Systematic review of management of chronic pain after surgery

Abstract

BackgroundPain present for at least 3 months after a surgical procedure is considered chronic postsurgical pain (CPSP) and affects 10–50 per cent of patients. Interventions for CPSP may focus on the underlying condition that indicated surgery, the aetiology of new‐onset pain or be multifactorial in recognition of the diverse causes of this pain. The aim of this systematic review was to identify RCTs of interventions for the management of CPSP, and synthesize data across treatment type to estimate their effectiveness and safety.Methods MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from inception to March 2016. Trials of pain interventions received by patients at 3 months or more after surgery were included. Risk of bias was assessed using the Cochrane risk‐of‐bias tool.ResultsSome 66 trials with data from 3149 participants were included. Most trials included patients with chronic pain after spinal surgery (25 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including antiepileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N‐methyl‐d‐aspartate receptor antagonists and opioids. Other interventions included acupuncture, exercise, postamputation limb liner, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness‐based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta‐analysis were limited by heterogeneity. For all interventions, there was insufficient evidence to draw conclusions on effectiveness.ConclusionThere is a need for more evidence about interventions for CPSP. High‐quality trials of multimodal interventions matched to pain characteristics are needed to provide robust evidence to guide management of CPSP.

Persistent breast pain in post-surgery breast cancer survivors and women with no history of breast surgery or cancer: associations with pain catastrophizing, perceived breast cancer risk, breast cancer worry, and emotional distress

“…However, continued pain at or near the surgical site lasting 3-6 months or longer is considered to be a distinct adverse outcome, which has been defined as 'persistent' or 'chronic' post-surgical pain [1,3]. Chronic or persistent pain is a common problem following a wide range of surgery types and has been found, in both cross-sectional and longitudinal studies, to have substantial negative psychological effects that reduce quality of life [4][5][6][7][8].…”

“…The negative impact of persistent pain following surgical treatment for breast cancer is a particularly important clinical problem because (1) the prevalence of persistent breast pain (PBP) is relatively high compared to other types of surgery [9]; (2) traditional approaches to managing persistent pain (e.g., long term opioids) are increasingly recognized as being ineffective in relieving pain and are accompanied by problematic side effects [5,10]; (3) there are millions of breast cancer survivors around the world [11,12]; and, 4) PBP has substantial negative psychological sequelae [4,11]. In a widely cited nationwide cross-sectional study (n ¼ 3253) from Denmark, 47% of women reported having pain in the surgical area two to three years after undergoing a mastectomy or breast-conserving surgery for primary breast cancer, and 13% reported severe pain [13].…”

Neuromuscular exercise and pain neuroscience education compared with pain neuroscience education alone in patients with chronic pain after primary total knee arthroplasty: study protocol for the NEPNEP randomized controlled trial

“…The aim of this trial is to evaluate the effects of a treatment that could potentially relieve pain and improve physical performance as well as provide education to assist patients in handling their chronic pain and disability. This is of definite importance since no other randomized controlled trial has been conducted regarding exercise as treatment for chronic pain after TKA [12,13]. The trial builds on the presence of sensitization in several studies examining painful knee OA and chronic pain after TKA [7,[43][44][45][46] and evaluates if it is possible to modulate sensitization outcomes by using NEMEX-TJR in combination with PNE.…”

“…For patients suffering from chronic pain after TKA, no such guidelines or standardized treatment regime exist. This is emphasized in two recent systematic reviews, summarizing the evidence regarding the treatment of chronic pain after TKA and reporting the absence of randomized controlled trials evaluating the effects of exercise therapy and other treatments [12,13].…”

Effects of presurgical interventions on chronic pain after total knee replacement: a systematic review and meta-analysis of randomised controlled trials

“…The secondary outcome of this review was adverse events, but reporting was lacking. The poor quality of adverse event reporting in surgical trials is recognised,85 and standardisation is required to improve quality and reduce heterogeneity, particularly in orthopaedics. Although patient reported outcomes are frequently considered to be at high risk of bias, we considered them to be appropriate in this review where questionnaires were completed over 6 months after a presurgical intervention.…”