Objectives: To review and synthesize the evidence on pain management interventions in nonpathological hip fracture patients following low-energy trauma. Outcomes include pain management (short and long term), mortality, functional status, pain medication use, mental status, health-related quality of life, quality of sleep, ability to participate in rehabilitation, return to pre-fracture living arrangements, health services utilization, and adverse effects.
Data Sources: Comprehensive literature searches were conducted in 25 electronic databases from 1990 to present. Searches of the grey literature, trial registries, and reference lists of previous systematic reviews and included studies were conducted to identify additional studies.
Methods: Study selection, quality assessment, data extraction, and grading of the evidence were conducted independently and in duplicate. Discrepancies were resolved by consensus or third-party adjudication. Meta-analyses were conducted where data were available and deemed appropriate.
Results: In total, 83 studies were included (69 trials, 14 cohort studies). Most participants were females older than 75 with no cognitive impairment. The methodological quality of cohort studies was generally moderate; most trials were at high or unclear risk of bias. Included studies were grouped into eight intervention categories: systemic analgesia, anesthesia, complementary and alternative medicine, multimodal pain management, nerve blocks, neurostimulation, rehabilitation, and traction.
Most studies examined peri- and postoperative pain management, albeit from few perspectives such as reported pain, mortality, and adverse effects. Long-term pain was not reported, and other outcomes were reported infrequently. Nerve blockade was effective for relief of acute pain; however, most studies were limited to either assessing acute pain or use of additional analgesia and did not report on how nerve blockades may affect rehabilitation such as ambulation or mobility if the blockade has both sensory and motor effects. Acupressure, relaxation therapy, and transcutaneous electrical neurostimulation may be associated with potentially clinically meaningful reductions in pain, but further evidence is warranted before any firm conclusions are reached. While the strength of evidence is insufficient to make firm conclusions, postoperative physical therapy may improve pain control, andintravenous parecoxib, a systemic analgesic not available in North America, may be a possible alternative to traditional intramuscular injections of opiates and older nonsteroidal anti-inflammatory drugs (NSAIDs). Preoperative traction and spinal anesthesia (with or without additional agents) did not consistently reduce pain or complications in any demonstrable way compared with standard care. Although most studies reported on adverse effects, they were short term and not adequately powered to identify significant differences.
None of the included studies exclusively examined participants from institutional settings or with cognitive impairment, which reduces the generalizability of results to the overall hip fracture patient population.
Conclusion: For most interventions in this review there were sparse data available, which precludes firm conclusions for any single approach or for the optimal overall pain management following hip fracture.