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Sommaire
Postoperative Pain
Douleur post-opératoire : évaluation de l'acupuncture
| Articles connexes: - Pain |
1. Systematic Reviews and Meta-Analysis
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Lederer 2018
Lederer AK, Schmucker C, Kousoulas L, Fichtner-Feigl S, Huber R. Naturopathic Treatment and Complementary Medicine in Surgical Practice. Dtsch Arztebl Int. 2018;115(49):815-821. [200295].
| Background | Many patients in Germany use naturopathic treatments and complementary medicine. Surveys have shown that many also use them as a concomitant treatment to surgery. |
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| Methods | Multiple databases were systematically searched for systematic reviews, controlled trials, and experimental studies concerning the use of naturopathic treatments and complementary medicine in the management of typical post-operative problems (PROSPERO CRD42018095330). |
| Results | Of the 387 publications identified by the search, 76 fulfilled the inclusion criteria. In patients with abnormal gastrointestinal activity, acupuncture can improve motility, ease the passing of flatus, and lead to earlier defecation. Acupuncture and acupressure can reduce postoperative nausea and vomiting, as well as pain. More-over, aromatherapy and music therapy seem to reduce pain, stress and anxiety and to improve sleep. Further studies are needed to determine whether phytotherapeutic treatments are effective for the improvement of gastrointestinal function or the reduction of stress. It also remains unclear whether surgical patients can benefit from the methods of mind body medicine. |
| Conclusion | Certain naturopathic treatments and complementary medical methods may be useful in postoperative care and deserve more intensive study. In the publications consulted for this review, no serious side effects were reported. |
1.1.2. Wu 2016 ☆☆
Wu MS, Chen KH, Chen IF, Huang SK, Tzeng PC, Yeh ML, Lee FP, Lin JG, Chen C. The efficacy of acupuncture in post-operative pain management: a systematic review and meta-analysis. PLoS One. 2016 Mar 9;11(3):e0150367.[170723].
| Objective | This systematic review and meta-analysis evaluated the effectiveness of acupuncture and acupuncture-related techniques in treating postoperative pain. |
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| Methods | Data Source : MEDLINE, Cochrane Library, and EMBASE databases were searched until Sep 30, 2014. Study Eligibility Criteria : Randomized controlled trials of adult subjects ( 18 years) who had undergone surgery and who had received acupuncture, electroacupuncture, or acupoint electrical stimulation for managing acute post-operative pain were included. |
| Results | We found that patients treated with acupuncture or related techniques had less pain and used less opioid analgesics on Day 1 after surgery compared with those treated with control (P < 0.001). Sensitivity analysis using the leave-one-out approach indicated the findings are reliable and are not dependent on any one study. In addition, no publication bias was detected. Subgroup analysis indicated that conventional acupuncture and transcutaneous electric acupoint stimulation (TEAS) were associated with less postoperative pain one day following surgery than control treatment, while electroacupuncture was similar to control (P = 0.116). TEAS was associated with significantly greater reduction in opioid analgesic use on Day 1 post surgery than control (P < 0.001); however conventional acupuncture and electroacupuncture showed no benefit in reducing opioid analgesic use compared with control (P 0.142). |
| Conclusions | Our findings indicate that certain modes of acupuncture improved postoperative pain on the first day after surgery and reduced opioid use. Our findings support the use of acupuncture as adjuvant therapy in treating postoperative pain. |
1.1.3. Fuentealba 2016 ☆
Fuentealba Cargill F, Biagini Alarcón L. [Acupuncture for postoperative pain, a literature review]. Rev Med Chil. 2016;144(3):325-32. [186279].
| Background | There is evidence that acupuncture may relieve pain. AIM: To assess the evidence about the effectiveness of acupuncture to relieve postoperative pain. |
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| Material and methods | A systematic review of the literature selecting controlled clinical trials and systematic reviews comparing acupuncture with standard pain management. The value and quality of reports were evaluated using Jadad scale and STRICTA protocol. Pain intensity and analgesic consumption were the primary endpoints sought. |
| Results | Five controlled trials and two systematic reviews were selected. A meta-analysis was not feasible due to the heterogeneity of studies. In the postoperative period of tonsillectomy, acupuncture reduced pain by 36 and 22% at 20 minutes and two hours, respectively. In knee replacement, acupuncture reduced pain by 2% and analgesic consumption by 42%. In the postoperative period of dental interventions, acupuncture reduced pain by 24% at two hours. |
| Conclusions | Acupuncture may be useful to manage postoperative pain, but more controlled studies are required. |
1.1.4. Sun 2008 ☆☆☆
Sun Y, Gan Tj, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth. 2008; 101(2):151-60. [149110].
| Objective | Postoperative pain management remains a significant challenge for all healthcare providers. The objective of this systematic review was to quantitatively evaluate the efficacy of acupuncture and related techniques as adjunct analgesics for acute postoperative pain management. |
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| Methods | We searched the databases of Medline (1966-2007), CINAHL, The Cochrane Central Register of Controlled Trials (2006), and Scopus for randomized controlled trials (RCTs) using acupuncture for postoperative pain management. We extracted data about postoperative opioid consumption, postoperative pain intensity, and opioid-related side-effects. Combined data were analysed using a random effects model. |
| Results | Fifteen RCTs comparing acupuncture with sham control in the management of acute postoperative pain were included. Weighted mean difference for cumulative opioid analgesic consumption was -3.14 mg (95% confidence interval, CI: -5.15, -1.14), -8.33 mg (95% CI: -11.06, -5.61), and -9.14 mg (95% CI: -16.07, -2.22) at 8, 24, and 72 h, respectively. Postoperative pain intensity (visual analogue scale, 0-100 mm) was also significantly decreased in the acupuncture group at 8 and 72 h compared with the control group. The acupuncture treatment group was associated with a lower incidence of opioid-related side-effects such as nausea (relative risk, RR: 0.67; 95% CI: 0.53, 0.86), dizziness (RR: 0.65; 95% CI: 0.52, 0.81), sedation (RR: 0.78; 95% CI: 0.61, 0.99), pruritus (RR: 0.75; 95% CI: 0.59, 0.96), and urinary retention (RR: 0.29; 95% CI: 0.12, 0.74). |
| Conclusions | Perioperative acupuncture may be a useful adjunct for acute postoperative pain management. |
1.2. Special Acupuncture Techniques
1.2.1. Auricular Acupuncture
1.2.1.1. Usichenko 2008 ☆
Usichenko TI, LehmanN CH, Ernst E. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia. 2008;63(12):1343-8. [153119].
| Objective | The number of publications on the peri-operative use of auricular acupuncture has rapidly increased within the last decade. The aim was to evaluate clinical evidence on the efficacy of auricular acupuncture for postoperative pain control. |
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| Methods | Electronic databases: Medline, MedPilot, DARE, Clinical Resource, Scopus and Biological Abstracts were searched from their inception to September 2007. All randomised clinical trials on the treatment of postoperative pain with auricular acupuncture were considered and their quality was evaluated using the Jadad scale. Pain intensity and analgesic requirements were defined as the primary outcome measures. |
| Results | Of 23 articles, nine fulfilled the inclusion criteria. Meta-analytic approach was not possible because of the heterogeneity of the primary studies. In eight of the trials, auricular acupuncture was superior to control conditions. Seven randomised clinical trials scored three or more points on the Jadad scale but none of them reached the maximum of 5 points. |
| Conclusions | The evidence that auricular acupuncture reduces postoperative pain is promising but not compelling. |
1.2.2. Comparison of Acupuncture Techniques
1.2.2.1. Zhu 2019 (Distal versus peri-incisional stimulation)
Zhu J , Xu Q , Zou R , Wu W , Wang X , Wang Y , Ji F Zheng Z, Zheng M. Distal acupoint stimulation versus peri-incisional stimulation for postoperative pain in open abdominal surgery: a systematic review and implications for clinical practice. BMC Complement Altern Med. 2019;19(1):192. [200913].
| Background | Acute postoperative pain remains a major clinical problem that affects patient recovery. Distal acupoint and peri-incisional stimulation are both used for relieving acute postoperative pain in hospital. Our objective was to assess and compare the effects of distal and peri-incisional stimulation on postoperative pain in open abdominal surgery. |
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| Methods | MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Chinese databases CNKI and Wanfangdata were searched to identify eligible randomized controlled trials. Intensity of postoperative pain, opioid consumption and related data were extracted and analyzed using a random effects model. Risk of bias was assessed. Subgroup analyses were conducted when data were enough. |
| Results | Thirty-five trials were included, in which 17 trials studied distal stimulation, another 17 trials studied peri-incisional stimulation and one studied the combination of the two approaches. No studies that directly compared the two approaches were identified. Subgroup analysis showed that both distal and peri-incisional stimulation significantly alleviated postoperative resting and movement pain from 4 h to 48 h after surgery by 6 to 25 mm on a 100 mm visual analogue scale. Peri-incisional stimulation showed a better reduction in postoperative opioid consumption. No studies compared the effects of the combined peri-incisional and distal stimulation with either mode alone. Overall the quality of evidence was moderate due to a lack of blinding in some studies, and unclear risk of allocation concealment. |
| Conclusion | Both distal and peri-incisional modes of stimulation were effective in reducing postoperative pain. Whether a combined peri-incisional stimulation and distal acupuncture has superior results requires further studies. |
1.3. Specific Conditions
1.3.1. Caesarean
1.3.1.1. Zimpel 2020
Zimpel SA, Torloni MR, Porfírio GJ, Flumignan RL, da Silva EM. Complementary and alternative therapies for post-caesarean pain. Cochrane Database Syst Rev. 2020. [212702]. doi
| Background | Pain after caesarean sections (CS) can affect the well-being of the mother and her ability with her newborn. Conventional pain-relieving strategies are often underused because of concerns about the adverse maternal and neonatal effects. Complementary alternative therapies (CAM) may offer an alternative for post-CS pain. |
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| Objectives | To assess the effects of CAM for post-caesarean pain. |
| Methods | Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, LILACS, PEDro, CAMbase, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (6 September 2019), and checked the reference lists of retrieved articles. Selection criteria: Randomised controlled trials (RCTs), including quasi-RCTs and cluster-RCTs, comparing CAM, alone or associated with other forms of pain relief, versus other treatments or placebo or no treatment, for the treatment of post-CS pain. Data collection and analysis: Two review authors independently performed study selection, extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE. |
| Main results | We included 37 studies (3076 women) which investigated eight different CAM therapies for post-CS pain relief. There is substantial heterogeneity among the trials. We downgraded the certainty of evidence due to small numbers of women participating in the trials and to risk of bias related to lack of blinding and inadequate reporting of randomisation processes. None of the trials reported pain at six weeks after discharge. Primary outcomes were pain and adverse effects, reported per intervention below. Secondary outcomes included vital signs, rescue analgesic requirement at six weeks after discharge; all of which were poorly reported, not reported, or we are uncertain as to the effect Acupuncture or acupressure We are very uncertain if acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus placebo plus analgesia) has any effect on pain because the quality of evidence is very low. Acupuncture or acupressure plus analgesia (versus analgesia) may reduce pain at 12 hours (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.64 to 0.07; 130 women; 2 studies; low-certainty evidence) and 24 hours (SMD -0.63, 95% CI -0.99 to -0.26; 2 studies; 130 women; low-certainty evidence). It is uncertain whether acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus analgesia) has any effect on the risk of adverse effects because the quality of evidence is very low. Aromatherapy Aromatherapy plus analgesia may reduce pain when compared with placebo plus analgesia at 12 hours (mean difference (MD) -2.63 visual analogue scale (VAS), 95% CI -3.48 to -1.77; 3 studies; 360 women; low-certainty evidence) and 24 hours (MD -3.38 VAS, 95% CI -3.85 to -2.91; 1 study; 200 women; low-certainty evidence). We are uncertain if aromatherapy plus analgesia has any effect on adverse effects (anxiety) compared with placebo plus analgesia. Electromagnetic therapy Electromagnetic therapy may reduce pain compared with placebo plus analgesia at 12 hours (MD -8.00, 95% CI -11.65 to -4.35; 1 study; 72 women; low-certainty evidence) and 24 hours (MD -13.00 VAS, 95% CI -17.13 to -8.87; 1 study; 72 women; low-certainty evidence). Massage We identified six studies (651 women), five of which were quasi-RCTs, comparing massage (foot and hand) plus analgesia versus analgesia. All the evidence relating to pain, adverse effects (anxiety), vital signs and rescue analgesic requirement was very low-certainty. Music Music plus analgesia may reduce pain when compared with placebo plus analgesia at one hour (SMD -0.84, 95% CI -1.23 to -0.46; participants = 115; studies = 2; I2 = 0%; low-certainty evidence), 24 hours (MD -1.79, 95% CI -2.67 to -0.91; 1 study; 38 women; low-certainty evidence), and also when compared with analgesia at one hour (MD -2.11, 95% CI -3.11 to -1.10; 1 study; 38 women; low-certainty evidence) and at 24 hours (MD -2.69, 95% CI -3.67 to -1.70; 1 study; 38 women; low-certainty evidence). It is uncertain whether music plus analgesia has any effect on adverse effects (anxiety), when compared with placebo plus analgesia because the quality of evidence is very low. Reiki We are uncertain if Reiki plus analgesia compared with analgesia alone has any effect on pain, adverse effects, vital signs or rescue analgesic requirement because the quality of evidence is very low (one study, 90 women). Relaxation Relaxation may reduce pain compared with standard care at 24 hours (MD -0.53 VAS, 95% CI -1.05 to -0.01; 1 study; 60 women; low-certainty evidence). Transcutaneous electrical nerve stimulation TENS (versus no treatment) may reduce pain at one hour (MD -2.26, 95% CI -3.35 to -1.17; 1 study; 40 women; low-certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce pain compared with placebo plus analgesia at one hour (SMD -1.10 VAS, 95% CI -1.37 to -0.82; 3 studies; 238 women; low-certainty evidence) and at 24 hours (MD -0.70 VAS, 95% CI -0.87 to -0.53; 108 women; 1 study; low-certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce heart rate (MD -7.00 bpm, 95% CI -7.63 to -6.37; 108 women; 1 study; low-certainty evidence) and respiratory rate (MD -1.10 brpm, 95% CI -1.26 to -0.94; 108 women; 1 study; low-certainty evidence). We are uncertain if TENS plus analgesia (versus analgesia) has any effect on pain at six hours or 24 hours, or vital signs because the quality of evidence is very low (two studies, 92 women). |
| Authors' conclusions | Some CAM therapies may help reduce post-CS pain for up to 24 hours. The evidence on adverse events is too uncertain to make any judgements on safety and we have no evidence about the longer-term effects on pain. Since pain control is the most relevant outcome for post-CS women and their clinicians, it is important that future studies of CAM for post-CS pain measure pain as a primary outcome, preferably as the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. Measuring pain as a dichotomous variable would improve the certainty of evidence and it is easy to understand for non-specialists. Future trials also need to be large enough to detect effects on clinical outcomes; measure other important outcomes as listed lin this review, and use validated scales. |
1.3.2. Anorectal Surgery
1.3.2.1. Di 2020
Di Qin, An-Mei Zhang, Min Chen, Tai-Chun Tang, … Hui Zheng. Acupuncture and related techniques for postoperative pain after hemorrhoidectomy: A systematic review and network meta-analysis. European Journal of Integrative Medicine. 2020;37. [212113]. doi
| Introduction | Several acupuncture related techniques are used in clinical practice for postoperative pain after hemorrhoidectomy. As the comparative effectiveness between these treatments was unclear, a systematic review and network meta-analysis was conducted. |
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| Methods | MEDLINE, Embase, the Cochrane Library Chinese biomedical database (CBM), and China journal full-text database (CNKI) were searched from January 1st, 1996 to February 1st, 2020, for randomized controlled trials (RCTs) assessing the effectiveness of acupuncture and related techniques. The Cochrane risk of bias tool and GRADE were used to assess the quality of the included RCTs. The effect sizes were pooled by using random-effects model and data presented as standardized mean difference (SMD) or relative ratio (RR). |
| Results | We included 107 RCTs (n = 10,972) for network meta-analysis assessing the relative effectiveness of 40 treatments and 48 RCTs (n = 5226) to analyse responder rate. Auricular acupressure plus acupuncture (RR, 1.44 [95 %CI, 1.15–1.81], P-score = 0.923), acupuncture (RR, 1.23, [95 %CI, 1.04–1.45], P-score = 0.723), other acupuncture techniques (RR, 1.22, [95 %CI, 1.04–1.44], P-score = 0.727) and auricular acupressure (RR, 1.22, [95 %CI, 1.09–1.36], P-score = 0.720) were significantly superior over usual care, and auricular acupressure plus acupuncture ranked the most effective. 72 RCTs (n = 7220) were analysed for pain intensity. Providing eight treatments was significantly superior compared with usual care. Auricular acupressure plus acupuncture (SMD, -1.82 [95 %CI, -3.33 to -0.31], P-score = 0.799) ranked the most effective. |
| Conclusion | Auricular acupressure plus acupuncture provided the best outcomes but findings were limited by the quality of the evidence. |
1.3.2.2. Lian 2020
Liang Jiabin. [Meta-analysis of the application of acupuncture and combined drug anesthesia in anorectal surgery]. Journal of Hainan Medical University. 2020. [212898].
| Objective | To evaluate the efficacy and safety of acupuncture combined with drug anesthesia and simple drug anesthesia in anorectal surgery. |
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| Methods | Cochrane system evaluation method was used to evaluate the randomized controlled trial of acupuncture combined with drug anesthesia. The search ranges from China HowNet, Wanfang, Chinese Biomedical Literature, Pubmed to Embase, till August 2019. Randomized controlled trials of acupuncture combined drug anesthesia were selected to meet the inclusion criteria. Cochrane risk bias was used to evaluate the quality of the trials. Finally, RevMan 5. 2 software was used for statistical analysis. |
| Result | Totally, 15 articles were included in this study, including 1 321 patients. The homogeneity was good, with the combined effect (OR=3. 55, 95% CI: 2. 06-6. 12), and the combined effect Z=4. 57, P<0. 000 01, which had statistical significance. It indicated that the combined drug anesthesia of acupuncture was superior to the simple drug anesthesia in anorectal surgery. The homogeneity of ADR analysis was good (OR=0. 16, 95% CI: 0. 11, 0. 24, Z=8. 88, P<0. 000 01), which showed that the ADR rate of acupuncture combined with drug anesthesia group was lower than that of simple drug anesthesia group in anorectal surgery. |
| Conclusion | Acupuncture combined with drug anesthesia can improve the anesthetic effect and reduce the incidence of adverse reactions in anorectal surgery compared with simple drug anesthesia. |
1.3.3. Orthopedic Surgery
1.3.3.1. Roberts 2012 Ø
Roberts M, Brodribb W, Mitchell G. Reducing the pain: a systematic review of postdischarge analgesia following elective orthopedic surgery. Pain Med. 2012;13(5):711-27. [166396].
| Objective | This study aimed to determine which analgesic modalities used following discharge have the greatest efficacy in reducing postoperative pain after elective non-axial orthopedic surgery. |
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| Design and setting | A systematic review was conducted using the databases CENTRAL, MEDLINE, and EMBASE, as well as clinical practice guidelines databases and trial registries. Titles and abstracts were perused by two reviewers for randomized clinical trials in English fulfilling inclusion and exclusion criteria. Quality assessments, including the Oxford Quality Score, selective reporting, and sources of funding, were also performed. OUTCOME MEASURES: Pain intensity/relief, global patient evaluation, and use of rescue analgesia, as well as adverse events and withdrawals. |
| Results | 2,167 articles were retrieved and 23 articles were eligible for inclusion. They investigated analgesic modalities including alternative therapies (5); cyclooxygenase-2 inhibitors (3); nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) (12); opioids (2); and other pharmaceutical classes (1). Cycooxygenase-2 inhibitors and opioids demonstrated significant efficacy with minimal side effects. Most nonselective NSAIDs were effective analgesics but had a poorer side-effect profile. Alternative therapies demonstrated no significant efficacy. |
| Conclusions | Opioids and cyclooxygenase-2 inhibitors are effective in providing analgesia in the extended postoperative period following orthopedic surgery with a minimal side-effect profile, while nonselective NSAIDs need to be treated with caution. Homeopathy is not an effective analgesic, while acupuncture has varied evidence and effectiveness. Treatment of postoperative fatigue may also improve analgesia control. This study provides orthopedic surgeons with a basis for evidence-based prescribing of postdischarge analgesia. However, further studies to validate these results against modern reporting standards are needed. |
| Acupuncture | Acupuncture was not an effective stand-alone therapy in this setting. |
1.3.4. Vertebral Surgery
1.3.4.1. Cho 2014 ☆
Cho YH, Kim CK, Heo KH, Lee MS, Ha IH, Son DW, Choi BK, Song GS, Shin BC. Acupuncture for acute postoperative pain after back surgery: a systematic review and meta-analysis of randomized controlled trials. Pain Pract. 2014. 15(3):279-91. [170693].
| Objectives | Acupuncture is commonly used as a complimentary treatment for pain management. However, there has been no systematic review summarizing the current evidence concerning the effectiveness of acupuncture for acute postoperative pain after back surgery. This systematic review aimed at evaluating the effectiveness of acupuncture treatment for acute postoperative pain (≤1 week) after back surgery. |
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| Methods | We searched 15 electronic databases without language restrictions. Two reviewers independently assessed studies for eligibility and extracted data, outcomes, and risk of bias. Random effect meta-analyses and subgroup analyses were performed. |
| Results | Five trials, including 3 of high quality, met our inclusion criteria. The meta-analysis showed positive results for acupuncture treatment of pain after surgery in terms of the visual analogue scale (VAS) for pain intensity 24 hours after surgery, when compared to sham acupuncture (standard mean difference -0.67 (-1.04 to -0.31), P = 0.0003), whereas the other meta-analysis did not show a positive effect of acupuncture on 24-hour opiate demands when compared to sham acupuncture (standard mean difference -0.23 (-0.58 to 0.13), P = 0.21). |
| Conclusion | Our systematic review finds encouraging but limited evidence for the effectiveness of acupuncture treatment for acute postoperative pain after back surgery. Further rigorously designed clinical trials are required. |
1.3.5. Knee Surgery
1.3.5.1. Yue 2018 (Total Knee Arthroplasty)
Yue C , Zhang X , Zhu Y , Jia Y , Wang H , Liu Y. Systematic Review of Three Electrical Stimulation Techniques for Rehabilitation After Total Knee Arthroplasty. J Arthroplasty. 2018;33(7):2330-2337. [193052].
| Background | The comparative effectiveness of neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and electroacupuncture (EA) for improving patient rehabilitation following total knee arthroplasty (TKA) is controversial. Therefore we conducted this systematic review to assess the available evidence. |
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| Methods | The PubMed, OVID, and ScienceDirect databases were comprehensively searched and studies were selected and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Data were extracted and qualitatively synthesized for several outcomes. |
| Results | Data were analyzed from 17 randomized controlled trials involving 1285 procedures: 8 NMES studies (608 procedures), 7 TENS studies (560 procedures), and 2 EA studies (117 procedures). Qualitative analysis suggested that NMES was associated with higher quadriceps strength and functional recovery after TKA. Recovery benefits were maximal when the stimulation was performed once or twice a day for 4-6 weeks at an intensity of 100-120 mA and frequency of 30-100 Hz. The electrode should be sufficiently large (100-200 cm2) to reduce discomfort. TENS at an intensity of 15-40 mA and frequency of 70-150 Hz provided effective analgesia after TKA. EA at an intensity of 2 mA and frequency of 2 Hz may also provide postoperative analgesia of TKA. |
| Conclusion | As adjunct modalities, NMES and TENS can effectively improve rehabilitation after TKA without triggering significant intolerance, and maximal benefits depend on optimized parameters and intervention protocols. EA may be an effective adjunct modality for analgesia after TKA. |
1.3.5.2. Tedesco 2017 (Total Knee Arthroplasty) ☆☆
Tedesco D, Gori D, Desai KR, Asch S , Carroll IR, Curtin C, McDonald KM, Fantini MP, Hernandez-Boussard T. Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. JAMA Surg. 2017;152(10):. [175769].
| Objective | To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty. |
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| Methods | Data Sources: Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016. Study Selection: Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included. Data Extraction and Synthesis: Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses. Main Outcomes and Measures: Postoperative pain and consumption of opioids and analgesics. |
| Results | Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%). |
| Conclusions and Relevance | In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption. |
1.3.5.3. Chesham 2016 (Total Knee Arthroplasty) Ø
Chesham RA, Shanmugam S. Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review. Physiother Theory Pract. 2016. [160683].
| Background | Knee osteoarthritis (OA) is a leading cause of disability in older adults (≥60) in the UK. If nonsurgical management fails and if OA severity becomes too great, knee arthroplasty is a preferred treatment choice. Preoperative physiotherapy is often offered as part of rehabilitation to improve postoperative patient-based outcomes. |
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| Objectives | Systematically review whether preoperative physiotherapy improves postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty (TKA) and compare study interventions to best-practice guidelines. |
| Method | A literature search of Randomized Controlled Trials (RCTs), published April 2004-April 2014, was performed across six databases. Individual studies were evaluated for quality using the PEDro Scale. |
| Results | Ten RCTs met the full inclusion/exclusion criteria. RCTs compared control groups versus: preoperative exercise (n = 5); combined exercise and education (n = 2); combined exercise and acupuncture (n = 1); neuromuscular electrical stimulation (NMES; n = 1); and acupuncture versus exercise (n = 1). RCTs recorded many patient-based outcomes including knee strength, ambulation, and pain. Minimal evidence is presented that preoperative physiotherapy is more effective than no physiotherapy or usual care. PEDro Scale and critical appraisal highlighted substantial methodological quality issues within the RCTs. |
| Conclusion | There is insufficient quality evidence to support the efficacy of preoperative physiotherapy in older adults who undergo total knee arthroplasty. |
1.3.5.4. Barlow 2013 (Ambulatory Knee Surgery) ☆
Barlow T, Downham C, Barlow D. the effect of complementary therapies on post-operative pain control in ambulatory knee surgery: a systematic review. Complement Ther Med. 2013;21(5):529-34. [172671].
| Objectives | Ambulatory knee surgery is a common procedure with over 100,000 knee arthroscopies performed in the U.K. in 2010-2011. Pain after surgery can decrease patient satisfaction, delay discharge, and decrease cost effectiveness. Multi-modal therapies, including complementary therapies, to improve pain control after surgery have been recommended. However, a comprehensive review of the literature regarding the use of complementary therapies to enhance pain control after ambulatory knee surgery is lacking, and this article aims to address this deficit. |
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| Methods | CINHAL, EMBASE, MEDLINE, AMED and CENTRAL databases were searched. Only Randomised Controlled Trials were included. All eligible papers were quality assessed using the Jadad system, and data was extracted using piloted forms. Two independent reviewers performed each stage of the review. Full details of the study methodology can be found on Prospero, a systematic review register. |
| Results | Five studies satisfied our eligibility criteria: three reporting on acupuncture, one on homeopathy, and one on acupoints. Acupoint pressure was the only study that demonstrated reduced pain compared with placebo. This study was the least methodologically robust. Arnica, although demonstrating a significant reduction in swelling, did not affect post-operative pain. Acupuncture did not affect post-operative pain; however, a reduction in ibuprofen use was demonstrated in two studies. |
| Conclusions | Before recommending complementary therapy for routine use in ambulatory knee surgery, further work is required. Two areas of future research likely to bear fruit are demonstrating robust evidence for the effect of acupoint pressure on post-operative pain, and quantifying the positive effect of homeopathic arnica on post-operative swelling. |
1.3.6. ENT Surgery
1.3.6.1. Cho 2016 (Tonsillectomy) ☆
Cho HK, Park IJ, Jeong YM, Lee YJ, Hwang SH. Can perioperative acupuncture reduce the pain and vomiting experienced after tonsillectomy? A meta-analysis. Laryngoscope. 2016;126(3):608-15. [186329].
| Objectives | Acupuncture has been shown to reduce pain, nausea, and vomiting. However, its use alongside surgical interventions remains a novel practice, despite the increasing applications of alternative medicine. The goal of this meta-analysis was to perform a systematic review of the literature addressing the effect of acupuncture on postoperative pain, nausea, and vomiting following tonsillectomy. |
|---|---|
| Methods | DATA SOURCES: MEDLINE, SCOPUS, and Cochrane database. METHODS: Two authors independently searched the databases from the inception of article collection until June 2015. We included 1) analysis studies that compared groups of patients who had received perioperative acupuncture (acupuncture groups) with those who had received a pain control agent or sham treatment (control group); and 2) analysis studies in which the outcomes of interest were postoperative pain intensity, rescue analgesic consumption, or nausea and vomiting. |
| Results | The pain score reported by patients during the first 48 hours and the postoperative need for analgesics were significantly lower in the acupuncture group versus the control group. Additionally, the incidence of postoperative nausea and vomiting was significantly lower in the acupuncture group than in the control group. No major adverse effects of perioperative acupuncture were reported in the enrolled studies. |
| Conclusion | perioperative acupuncture may provide pain relief without side effects in patients undergoing tonsillectomy. However, there were high levels of heterogeneity in several of the measured parameters; thus, the efficacy of acupuncture cannot be considered to have been evaluated sufficiently. For this reason, additional large well-designed trials are required to further support the results of this study. |
1.3.7. Neurosurgery
1.3.7.1. Tsaousi 2016 (Craniotomy) Ø
Tsaousi GG, Logan SW, Bilotta F. Postoperative Pain Control Following Craniotomy: A Systematic Review of Recent Clinical Literature. Pain Pract. 2016. [190370].
| Objectives | Pain intensity after craniotomy is considered to be moderate to severe during the first 2 postoperative days. The ideal pain treatment to facilitate a rapid postoperative recovery and optimize outcome is unknown. Objectives: This systematic review aims to report current clinical evidence related to pharmacological and adjuvant analgesic modalities for postcraniotomy pain control. |
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| Methods | Systematic review of randomized controlled trials (RCTs). DATA SOURCES: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (January 2011 to April 2016). ELIGIBILITY CRITERIA: Use of any analgesic drug, analgesic method, or nonpharmacological intervention for postcraniotomy pain relief. Also reported data on pain scores up to 48 hours postoperatively, supplemental analgesic requirements, or adverse events. |
| Results | Nineteen RCTs enrolling a total of 1,805 patients were included. Most of the retrieved studies were of moderate to good methodological quality. Systemic pharmacological intervention was assessed in 14 RCTs. Opioids (5 RCTs) provided superior pain relief to other analgesics with no significant side-effects, but the quality of studies was low. Diclofenac (3 RCTs) presented adequate craniotomy pain control without any adverse effects, while the use of parecoxib is not supported. Dexmedetomidine (3 RCTs) provided adequate transitional analgesia, but further research is needed. Data on the analgesic efficacy of gabapentin, pregabalin, and intravenous lidocaine is very limited (1 RCT for each). Scalp infiltration/block (3 RCTs) provided adequate analgesia in the early postoperative period, while more studies are needed to verify the analgesic benefit obtained from nonpharmacological interventions, such as multipoint electro-acupuncture, in craniotomy surgery (2 RCTs). |
| Conclusions | No definite recommendations can be made based on this systematic review of pharamacological interventions following craniotomy due to significant divergence in the methodology of available studies. Limited evidence on scalp infiltration/block suggests an adequate analgesic effect in the early postoperative period. Analgesic efficacy of dexmedetomidine and multipoint electro-acupuncture needs further evaluation. |
2. Clinical Practice Guidelines
| ⊕ positive recommendation (regardless of the level of evidence reported) Ø negative recommendation (or lack of evidence) |
2.1. European Society of Regional Anaesthesia and Pain Therapy 2020 ⊕
PROSPECT (PROcedure-SPECific postoperative pain managemenT) [tonsillectomy]
Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H, PROSPECT Working Group collaborators. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2020. [211868]. doi
| The analgesic regimen for tonsillectomy should include paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra-operative and postoperative acupuncture as well as postoperative honey are also recommended. |
2.2. Arbeitsgemeinschaft Gynäkologische Onkologie 2018 (AGO, Allemagne) Ø
Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Complementary Therapy Survivorship. Arbeitsgemeinschaft Gynäkologische Onkologie (AGO). 2018;:35P. [182073].
| Postoperative: pain relief, anxiety. Acupuncture. Level of evidence : 1b (individual RCT), grade of evidence (B), AGO recommendation grade (+/-) This examination or therapeutic intervention has for the patient no advantage shown. It can be done in individual cases. Based on current knowledge, there is currently no general recommendation to be pronounced. |
2.3. American Pain Society, American Society of Regional Anesthesia and Pain Medicine (USA) 2016 Ø
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, et al. J Pain. 2016. 2016;17(2):131-57. [180924].
| The panel can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments (insufficient evidence). |
2.4. Australian and New Zealand College of Anaesthetists (ANZCA, Autralia- New Zealand) 2015 ⊕
Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anaesthetists. 2015:714P. [196721].
| 5. Acupuncture (S) (Level I), specifically auricular acupuncture (N) (Level I [PRISMA] reduces postoperative pain, opioid requirements as well as opioid-related adverse effects compared to a variety of controls. Beneficial effects of acupuncture on postoperative pain have been confirmed after back surgery and ambulatory knee surgery (N) (Level I [PRISMA]) and total knee joint replacement (N) (Level II). |
2.5. Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou (SFORL, France) 2014 ⊕
Prise en charge de la douleur dans le cadre de l’amygdalectomie chez l’enfant et chez l’adulte Société Française d’Oto-Rhino-Laryngologie et de Chirurgie de la Face et du Cou. 2014. 57P. [167270].
| Recommandation 9. Le groupe de travail recommande de délivrer une information sur les méthodes de prises en charge complémentaires [dont l'acupuncture] lors de la consultation préopératoire (Grade B). |
2.6. Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine [Pédiatrie] (ÖGARI, Autriche) 2014 ⊕
Messerer B, Krauss-Stoisser B, Urlesberger B. [Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz. 2014;28(1):31-42. [170629].
| Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy. |
2.7. U.S. Navy Bureau of Medicine and Surgery (USA) 2013 ⊕
Acupuncture. U.S. Navy Bureau of Medicine and Surgery. 2013.17p. [180539].
| Category A (fair to high quality evidence): Authorized and recommended for routine use. Adult postoperative surgery pain |
2.8. Haute Autorité de Santé (HAS, France) [chirurgie buccale] 2005 Ø
HAS. Prévention et traitement de la douleur postopératoire en chirurgie buccale. Paris: Haute Autorité de Santé (HAS). 2005. Recommandations [169381]. Argumentaire [169360]
| Recommandation: D’autres approches thérapeutiques à visée antalgique postopératoire ont fait l’objet de publications : acupuncture, lasers, morphine locale, cryothérapie et antibiothérapie. Les données de la littérature ne permettent pas de démontrer leur efficacité antalgique en chirurgie buccale. Ces études ne permettent pas de recommander ces approches (accord professionnel) Argumentaire : Les études sur l’acupuncture sont d’interprétation malaisée mais montrent que cette technique retarde légèrement l’apparition de la douleur postopératoire (niveau de preuve 4). |
