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Annals of Internal Medicine Apr 2017The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.
DESCRIPTION
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.
METHODS
Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.
TARGET AUDIENCE AND PATIENT POPULATION
The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.
RECOMMENDATION 1
Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).
RECOMMENDATION 2
For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).
RECOMMENDATION 3
In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).
Topics: Acupuncture Therapy; Acute Pain; Analgesics; Chronic Pain; Hot Temperature; Humans; Laser Therapy; Low Back Pain; Mind-Body Therapies; Physical Therapy Modalities; Psychotherapy
PubMed: 28192789
DOI: 10.7326/M16-2367 -
American Family Physician Jul 2019Acupuncture has been increasingly used as an integrative or complementary therapy for pain. It is well-tolerated with little risk of serious adverse effects. Traditional... (Review)
Review
Acupuncture has been increasingly used as an integrative or complementary therapy for pain. It is well-tolerated with little risk of serious adverse effects. Traditional acupuncture and nontraditional techniques, such as electroacupuncture and dry needling, often result in reported pain improvement. Multiple factors may contribute to variability in acupuncture's therapeutic effects, including needling technique, number of needles used, duration of needle retention, acupuncture point specificity, number of treatments, and numerous subjective (psychological) factors. Controlled trials have been published on pain syndromes, such as acupuncture for acute and chronic low back pain, knee osteoarthritis, headache, myofascial pain, neck pain, and fibromyalgia. For some conditions, enough data are available for systematic evaluations or meta-analyses. Acupuncture may provide modest benefits in the treatment of chronic low back pain, tension headache and chronic headache, migraine headache prophylaxis, and myofascial pain. Although patients receiving acupuncture for acute low back pain and knee osteoarthritis report less pain, the improvement with true (verum) acupuncture over sham acupuncture is not clinically significant for these conditions. These two conditions illustrate a recurring pattern in acupuncture trials, in which the additional improvement that can be attributed to verum over sham acupuncture, even when statistically significant, is of less clinical significance. This pattern supports the notion that acupuncture treatment has a notable placebo response, or meaning response, that may be responsible for much of its demonstrated benefits. For certain patients, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option.
Topics: Acupuncture Therapy; Acute Pain; Chronic Pain; Humans
PubMed: 31305037
DOI: No ID Found -
American Family Physician Jul 2021Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions.... (Review)
Review
Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain. Topical NSAIDs are recommended for non-low back, musculoskeletal injuries. Acetaminophen is well tolerated; however, lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder. Nonselective NSAIDs are effective but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease. Selective cyclooxygenase-2 NSAIDs are a more expensive treatment alternative and are used to avoid the gastrointestinal adverse effects of nonselective NSAIDs. Adjunctive medications may be added as appropriate for specific conditions if the recommended dose and schedule of first-line agents are inadequate (e.g., muscle relaxants may be useful for acute low back pain). For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors (e.g., tramadol, tapentadol) or with the use of acetaminophen/opioid or NSAID/opioid combinations. The opioid epidemic has increased physician and community awareness of the harms of opioid medications; however, severe acute pain may necessitate short-term use of opioids with attention to minimizing risk, including in patients on medication-assisted therapy for opioid use disorder.
Topics: Acute Pain; Analgesics; Humans; Pain Management
PubMed: 34264611
DOI: No ID Found -
Minerva Anestesiologica Feb 2012In recent years, increasing attention has been focused on the treatment of acute and chronic pain with a considerable number of publications about it. Nevertheless all... (Review)
Review
In recent years, increasing attention has been focused on the treatment of acute and chronic pain with a considerable number of publications about it. Nevertheless all the attention focused on it, the evidence of pain treatments is still unfolding, and occasionally conflicting. Hence it is still necessary that we point out our research efforts in trying to obtain a better understand of pathophysiology of pain and of real efficacy and safety of acute and chronic pain treatments. Our goal with this review is to summarize the latest research trends and the most advanced therapeutic standards for pain syndromes described in the literature, the discussion will be divided in four main topics, as these topics were treated during the SIMPAR (Study In Multidisciplinary PAin Research) meeting, held on December 2010 in Pavia: pathophysiology of pain, acute postoperative pain, opioids and pain, and chronic pain (Failed Back Surgery Syndrome). In the chapter of pathophysiology of pain we analyzed how to obtain a more personalized treatment through the study of the genetic and neurophysiological characteristics of patients and how to select the right local anesthetic according to anatomic and metabolizing patterns of patients. In acute postoperative pain we focalized our attention on the evidence supporting the use of continuous peripheral nerve blocks in the treatment of postoperative pain and in the prevention of chronic persistent post-operative pain, with a special attention in preventing side effects of regional anesthesia. We also reviewed the current evidence about the use of new very interesting modality to control postoperative pain after laparoscopy: pre-emptive nebulization of local anesthetic in abdominal cavity. As opioids are currently widely used to control chronic oncologic and non-oncologic pain, in this review we analyzed the level of evidence for their use, how to manage them better and psychological factors that can affect their success and/or determine addiction. Finally, we summarized the current evidence about Failed Back Surgery Syndrome focalizing our attention both in diagnosing it correctly and treating this syndrome with specific knowledge of the anatomic space that we have to approach and applying the possible treatments depending on pain pathophysiology and patient characteristics. In conclusion, it is important to try to personalize even better the therapy of patients with acute and chronic pain through a more accurate knowledge of anatomy, pathophysiology of pain, pharmacokinetic of pain drugs and of new device/therapies available.
Topics: Acute Pain; Back Pain; Chronic Pain; Humans; Neoplasms; Pain, Postoperative; Treatment Failure
PubMed: 22095106
DOI: No ID Found -
Journal of Anesthesia Jun 2020In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact... (Review)
Review
In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact the management of pain in children. The purpose of this review is to provide a practical clinical approach to the management of acute pain in the pediatric inpatient population. This will include an overview of commonly used pain management modalities and their potential pitfalls. For institutions that have a pediatric acute pain service or are considering initiating one, it is our hope to provide a useful tool to aid clinicians in the safe and effective treatment of pain in children.
Topics: Acute Pain; Child; Humans; Pain Management
PubMed: 32236681
DOI: 10.1007/s00540-020-02767-x -
Veterinary Journal (London, England :... Jul 2018The mechanisms by which noxious stimuli produce the sensation of pain in animals are complex. Noxious stimuli are transduced at the periphery and transmitted to the CNS,... (Review)
Review
The mechanisms by which noxious stimuli produce the sensation of pain in animals are complex. Noxious stimuli are transduced at the periphery and transmitted to the CNS, where this information is subject to considerable modulation. Finally, the information is projected to the brain where it is perceived as pain. Additionally, plasticity can develop in the pain pathway and hyperalgesia and allodynia may develop through sensitisation both peripherally and centrally. A large number of different ion channels, receptors, and cell types are involved in pain perception, and it is hoped that through a better understanding of these, new and refined treatments for pain will result.
Topics: Acute Pain; Animals; Hyperalgesia; Neural Pathways; Nociceptors; Pain Measurement; Sensation; Signal Transduction; Spinal Cord
PubMed: 30089546
DOI: 10.1016/j.tvjl.2018.05.004 -
Regional Anesthesia and Pain Medicine Jul 2018Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments,...
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.
BACKGROUND
Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines.
METHODS
The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls.
RESULTS
Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions.
CONCLUSIONS
Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.
Topics: Acute Pain; Analgesics; Anesthesia, Conduction; Anesthesiologists; Consensus; Humans; Infusions, Intravenous; Ketamine; Pain Management; Societies, Medical; United States
PubMed: 29870457
DOI: 10.1097/AAP.0000000000000806 -
Medicina (Kaunas, Lithuania) Nov 2018Paediatric pain and its assessment and management are challenging for medical professionals, especially in an urgent care environment. Patients in a paediatric emergency... (Review)
Review
Paediatric pain and its assessment and management are challenging for medical professionals, especially in an urgent care environment. Patients in a paediatric emergency room (PER) often undergo painful procedures which are an additional source of distress, anxiety, and pain. Paediatric procedural pain is often underestimated and neglected because of various myths, beliefs, and difficulties in its evaluation and treatment. However, it is very different from other origins of pain as it can be preventable. It is known that neonates and children can feel pain and that it has long-term effects that last through childhood into adulthood. There are a variety of pain assessment tools for children and they should be chosen according to the patient's age, developmental stage, communication skills, and medical condition. Psychological factors such as PER environment, preprocedural preparation, and parental involvement should also be considered. There are proven methods to reduce a patient's pain and anxiety during different procedures in PER. Distraction techniques such as music, videogames, virtual reality, or simple talk about movies, friends, or hobbies as well as cutaneous stimulation, vibration, cooling sprays, or devices are effective to alleviate procedural pain and anxiety. A choice of distraction technique should be individualized, selecting children who could benefit from nonpharmacological pain treatment methods or tools. Nonpharmacological pain management may reduce dosage of pain medication or exclude pharmacological pain management. Most nonpharmacological treatment methods are cheap, easily accessible, and safe to use on every child, so it should always be a first choice when planning a patient's care. The aim of this review is to provide a summary of paediatric pain features, along with their physiology, assessment, management, and to highlight the importance and efficacy of nonpharmacological pain management in an urgent paediatric care setting.
Topics: Acute Pain; Adolescent; Anxiety; Child; Child, Preschool; Emergency Service, Hospital; Humans; Infant; Infant, Newborn; Medical Staff; Pain Management; Pain Measurement; Pain, Procedural; Parent-Child Relations; Pediatric Emergency Medicine
PubMed: 30486427
DOI: 10.3390/medicina54060094 -
Journal of Burn Care & Research :... Nov 2020The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn... (Review)
Review
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps.
The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.
Topics: Acute Pain; Adult; Burns; Evidence-Based Medicine; Humans; Pain Management; Pain Measurement; United States
PubMed: 32885244
DOI: 10.1093/jbcr/iraa119 -
Deutsches Arzteblatt International Apr 2016Back pain has many causes. In Germany, about 70% of adults have at least one episode of back pain per year. (Review)
Review
BACKGROUND
Back pain has many causes. In Germany, about 70% of adults have at least one episode of back pain per year.
METHODS
This review is based on a selective literature search and on the German National Disease Management Guideline for Low Back Pain.
RESULTS
The physician taking the history from a patient with back pain should ask about the nature, onset, course, localization, and radiation of the pain and its dependence on physical activity and/or emotional stress. In the differential diagnosis, neurologic deficits and any "red flags" suggesting dangerous conditions such as spinal fracture, bacterial infection, and tumors must be ruled out. If no specific cause of the pain can be identified, no imaging studies are indicated on initial presentation. The treatment of acute, nonspecific low back pain focuses on pain relief and functional improvement. Adequate patient education and counseling are essential. Exercise therapy is no more effective than the continuation of normal daily activities. Restriction of activity, including bed rest, is of no benefit and merely prolongs recovery and the resumption of normal activity. Further diagnostic testing is indicated if there is any suspicion of a fracture, infection, or tumor.
CONCLUSION
After dangerous conditions have been ruled out, low back pain can be pragmatically classified as either nonspecific or specific. More research is needed so that the diagnostic assessment and individualized treatment of acute lower back pain can be further refined.
Topics: Acute Pain; Analgesics; Diagnosis, Differential; Evidence-Based Medicine; Exercise Therapy; Germany; Humans; Immobilization; Low Back Pain; Pain Management; Practice Guidelines as Topic; Treatment Outcome
PubMed: 27120496
DOI: 10.3238/arztebl.2016.0223