TENS reduces pain intensity over and above that seen with placebo (no current) TENS when administered as a stand-alone treatment for acute pain in adults. The high risk of bias associated with inadequate sample sizes in treatment arms and unsuccessful blinding of treatment interventions makes definitive conclusions impossible. There was incomplete reporting of treatment in many reports making replication of trials impossible.
Topics: Acute Pain; Adult; Humans; Pain Measurement; Randomized Controlled Trials as Topic; Transcutaneous Electric Nerve Stimulation
PubMed: 26075732
DOI: 10.1002/14651858.CD006142.pub3 -
The Journal of Trauma and Acute Care... Aug 2020In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study...
BACKGROUND
In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation.
METHODS
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality.
RESULTS
Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation.
CONCLUSION
Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low.
LEVEL OF EVIDENCE
Systematic Review, level III.
Topics: Flail Chest; Fracture Fixation, Internal; Fracture Healing; Fractures, Multiple; Fractures, Ununited; Humans; Internal Fixators; Postoperative Complications; Quality of Life; Respiration Disorders; Respiratory Tract Diseases; Rib Fractures; Surgical Wound Infection
PubMed: 32282759
DOI: 10.1097/TA.0000000000002716