Scheduled Analgesic Regimen Improves Rehabilitation After Hip Fracture Surgery
Postoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery.
We compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points.
We conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols.
As expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk.
The study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery.
Level of Evidence
Level II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.
- Abou-Setta AM, Beaupre LA, Jones CA, Rashig S, Hamm MP, Sadowski CA, Menon MR, Majumdar SR, Wilson DM, Karkhaneh M, Wong K, Mousavi SS, Tjosvold L, Dryden DM. Comparative Effectiveness Review No. 30. Pain management interventions for hip fracture: executive summary. Agency for Health Care Research and Quality. (Prepared by the University of Alberta Evidence-based under Contract No. 290-02-0023.) AHRQ Publication No. 11-EHC022-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm. Accessed June 14, 2012.
- Archibald G. Patients’ experiences of hip fracture. J Adv Nurs. 2003;44:385–392. CrossRef
- Arinzon Z, Gepstein R, Shabat S, Berner Y. Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool. Disabil Rehabil 2007;29:651–658. CrossRef
- Benaim C, Froger J, Cazottes C, Gueben D. Porte M, Desnuelle C, Pelissier JY. Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain. 2007;128:52–58. CrossRef
- British Orthopaedic Association. The care of patients with fragility fracture. London, UK: British Orthopaedic Association; 2007;1–74.
- Bruckenthal P. Assessment of pain in the elderly adult. Clin Geriatr Med. 2008;24:213–236, v–vi.
- Catananti C, Gambassi G. Pain assessment in the elderly. Surg Oncol. 2010;19:140–148. CrossRef
- Cavalieri TA. Management of pain in older adults. J Am Osteopath Assoc. 2005;105(3 suppl 1):S12–S17.
- Collett B, O’Mahoney S, Schofield P, Closs SJ, Potter J. Guideline Development Group. Clin Med. 2007;7:496–500. CrossRef
- de Morton NA, Berlowitz DJ, Keating JL. A systematic review of mobility instruments and their measurement properties for older acute medical patients. Health Qual Life Outcomes. 2008;6:44. CrossRef
- Dhillon S. Tramadol/paracetamol fixed-dose combination: a review of its use in the management of moderate to severe pain. Clin Drug Investig. 2010;30:711–738. CrossRef
- Dolmatova EV, Imaev AA, Lubnin AY. ‘Scheduled’ dosing of lornoxicam provides analgesia superior to that provided by ‘on request’ dosing following craniotomy. Eur J Anaesthesiol. 2009;26:633–637. CrossRef
- Dromerick AW, Edwards DF, Diringer MN. Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials. J Rehabil Res Dev. 2003;40:1–8. CrossRef
- Drugs.com. Paracetamol. Available at: http://www.drugs.com/search.php?searchterm=paracetamol. Accessed March 7, 2013.
- Drugs.com. Tramadol hydrochloride. Available at: http://www.drugs.com/monograph/tramadol-hydrochloride.html. Accessed March 7, 2013.
- Feldt KS, Oh HL. Pain and hip fracture outcomes for older adults. Orthop Nurs. 2000;19:35–44. CrossRef
- Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain. 2011;152:2399–2404. CrossRef
- Filitz J, Ihmsen H, Gunther W, Troster A, Schwilden H, Schuttler J, Koppert W. Supra-additive effects of tramadol and acetaminophen in a human pain model. Pain. 2008;136:262–270. CrossRef
- Foss NB, Kristensen MT, Palm H, Kehlet H. Postoperative pain after hip fracture is procedure specific. Br J Anaesth. 2009;102:111–116. CrossRef
- Fricke JR Jr, Hewitt DJ, Jordan DM, Fisher A, Rosenthal NR. A double-blind placebo-controlled comparison of tramadol/acetaminophen and tramadol in patients with postoperative dental pain. Pain. 2004;109:250–257. CrossRef
- Glenny C, Stolee P. Comparing the functional independence measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature. BMC Geriatr. 2009;9:52. CrossRef
- Granger CV, Markello SJ, Graham JE, Deutsch A, Reistetter TA, Ottenbacher KJ. The uniform data system for medical rehabilitation: report of patients with lower extremity joint replacement discharged from rehabilitation programs in 2000-2007. Am J Phys Med Rehabil. 2010;89:781–794. CrossRef
- Granger CV, Reistetter TA, Graham JE, Deutsch A, Markello SJ, Niewczyk P, Ottenbacher KJ. The Uniform Data System for Medical Rehabilitation: report of patients with hip fracture discharged from comprehensive medical programs in 2000–2007. Am J Phys Med Rehabil. 2011;90:177–189. CrossRef
- Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin RH, Helme R, Jackson K, Parmelee PA, Rudy TE, Lynn Beattie B, Chibnall JT, Craig KD, Ferrell B, Ferrell B, Fillingim RB, Gagliese L, Gallagher R, Gibson SJ, Harrison EL, Katz B, Keefe FJ, Lieber SJ, Lussier D, Schmader KE, Tait RC, Weiner DK, Williams J. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain. 2007;23(1 suppl):S1–S43. CrossRef
- Handoll HH, Sherrington C, Mak JC. Interventions for improving mobility after hip fracture surgery in adults. Cochrane Database Syst Rev. 2011;3:CD001704.
- Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S. European Palliative Care Research Collaborative (EPCRC). Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage. 2011;41:1073–1093. CrossRef
- Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972;1:233–238. CrossRef
- Jones GR, Miller TA, Petrella RJ. Evaluation of rehabilitation outcomes in older patients with hip fractures. Am J Phys Med Rehabil. 2002;81:489–497. CrossRef
- Kagaya H, Takahashi H, Sugawara K, Dobashi M, Kiyokawa N, Ebina H. Predicting outcomes after hip fracture repair. Am J Phys Med Rehabil. 2005;84:46–51. CrossRef
- Krebs EE, Carey TS, Weinberger M. Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med. 2007;22:1453–1458. CrossRef
- Kunz M, Scharmann S, Hemmeter U, Schepelmann K, Lautenbacher S. The facial expression of pain in patients with dementia. Pain. 2007;133:221–228. CrossRef
- Kuys SS, Brauer SG. Validation and reliability of the modified elderly mobility scale. Australasian Journal on Ageing. 2006;25:140–144. CrossRef
- Li L, Herr K, Chen P. Postoperative pain assessment with three intensity scales in Chinese elders. J Nurs Scholarsh. 2009;41:241–249. CrossRef
- Loggia ML, Juneau M, Catherine Bushnell M. Autonomic responses to heat pain: heart rate, skin conductance, and their relation to verbal ratings and stimulus intensity. Pain. 2011;152:592–598. CrossRef
- Mak JC, Cameron ID, March LM, National Health and Medical Research Council. Evidence-based guidelines for the management of hip fractures in older persons: an update. Med J Aust. 2010;192:37–41.
- McCaffery M, Beebe A. Pain: Clinical Manual for Nursing Practice. Baltimore, MD: CV .Mosby Company; 1993. Available at: http://painconsortium.nih.gov/. Accessed Jan 12, 2013.
- Mehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88:1314–1319. CrossRef
- Miro J, Huguet A. Evaluation of reliability, validity, and preference for a pediatric pain intensity scale: the Catalan version of the faces pain scale—revised. Pain. 2004;111:59–64. CrossRef
- Morrison RS, Flanagan S, Fischberg D, Cintron A, Siu AL. A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery. J Am Geriatr Soc. 2009;57:1–10. CrossRef
- Morrison RS, Magaziner J, McLaughlin MA, Orosz G, Silberzweig SB, Koval KJ, Siu AL. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303–311. CrossRef
- Myles PS, Power I. Clinical update: postoperative analgesia. Lancet. 2007;369:810–812. CrossRef
- Narayan MC. Culture’s effects on pain assessment and management. Am J Nurs. 2010;110:38–47; quiz 48–49.
- Ni Thuathail A, Welford C. Pain assessment tools for older people with cognitive impairment. Nursing Standard. 2011;26:39–46.
- Oldmeadow LB, Edwards ER, Kimmel LA, Kipen E, Robertson VJ, Bailey MJ. No rest for the wounded: early ambulation after hip surgery accelerates recovery. ANZ J Surg. 2006;76:607–611. CrossRef
- Paice JA, Noskin GA, Vanagunas A, Shott S. Efficacy and safety of scheduled dosing of opioid analgesics: a quality improvement study. J Pain. 2005;6:639–643. CrossRef
- Petrie A, Sabin C. Sample size calculations. Medical Statistics at a Glance. Oxford, UK: Blackwell Science; 1993:84–86.
- Pillai Riddell RR, Craig KD. Time-contingent schedules for postoperative analgesia: a review of the literature. J Pain. 2003;4:169–175. CrossRef
- Rhudy JL, Meagher MW. Fear and anxiety: divergent effects on human pain thresholds. Pain. 2000;84:65–75. CrossRef
- Sarasqueta C, Bergareche A, Arce A, Lopez de Munain A, Poza JJ, De La Puente E, Urtasun M, Emparanza JE, Marti Masso JF. The validity of Hodkinson’s Abbreviated Mental Test for dementia screening in Guipuzcoa, Spain. Eur J Neurol. 2001;8:435–440. CrossRef
- Scherder E, Herr K, Pickering G, Gibson S, Benedetti F, Lautenbacher S. Pain in dementia. Pain. 2009;145:276–278. CrossRef
- Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people. Available at: http://www.sign.ac.uk/guidelines/fulltext/111/index.html. Accessed February 8, 2013.
- Senior Health 365. Elderly mobility scale for frail elderly patients. Available at: http://www.seniorhealth365.com/2012/01/12/elderly-mobility-scale-for-frail-elderly-patients/. Accessed June 19, 2012.
- Siu AL, Penrod JD, Boockvar KS, Koval K, Strauss E, Morrison RS. Early ambulation after hip fracture: effects on function and mortality. Arch Intern Med. 2006;166:766–771. CrossRef
- Sun V, Borneman T, Piper B, Koczywas M, Ferrell B. Barriers to pain assessment and management in cancer survivorship. J Cancer Surv. 2008;2:65–71. CrossRef
- Sutters KA, Miaskowski C, Holdridge-Zeuner D,Waite S, Paul SM, Savedra MC, Lanier B, Mahoney K. A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children following tonsillectomy. Clin J Pain. 2010;26(2):95–103. CrossRef
- Tarazona-Santabalbina FJ, Belenguer-Varea A, Rovira-Daudi E, Salcedo-Mahiques E, Cuesta-Peredo D, Domenech-Pascual JR, Salvador-Perez MI, Avellana-Zaragoza JA. Early interdisciplinary hospital intervention for elderly patients with hip fractures: functional outcome and mortality. Clinics (Sao Paulo). 2012;67:547–555. CrossRef
- Ullrich C, Wolfe J. Paediatric pain and symptom control. In: Walsh D, Caraceni AT, Fainsinger R, Foley K, eds. Palliative Medicine. Philadelphia, PA: Elsevier; 2009:1096–1105.
- Von Baeyer CL.Numerical rating scale for self-report of pain intensity in children and adolescents: recent progress and further questions. Eur J Pain. 2009;13:1005–1007. CrossRef
- Von Korff M, Merrill JO, Rutter CM, Sullivan M, Campbell CI, Weisner C. Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy. Pain. 2011;152:1256–1262. CrossRef
- Wikipedia. Paracetamol. Available at: http://en.wikipedia.org/wiki/Paracetamol. Accessed January 15, 2013.
- Wikipedia. Tramadol hydrochloride. Available at: http://en.wikipedia.org/wiki/Tramadol_hydrochloride. Accessed January 15, 2013.
- Williams CS, Tinetti ME, Kasl SV, Peduzzi PN. The role of pain in the recovery of instrumental and social functioning after hip fracture. J Aging Health. 2006;18:743–762. CrossRef
- Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14:798–804. CrossRef
- Wong NM, Cheung WL, Ng CK, Wong KK, Lau SW, Hung T. A new multi-disciplinary rehabilitation outcome checklist for the rehabilitation of total knee and total hip replacement patients. J Orthop Trauma Rehabil. Epub 28 May 2012.
- Wong-Baker Faces Foundation. Instruction guide for using the Wong-Baker Faces Pain Rating Scale. Available at: http://www.wongbakerfaces.org/. Accessed January 12, 2013.
- Wylde V, Rooker J, Halliday L, Blom A. Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep. Orthop Traumatol Surg Res. 2011;97:139–144. CrossRef
- Yilmaz U, Liu YW, Berger RE, Yang CC. Autonomic nervous system changes in men with chronic pelvic pain syndrome. J Urol. 2007;177:2170–2174; discussion 2174. CrossRef
- Young Y, Fan MY, Hebel JR, Boult C. Concurrent validity of administering the functional independence measure (FIM) instrument by interview. Am J Phys Med Rehabil. 2009;88:766–770. CrossRef
- Yu MS, Chan CC, Tsim RK. Usefulness of the Elderly Mobility Scale for classifying residential placements. Clin Rehabil. 2007;21:1114–1120. CrossRef
- Zabari A, Lubart E, Ganz FD, Leibovitz A. The effect of a pain management program on the rehabilitation of elderly patients following hip fracture surgery. Isr Med Assoc J. 2012;14:104–106.
- Scheduled Analgesic Regimen Improves Rehabilitation After Hip Fracture Surgery
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- 1. Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Hospital Authority, 3/Floor, M Block, 30 Gascoigne Road, Jordon, Kowloon, Hong Kong, China
- 2. Orthopaedic Rehabilitation Centre, Kowloon Hospital, Hospital Authority, Hong Kong, China