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Pain Treatment - Guidelines Descriptions
 The following guidelines are organized by year of publication (descending order) within logical clinical categories. A guideline will be replaced when it is reviewed and updated, or it will be removed when the sponsoring organization determines that the content is outdated.
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Document Researchers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD
 Guidelines marked with this symbol are from external sources that are not in accord with the published Pain Treatment Topics Open Access Policy and require purchase from the publisher to view the full documents. In most cases, an abstract or a summary may be viewed at no charge.
 = entry added or changed during latest update.
CONTENTS
General Pain & Safety Topics
Guidelines on Pain Management
Access: http://www.uroweb.org/fileadmin/tx_eauguidelines/2009/Full/Pain_Mngt.pdf
Source: European Association of Urology
Date: 2009
Description: This
revised 2009 guideline differs from an older, 2003, version in several ways. In a new discussion of pain assessment, more emphasis is placed on the evaluation of the patient's overall quality of life, and summaries are provided for neuropathic pain processes (central and peripheral). Evidence-based cancer pain treatment recommendations for non-pharmacologic modalities (including radiotherapy and physical therapies) and pharmacotherapy (including options for neuropathic pain relief) have both been expanded. The sections on pain management in male and female urological cancers include more options for the treatment of pain due to metastases. One important strength of the guideline is the thorough description of the pathophysiology of pain as it relates to the male and female urogenital systems. Opioid recommendations include information on dosing, routes of administration and the management of adverse effects. Presentations of evidence-based contraindications and cautions are specific to each relevant therapy. 84 Pages. Access checked April 13, 2009.
Use of Nonsteroidal Antiinflammatory Drugs. An Update for Clinicians. A Scientific Statement From the American Heart Association
Access: http://www.circ.ahajournals.org/cgi/reprint/115/12/1634
Source: American Heart Association (AHA)
Date: 2007
Print Reference: Antman EM, Bennett JS, Daugherty A, et al. Use of nonsteroidal antiinflammatory drugs. An update for clinicians. A scientific statement from the American Heart Association. Circulation. 2007(Mar);115(12):1634-1642.
Description: These guidelines were developed to update clinicians on the AHA recommendations for the selection of nonsteroidal anti-inflammatory drugs (NSAIDs) for patients with existing cardiovascular disease or risk. Growing evidence demonstrating an increased risk of cardiovascular events with the use of NSAIDs has led to confusion about the selection of analgesic medications for pain relief. This scientific statement summarizes the trials that reported cardiovascular events in patients who took analgesic drugs that inhibit COX enzymes. The recommendations for pain management include a stepped approach beginning with nonpharmacologic interventions and continuing with appropriate drug therapy that is based on an individual risk-benefit analysis for each patient. 9 Pages. Access checked April 14, 2009.
Nursing Best Practice Guideline: Assessment and Management of Pain
Access: http://rnao.ca/sites/rnao-ca/files/Assessment_and_Management_of_Pain.pdf
Source: Registered Nurses Association of Ontario
Date: 2002, includes year 2007 revisions
Description: Recommendations for best nursing practices are presented as evidence-based guidelines for registered nurses and registered practical nurses. Seventy-nine recommendations are made for assessment (including documentation), healthcare organization policies, and pharmacological treatment. An appendix includes assessment tools, an analgesic ladder, sample subcutaneous injection protocol, and non-pharmacological interventions. This document includes the original guideline as well as a supplement that includes guidance refinements based on practice evidence published between the years 2002 and 2007. 174 Pages. Access checked June 21, 2012.
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Acute Pain
APS 2005 Recommendations for Improving the Quality of Acute and Cancer Pain Management
Access: http://www.ampainsoc.org/pub/bulletin/fal05/inno1.htm
Source: American Pain Society
Date: 2005 (Revision and expansion of the 1995 Quality Improvement Guidelines)
Print Reference: Gordon DB, Dahl JL, Miaskowski C, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Internal Med. 2005(Jul);165(14):1574-1580.
Description: Based on expert consensus and a systematic review of the literature on quality improvement in pain management, recommendations were made to improve the quality of pain management in all care settings. Recent knowledge in pain management led to the design and testing of new ways for communication and treatment continuity across care environments. Quality improvement recommendations are available at no charge by calling APS at (847) 375-4715 or writing info@ampainsoc.org. 7 Pages. Access checked April 14, 2009.
Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease
Access: http://www.ampainsoc.org/pub/sc.htm
Source: American Pain Society
Date: 2000
Description: An overview of sickle cell disease and the associated pain experience is described in this guideline. The pain assessment section includes a discussion of acute and chronic pain in the developmental stages of sickle cell disease. Pain management recommendations are multi-disciplined in approach and cover pharmacologic and nonpharmacologic therapies. Available for purchase only through the website (click on the APS Online Store); members $10, non-members $15. 60 Pages. Access checked April 14, 2009.
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Cancer Pain
 Adult Cancer Pain
Access: http://www.nccn.org/professionals/physician_gls/PDF/pain.pdf
NOTE: Access is free after completing brief registration through 'User Login' section on this page.
Source: National Comprehensive Cancer Network
Date: 2012
Description: This NCCN guideline is presented in a concise, easy-to-use format that includes algorithms for assessment, follow-up, and decisions related to referral for interventional therapies. Prescribing and titration tables for opioids, non-opioid dosing, and a guide for the management of opioid adverse effects are all summarized in an at-a-glance format. Recommendations for the appropriate use of adjuvant analgesics in the management of cancer pain include examples with dosing instructions. Some guidance is offered for specific pain problems, referrals for complementary therapy, and patient education. 70 Pages. Access checked January 7, 2013.
Management of Cancer Pain: ESMO Clinical Practice Guidelines
Access: http://annonc.oxfordjournals.org/content/23/suppl_7/vii139.full.pdf+html
Source: European Society for Medical Oncology
Date: 2012
Print Reference: Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F, on behalf of the ESMO Guidelines Working Group. Annals of Oncology. (Oct 2012);23(Suppl 7):vii139-vii154.
Description: This guideline emphasizes the need for thorough initial patient assessment, as well as regular follow-up evaluations due to the potential for dynamic and changing patient needs in cancer pain management. The World Health Organization (WHO) pain management guidelines are reviewed and a discussion, with supporting literature, includes the recent controversial aspects of the WHO analgesic ladder. Comparison tables for mild to strong analgesic drugs include a listing of individual agents with information on dosing levels and length of analgesic effect. The recommendations include the evidence for pain relief in patients with metastatic bone pain, resistant neuropathic pain, and end-of-life refractory pain. Access checked November 29, 2012.
Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain
Access: http://www.painphysicianjournal.com/2011/may/2011;14;E283-E312.pdf
Date: 2011
Print Reference: Deer TR, Smith HS, Burton AW, et al. Comprehensive Consensus Based Guidelines on Intrathecal Drug Delivery Systems in the Treatment of Pain Caused by Cancer Pain. Pain Physician (May-Jun 2011);14(3):E283-E312.
Description: Chronic pain—common in cancer patients—may be the result of the disease process or necessary treatment. Long-term management of intractable cancer pain using an invasive alternative may be an appropriate option for select patients whose pain is unrelieved by standard pain management therapies. This 30-page evidence-based consensus guideline begins with a discussion of the differences between cancer-related pain and other causes of chronic persistent pain. The guideline provides a wealth of practical information including drug administration concerns, cautions on known equipment failures, and cost considerations. To achieve successful therapeutic outcomes and maximize safety, the authors explain the need for a full and multifaceted patient evaluation—including physical, psychological, and social concerns—before initiating intrathecal drug treatment. Additional features of this guideline include a summary of the evidence and recommendations from other relevant guidelines, techniques for a pre-implant trial, and a table containing key considerations for patient selection. Access checked November 30, 2011.
Management of Cancer Pain
Access: http://annonc.oxfordjournals.org/cgi/reprint/19/suppl_2/ii119
Source: European Society for Medical Oncology
Date: 2008
Print Reference: Jost L, Roila F. Management of cancer pain. ESMO clinical recommendations. Annals of Oncology. 2008;19(Suppl. 2):ii119-ii121.
Description: This easy-to-read guideline addresses the basic management of cancer pain using the step-wise escalation approach of the World Health Organization (WHO). Route and administration (including scheduling and dosing) guidelines are provided; the management of adverse effects is discussed briefly. A table of selected co-analgesics contains dosing ranges and information on formulation strength. 3 Pages. Access checked April 14, 2009.
Intrathecal Drug Delivery for the Management of Cancer Pain: A Multidisciplinary Consensus of Best Clinical Practices
Access: http://jso.imng.com/jso/journal/articles/0306399.pdf
Source: Multidisciplinary workshop; unrestricted grant to Valley Cancer Pain Foundation
Date: 2005
Print Reference: Stearns L, Boortz-Marx R, DuPen S, et al. Intrathecal drug delivery for the management of cancer pain. A multidisciplinary consensus of best clinical practices. J Support Oncol. 2005(Nov-Dec);3(6):399-408.
Description: The management of cancer pain often requires an interdisciplinary approach, and intrathecal delivery is a rapid method of treating intractable pain that can be used concurrently during radiology treatment or a chemotherapy regimen. It can provide effective pain management for patients who cannot tolerate oral medications, those with complex pain syndromes or opioid intolerance concerns. The guidelines include dosing and titration recommendations and algorithms for short-term and long-term cancer survivors. 10 Pages. Access checked March 6, 2012.
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Cardiac & Chest Pain
2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST- Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)
Access Update: http://circ.ahajournals.org/content/126/7/875
Access Full 2007 Guideline: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.181940
Source: American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Date: Update 2012, Full Guideline 2007 (Originally published in 2000)
Description: These guidelines focus on 2 components of acute coronary syndrome, a life-threatening disorder that frequently requires emergency medical care. Pathophysiology, presentation, assessment, and risk stratification are examined in the first two sections; hospital care (early and late), coronary revascularization, and the management of special populations are covered in the last 4 sections. Based on clinical trial results through October 2011, the update focuses on 4 important areas in the management of unstable angina (UA) / non-ST-elevation myocardial infarction (NSTEMI) patients. The practice areas are: 1) the timing of acute interventional therapy, 2) the timing and administration of antiplatelet therapy, 3) therapy considerations in patients with advanced renal dysfunction, and 4) the importance of participation in quality-of-care data registries. Update - 60 pages, 2007 guideline - 157 pages. Access checked October 31, 2012.
Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS)
Access: https://www.icsi.org/_asset/ydv4b3/ACS-Interactive1112b.pdf
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: November 2012
Description: Timely treatment is crucial to the success of emergency intervention for patients with high-risk chest pain. Seven clinical algorithms are presented: chest pain screening, emergency intervention, ST-segment elevation myocardial infarction (STEMI), acute myocardial infarction complications, special work-up for chest pain unrelated to coronary artery disease, non-cardiac causes, and clinic evaluation. Algorithm annotations include detailed risk assessment information on the significance of the timing of chest pain symptoms that are suggestive of immediate adverse outcomes. 92 Pages. Access checked April 24, 2013.
Management of Cocaine-Associated Chest Pain and Myocardial Infarction. A Scientific Statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology
Access: http://circ.ahajournals.org/cgi/reprint/117/14/1897
Source: American Heart Association (AHA)
Date: 2008
Print Reference: McCord J, Jneid H, Hollander JE, et al. Circulation. 2008(Apr 8);117(14):1897-1907.
Description: Symptoms of cocaine use can mimic those of myocardial infarction (MI) and 2 treatments typically used to treat an MI can be dangerous to cocaine users. Following a critical analysis of existing literature, the AHA developed recommendations for diagnostic evaluation and treatment by levels-of-evidence. The guidelines recommend early identification of cocaine use by self-report or by laboratory testing. While research showed that only 1% to 6% of patients with cocaine-associated chest pain actually had an MI, there are several important reasons for early identification of cocaine use. Access checked April 14, 2009.
ACC/AHA 2007 Focused Update and 2002 Guidelines for the Management of Patients With Chronic Stable Angina (with correction)
Access: http://circ.ahajournals.org/content/116/23/2762.full.pdf+html
Source: American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Date: 2007 Update of the 2002 Guideline (Originally published in 1999); including correction.
Description: The most common manifestation of ischemic heart disease is chronic stable angina. Considering the high rates of morbidity and mortality, the aim of the ACC/AHA Task Force was to improve patient outcomes and use the most effective strategies to reduce the overall cost of care. These guidelines use 3 classifications for levels of evidence in the recommendations presented in all 4 sections: diagnosis, risk stratification, treatment, and patient follow-up. Three algorithms for management are presented: clinical assessment, stress testing/angiography, and treatment. A treatment mnemonic highlights the 10 treatment components that the Task Force identified as most important. Access checked February 5, 2013.
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Chronic & Intractable Pain (including CRPS/RSD)
Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines
Access: http://www.rsds.org/pdfsall/CRPS-guidlines-4th-ed-2013-PM.pdf
Source: Reflex Sympathetic Dystrophy Syndrome Association
Date: 4th Edition; 2013
Print Reference: Harden RN, Oaklander AL, Burton AW, et al. Pain Medicine. 2013(Feb);14(2):180-229.
Description: Complex Regional Pain Syndrome (CRPS), formerly called Reflex Sympathetic Dystropy, is challenging to diagnose and treat. This 4th edition guideline presents a history of the challenges involved in the validation of existing diagnostic criteria. The authors provide a summary of their literature research review for this guideline update and report a disappointing number of low quality studies. They further explain that, while their goal was to provide clinicians with the best available practice evidence, this guideline includes some less rigorous preliminary research results to give practitioners the benefit of the most comprehensive set of treatment options. The section that focuses on an interdisciplinary approach to CRPS therapy emphasizes the need to improve patient functionality by aggressively managing pain, motor dysfunction, edema, psychological issues, and other symptoms. The history, principles, and therapeutic strategies for functional restoration are explored in detail. Treatment algorithms and recommendations for an evidence-based approach to pharmacology and interventional therapy are presented; physical therapy and psychological interventions are examined as crucial components of the overall treatment program. 50 Pages. Access checked May 21, 2013.
Treatment Improvement Protocol (TIP 54): Managing Chronic Pain in Adults With or In Recovery From Substance Use Disorders
Access: http://www.ncbi.nlm.nih.gov/books/NBK92048/pdf/TOC.pdf
Source: Substance Abuse and Mental Health Services Administration (SAMHSA)
Date: 2012
Description: This expert consensus document provides evidence-based guidance for healthcare providers treating chronic pain in adults with a past or current history of substance-use disorder. The section on performing a comprehensive patient evaluation includes definitions and an explanation of DSM criteria, plus tools for pain assessment, opioid risk screening, and emotional assessment. Treatment recommendations consider the importance of addressing psychiatric comorbidities, strategies for opioid selection and dosing in this population, and patient counseling. Access checked November 9, 2012.
 Also see discussion of this document’s limitations at the Pain-Topics UPDATE [click here].
Assessment and Management of Chronic Pain
Access: https://www.icsi.org/_asset/bw798b/ChronicPain-Interactive1111.pdf
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: November 2011
Description: This ICSI guideline aims to improve the effectiveness of chronic pain treatment and resulting physical functionality by using a biopsychosocial model and a multi-specialty team approach. Assessment and management algorithms are presented; patient questionnaires, agreements, and a pain inventory are also included. To learn more about ICSI or to order a printed copy ($10), visit www.icsi.org. 113 Pages. Access checked April 24, 2013.
Consensus Guidelines for the Selection and Implantation of Patients with Noncancer Pain for Intrathecal Drug Delivery
Access: http://www.rsds.org/2/library/article_archive/pop/Deer_PainPhysician_2010.pdf
Date: 2010
Print Reference: Deer TR, Smith HS, Cousins M, et al. Consensus Guidelines for the Selection and Implantation of Patients With Noncancer Pain for Intrathecal Drug Delivery. Pain Physician. 2010(May-Jun);13(3):E175-E213.
Description: Long-term management of intractable noncancer pain using an invasive alternative may be an appropriate option for select patients whose pain is unrelieved by standard pain management therapies. This 40-page evidence-based consensus guideline is rich with practical information including drug administration concerns, cautions on known equipment failures, and cost considerations. To achieve successful therapeutic outcomes, minimize treatment failure, and maximize safety, the authors explain the need for a full and multifaceted patient evaluation — including physical, psychological, and social concerns — before initiating intrathecal drug treatment. Additional features of this guideline include a summary of the evidence and recommendations from other relevant guidelines and a table listing key considerations for patient selection. Access checked March 28, 2011.
Evidence Based Guidelines for Complex Regional Pain Syndrome Type 1
Access: http://www.rsds.org/2/library/article_archive/pop/Perez_Zollinger_BMCNeurol_2010.pdf
Date: 2010
Print Reference: Perez RS, Zollinger PE, Dijkstra PU, et al. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurology. 2010;10(20).
Description: A multidisciplinary task force graded literature evaluating treatment effects for CRPS-1 — formerly known as reflex sympathetic dystrophy (RSD) — according to their strength of evidence. Based on the findings treatment recommendations were formulated and approved for general pain treatment, neuropathic pain, inflammatory symptoms, promoting peripheral blood flow, and decreasing functional limitations. The prevention of primary and secondary CRPS-1 also is discussed. Access checked May 29, 2010.
Practice Guidelines for Chronic Pain Management [ASA/ASRA]
Access: http://journals.lww.com/anesthesiology/...13.aspx (PDF version also available at this site)
Source: American Society of Anesthesiologists (ASA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA).
Date: 2010 (April)
Print Reference: Rosenquist RW, Benzon HT, Connis RT, et al. Practice Guidelines for Chronic Pain Management. Anesthesiology. 2010;112(4):810-833.
Description: These new recommendations, an evidence-based update of guidelines published by ASA/ASRA more than a decade ago, are designed to help all clinicians who treat chronic pain. Topics apply to patients with chronic noncancer, neuropathic, somatic, or visceral pain. A diversity of modalities are addressed, such as the latest advances in interventional and surgical procedures, medication management, and the full range of adjunctive or alternative therapies. Access checked April 3, 2010.
Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome Clinical Practice Guidelines, 3rd Edition
Access: http://rsdfoundation.org/en/en_clinical_practice_guidelines.html
Source: International Research Foundation for RSD/CRPS
Date: 2003 (Updated January, 2009)
Description: Reflex Sympathetic Dystrophy Syndrome (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a multi-symptom, multi-system, syndrome usually affecting one or more extremities, and continues to be poorly understood. This guideline covers the clinical features of RSD/CRPS and important diagnostic strategies. A comprehensive treatment protocol is defined and video presentations on sympathetic lumbar nerve block techniques are included. Additionally, a video on sympathetic nerve blocks in children has been added since the last update. 26 Pages. Access checked April 14, 2009.
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Geriatric Pain
Pharmacological Management of Persistent Pain in Older Persons
Access: http://www.americangeriatrics.org/.../clinical_practice/clinical_guidelines_recommendations/2009/
Source: American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons.
Date: 2009
Print Reference: AGS Panel on Persistent Pain in Older Persons. Pharmacological Management of Persistent Pain
in Older Persons. American Geriatrics Society. J Am Geriatr Soc. 2009 [in press].
Description: This AGS guideline on the pharmacological management of persistent pain in older adults replaces the 2002 edition. Based on more recent studies that show increased cardiovascular risk and gastrointestinal toxicity with the use of NSAIDs or COX-2 inhibitors, it is important to note that this guideline has nearly eliminated any recommendation of these agents in this population. Overall, 27 recommendations are presented for managing persistent pain in patients 75-years and older who have a tendency to be more frail and suffer from multiple chronic illnesses. The panel also recommends opioid therapy for elderly patients with moderate-to-severe pain or diminished quality of life due to pain. Adequate management of pain could reduce unwanted adverse outcomes like falls, sleep disruption, depression, and anxiety. A brief discussion on the use of newer adjuvant drugs and topical analgesics is also presented. Access checked May 21, 2010.
Clinical Practice Guideline: Pain Management in the Long Term Care Setting
Access: http://www.amda.com/tools/cpg/chronicpain.cfm
Source: American Medical Directors Association
Date: 2009 (Originally published in 1999, updated/revised in 2009)
Description: This guideline examines barriers to effective pain management as well as acute pain management in response to the Centers for Medicare & Medicaid Services (CMS) quality initiative measure for pain. The challenges of recognizing pain in the cognitively impaired, pain management in palliative care, and alternative therapies are also described. Available for purchase only; members $20, non-members $30. 31 Pages. Access checked April 10, 2009.
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Gynecological or Obstetrical Pain
Guidelines for the Management of Vulvodynia
Access: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.2010.09684.x/pdf
Source: British Society for the Study of Vulval Disease Guideline Group
Date: 2010
Print Reference: Mandal D, Nunns D, Byrne M, et al. Guidelines for the Management of Vulvodynia. British Journal of Dermatology. (Jun 2010);162(6):1180-1185.
Description: Vulvodynia, a chronic pain syndrome commonly characterized by burning pain, can have a physical, psychological, and social impact on the patient. This guideline includes 12 evidence-based recommendations to aid the diagnosis and management of this condition. A multidisciplinary approach to evaluation and therapy includes recommendations ranging from topical or systemic drug therapy to non-pharmacologic and complementary approaches. Access checked April 6, 2011.
European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain
Access: http://www.backpaineurope.org/web/files/586_2008_602_OnlinePDF.pdf
Source: Working Group 4 of the European Commission Research Directorate General
Date: 2008
Print Reference: Vleeming A, Albert HB, Ostgaard HC, et al. European Spine Journal. 2008(Feb 8); Early online publication prior to print.
Description: This guideline was developed following an evaluation of evidence-based literature and the creation of a grading system for recommendations on the diagnosis and treatment of patients with pelvic girdle pain (PGP). Working Group 4 concluded that PGP is a form of low back pain that can occur with or without low back pain. Factors that influence and those that appear not to influence risk are listed and explained. Treatment recommendations include medication use for nonpregnant women, education and reassurance, individualized exercises, and multidisciplined therapy. Access checked April 14, 2009.
Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.
Access: http://www.asahq.org/For-Members/Practice-Management/.../ObstetricAnesthesia.ashx
Source: American Society of Anesthesiologists (ASA)
Date: 2007
Print Reference: Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007(Apr);106(4):843-863.
Description: The ASA Task Force reviewed evidence-based literature and invited the opinions of a panel of consultants and practitioners to develop an update to guidelines that were originally adopted in 1998. The update provides expanded recommendations for pain management during labor, operative and non-operative deliveries, and the postpartum period. The revised guidelines include the recommendation that the level of care and equipment available to patients in the main operating room also be provided to all obstetric patients. Each recommendation is supported by a strength-of-evidence evaluation and the appendix to the guideline includes a meta-analysis summary. Text version: 52 Pages. Access checked April 14, 2009.
Consensus Guidelines for the Management of Chronic Pelvic Pain - Part One and Part Two
Access: Part One: http://www.sogc.org/guidelines/public/164E-CPG1-August2005.pdft
Access: Part Two: http://www.sogc.org/guidelines/public/164E-CPG2-September2005.pdf
Source: Chronic Pelvic Pain Working Group, Society of Obstetricians and Gynaecologists of Canada
Date: 2005
Print Reference: Part One: Jarrell JF, Vilos GA, Abu-Rafea B, et al. Chronic Pelvic Pain Committee. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005(Aug);27(8):781-826.
Print Reference: Part Two: Jarrell JF, Vilos GA, Abu-Rafea B, et al. Chronic Pelvic Pain Committee. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005(Sep);27(9):869-887.
Description: Part one contains 6 chapters which address individual aspects of chronic pelvic pain. Physiology, etiology, assessment, and laparoscopic investigations are examined in the first 4 chapters; specific gynecological, urological and gastrointestinal conditions are explored in chapters 5 and 6 (21 Pages). Part two contains 8 chapters covering myofascial dysfunction plus recommendations for medical, surgical and complementary/alternative interventions for the management of chronic pelvic pain (19 Pages). Access checked April 14, 2009.
The Initial Management of Chronic Pelvic Pain
Access: http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT41InitialManagementChronicPelvicPain2005.pdf
Source: Royal College of Obstetricians and Gynaecologists
Date: 2005
Description: Because chronic pelvic pain is a symptom, not a diagnosis, this guideline stresses the importance of a comprehensive history and assessment that include psychological and social considerations. Diagnostic imaging and laparoscopy are recommended according to levels of evidence. A flowchart summarizes management and referral of chronic pelvic pain patients. 12 Pages. Access checked April 14, 2009.
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Headache
Health Care Guideline: Diagnosis and Treatment of Headache
Access:
https://www.icsi.org/_asset/qwrznq/Headache.pdf
NOTE: Adobe Reader Ver 7.0 or higher is required to access this file.
Source: Institute for Clinical Systems Improvement (ICSI)
Date: 2013
Description: This guideline emphasizes appropriate assessment and provides a thorough analytical framework that includes 10 algorithms for the diagnosis and treatment of headache. A drug table with a discussion of treatment considerations for the female population is provided. The authors include a presentation of the warning signs of potential disorders other than primary headache. To learn more about ICSI or to order a printed copy ($10), visit www.icsi.org. 91 Pages. Access checked April 4, 2013.
Evidence-Based Guideline Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.
Access: http://www.neurology.org/content/78/17/1337.full.pdf+html
Source: American Academy of Neurology; American Headache Society
Date: 2012
Print Reference: Silberstein SD, Holland S, Freitag F, et al. Neurology. 2012(Apr 24);78(17):1337-1345.
Description: Using published clinical evidence from 1999 to 2009, this guideline provides standard pharmacologic recommendations for migraine prevention. The results report Level A evidence for 6 drugs that can be used to reduce the frequency and severity of migraine attacks. In addition, one drug has been shown to reduce the incidence of menstrual migraine. A discussion includes the rationale for the exclusion or lack of recommendation for other drugs sometimes used in migraine prevention. 10 pages. Also see the guideline below. Access checked May 3, 2012.
Evidence-Based Guideline Update: NSAIDs and Other Complementary Treatments for Episodic Migraine Prevention in Adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society.
Access: http://www.neurology.org/content/78/17/1346.full.pdf+html
Update Summary (table format, listed by product and evidence): http://www.aan.com/.../uploads/538.pdf
Source: American Academy of Neurology; American Headache Society
Date: 2012
Print Reference: Holland S, Silberstein SD, Freitag F, et al. Neurology. 2012(Apr 24);78(17):1346-1353.
Description: This guideline reviews the efficacy and safety results of recently published studies that evaluated anti-inflammatory, complementary, and non-traditional therapies in the prevention of migraine attacks. Each product includes a discussion of the analysis of the evidence, including any special considerations regarding dosing or adverse effects. Petasites (butterbur) is the only product that shows Level A evidence for the reduction in frequency and severity of migraine attacks. Study evaluations support a total of 9 NSAIDs and complementary products as qualifying for Level B evidence for efficacy in migraine prevention. 9 pages. Also see the guideline above. Access checked May 3, 2012.
EFNS Guideline on the Drug Treatment of Migraine – Revised Report of an EFNS Task Force
Access: https://www.efns.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2009...pdf
Source: European Federation of Neurological Societies
Date: 2009
Print Reference: Evers S, Afra J, Frese A, et al. EFNS guidelines on the drug treatment of migraine—revised report of an EFNS task force. Eur J Neurol. 2009(Sep);16(9):968-981.
Description: This revised guideline provides evidence-based drug therapy recommendations for the treatment of acute migraine attacks as well as prophylactic management. Based on the evidence of existing studies and the consensus of an expert panel, recommendations follow the concept of stratified treatment and provide guidance for the treatment of moderate to very severe attacks. A section on triptans discusses individual drug differences in efficacy, time to onset, and adverse effects or cautions. 14 Pages. Access checked October 13, 2009.
Standards of Care for Headache Diagnosis and Treatment
Access: (NHF summary) http://www.headaches.org/Standards...Headache_DiagnosisTreatment
Source: National Headache Foundation (NHF)
Date: 2008
Description: This expanded edition includes a wealth of information on assessment and therapy for all primary headache types as well as secondary causes of chronic daily headache. Additional chapters on pediatric headache, alternative therapy, and patient education provide comprehensive coverage of headache disorders. The authors also discuss specific issues such as the importance of selecting drugs for acute treatment while considering the risk of complicating the chronic treatment regimen. A print copy of the 181-page book Standards of Care for Headache Diagnosis and Treatment is available to healthcare practitioners for $12 from the NHF by calling 888-NHF-5552. The link above provides a 4-page abbreviated version. Access checked March 19, 2010.
Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache
Access: http://217.174.249.183/upload/NS_BASH/2010_BASH_Guidelines.pdf
Source: British Association for the Study of Headache
Date: 2010; Third Edition (1st Revision)
Description: The evidence for improved outcomes in headache management was evaluated and guidelines were developed by a team of headache specialists, members of the British Association for the Study of Headache and the Association of British Neurologists. These guidelines utilize the headache criteria of the 2003 International Class of Headache Disorders (ICHD-II) and address all forms of headache diagnosis and management. In addition to migraine, tension-type headache, cluster headache, and multiple coexistent headache disorders, recommendations are also included for medication overuse headache. A brief 6-part history questionnaire is included as a tool for diagnosis. 52 Pages. Access checked December 13, 2010.
EFNS Guidelines on the Treatment of Cluster Headache and Other Trigeminal-Autonomic Cephalalgias
Access:http://www.efns.org/...2006_cluster_headache_and_other_trigeminal_autonomic.pdf
Source: European Federation of Neurological Societies
Date: 2006
Print Reference: May A, Leone M, Afra J, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol. 2006(Oct);13(10):1066-1077.
Description: This guideline begins with a description of each headache disorder using the International Headache Society’s diagnostic criteria. Cluster headache, paroxysmal hemicrania, and SUNCT syndrome are addressed individually. Following an extensive literature review and expert consensus, three grades of evidence-based recommendations for the treatment of these specific headache disorders are made; practice pointers for dosing and length of treatment are included. Guidelines are provided for prophylactic therapy as well as for the treatment of the acute cluster headache attack. 12 Pages. Access checked April 14, 2009.
The International Classification of Headache Disorders, 2nd Edition
Access: Web-based edition at http://ihs-classification.org/en/
Source: International Headache Society (IHS)
Date: regularly updated
Print Reference: Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, Second Edition, first revision. (May) 2005.
Description: This edition replaces the original International Classification of Headache Disorders published in 1988 and was developed for research and clinical practice alike. Many sources of evidence were used to update the classification, including epidemiological studies and longitudinal studies that focused on diagnostic and treatment results. Additions to this version include a new classification for ‘Chronic Migraine’, as well as a chapter that looks at the small field of research on headaches that can be attributed to psychiatric disorders. 232 Pages. Access checked December 13, 2010.
2006 Report: New Appendix Criteria Open for a Broader Concept of Chronic Migraine. Following the release of the 2004 revised classification above, the Headache Classification Committee of the IHS expanded the ‘Chronic Migraine’ category in response to additional clinical evidence that the existing category included very few patients. In addition, the ‘Medication Overuse Headache’ category has been redefined. The abstract is available at: http://dx.doi.org/10.1111/j.1468-2982.2006.01172.x Access checked April 14, 2009.
Print Reference: Headache Classification Committee of the International Headache Society. New appendix criteria open for a broader concept of chronic migraine. Cephalalgia. 2006(Jun);26(6):742-746.
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Musculoskeletal Pain (incl: Back Pain, Arthritis, Fibromyalgia, Gout)
2012 ACR Guidelines for Management of Gout
Part 1: Nonpharmacologic and Pharmacologic Therapy for Hyperuricemia
Part 2: Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis
Access: Parts 1 and 2: http://www.rheumatology.org/practice/clinical/guidelines/gout.asp
Source: American College of Rheumatology (ACR)
Date: 2012
Print Reference Part 1: Khanna D, Fitzgerald JD, Khanna PP, et al. Arthritis Care & Research. 2012(Oct);64(10)1431-1446.
Print Reference Part 2: Khanna D, Khanna PP, Fitzgerald JD, et al. Arthritis Care & Research. 2012(Oct);64(10)1447-1461.
Description: These new guidelines were developed to educate practitioners on the increasing range of therapeutic options for the treatment of gout and to increase awareness of the need for urate control. Part 1 provides published outcomes evidence and recommendations for the treatment of hyperuricemia in patients with evidence of gout (or gouty arthritis). An algorithm summarizes strategies for urate-lowering therapy and management decisions for gout. The investigators encourage practitioners to identify potential comorbidities — like kidney disease and cardiovascular conditions — and other causes of hyperuricemia on a patient-by-patient basis. The evidence-based recommendations include lifestyle and diet modifications and emphasize safety and the quality of therapy. Part 2 addresses specific management strategies for acute attacks and antiinflammatory prophylaxis.
Also see... a slide show entitled "A Quick and Easy Guide" for the above guidelines was developed by Medscape authors and can be accessed at: http://www.medscape.com/features/slideshow/gout?src=mpnews#13 (Medscape login required). Access checked November 29, 2012.
Low Back Pain - Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association
Access: http://www.jospt.org/issues/articleID.2744/article_detail.asp
(This page contains a link to access full-text PDF. Be patient when downloading, the file size is 6.23 MB.)
Source: American Physical Therapy Association (APTA)
Date: 2012
Print Reference: Delitto A, George SZ, Van Dillen LR, Whitman JM, et al; J Orthop Sports Phys Ther. 2012;42(4):A1-A57
Description: This APTA guideline reviews the identification of musculoskeletal impairments with low back pain (LBP) symptoms according to ICD (disease) and ICF (body-function) codes of the World Health Organization's International Classification System. Investigators examined recent literature for evidence of effective evaluation methodology and have provided a thorough list of functional assessment methods and reliable instruments. The review includes tables containing common risk factors, pathoanatomical origins of pain, and red flags for serious medical conditions that can cause LBP. Major emphasis is placed on manual therapy for a wide range of LBP subgroup categories and focuses on early interventions aimed at reducing activity-limiting pain — including the use of flexion, strengthening, and coordination exercises to restore motion and reduce pain. The full guideline provides a very detailed review of evaluation and treatment evidence, but it may be worthwhile to initially identify the overall scope of the guideline by reading the 'Summary of Recommendations' on pages 44-46. Access checked August 30, 2012.
Multinational Evidence-Based Recommendations for Pain Management by Pharmacotherapy in Inflammatory Arthritis: Integrating Systematic Literature Research and Expert Opinion of a Broad Panel of Rheumatologists in the 3e Initiative
Access: http://rheumatology.oxfordjournals.org/content/early/2012/03/23/rheumatology.kes032.full.pdf+html
Source: Multinational 3e Initiative
Date: 2012
Print Reference: Whittle SL, Colebatch AN, Buchbinder R, et al. Rheumatology. 2012(Mar 24) [advance epub].
Description: Inflammatory arthritis (IA) can reduce patient quality of life due to pain, stiffness, and loss of function. Rheumatology experts from 17 countries who participated in the 3e Initiative — combining evidence, expertise, and exchange — developed pain management guidelines for IA by combining the treatment evidence identified in a systematic review of published literature and expertise shared by professionals. The resulting guidelines include 11 graded recommendations for pain assessment, combination drug treatment plans, and strategies for patients with gastrointestinal comorbidities and cardiovascular or renal disease. Discussions on pharmacotherapeutic agents to treat IA include the appropriate use of NSAIDs, cautious use of glucocorticoids, and effective adjuvant agents. An algorithm for pain management in patients whose pain is not well-managed by anti-inflammatory agents is provided. 10 Pages. Access checked May 16, 2012.
2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis
Access: http://www.rheumatology.org/practice/clinical/guidelines/...May%202012%20AC&R.PDF
Source: American College of Rheumatology
Date: 2012
Print Reference: Singh JA, Furst DE, Bharat A, et al. Arthritis Care & Research. 2012(May);64(5):625-639.
Description: Five specific topic areas are examined: 1) treatment indication, 2) switching between therapies, 3) biologic agent prescribing in high-risk patients, 4) tuberculosis screening in patients receiving biologic agents, and 5) vaccinations in patients taking DMARDs or biologic agents. Recommendations for both nonbiologic and biologic DMARDs are presented in 3 separate algorithms based on disease duration and several specific concomitant disease entities. An additional algorithm helps to screen patients who may be at risk for latent TB infection. Recommendations on the use of vaccines in patients with RA who are beginning or already receiving DMARDs or biologic agents are provided in an easy-to-use table. 15 Pages. Access checked April 12, 2012.
2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis
While the 2012 update (above) does incorporate treatment evidence from the 2008 ACR RA recommendations, this older version is provided here because it still contains other valuable information. Topics covered in the 2008 recommendations, but not the 2012 update, include monitoring of treatment adverse effects and economic concerns when choosing a biologic agent. Access checked April 12, 2012.
Access: http://www.rheumatology.org/practice/clinical/guidelines/recommendations.pdf
Print Reference: Saag KG, Teng GG, Patkar NM, et al. Arthritis & Rheumatism. 2008(Jun 15);59(6):762-784.
American College of Rheumatology 2012: Recommendations for the Use of Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee
Access: http://www.rheumatology.org/practice/clinical/guidelines/PDFs/ACR_OA_Guidelines_FINAL.pdf
Source: American College of Rheumatology
Date: 2012 (April)
Print Reference: Hochberg MC, Altman RD, April KT, et al. Arthritis Care & Research. 2012(Apr);64(4):465-474.
Description: These evidence-based guidelines update recommendations from year 2000. The Expert Panel chose the best evidence for efficacy and safety available in each modality. All 3 sets of recommendations -- for Hand, Knee, and Hip -- include guidance for pharmacologic and nonpharmacologic therapies. Recommendations for all therapies were graded and panel confidence levels for individual interventions are reflected as strong, conditional, or no recommendation. 10 Pages. Access checked April 5, 2012.
Adult Acute and Subacute Low Back Pain
Access: https://www.icsi.org/_asset/bjvqrj/LBP.pdf
Source: Institute for Clinical Systems Improvement (ICSI)
Date: November 2012
Description: The identification of symptoms that would indicate the presence of a serious underlying condition requiring urgent care is crucial to the initial patient evaluation. The guideline reviews x-ray evidence of these "red flag" indications. An algorithm aids in the identification of acute versus chronic conditions; the guideline continues with an emphasis on the management of low back pain and sciatica, including the indications for medical, surgical, and non-surgical referral. Discussions on prevention, lifestyle modifications, and self-care treatments are included. 92 Pages. Access checked April 24, 2013.
Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients with Low Back Pain
Access PDF: http://www.jaoa.org/cgi/reprint/110/11/653
Source: American Osteopathic Association
Date: 2010
Print Reference: Clinical Guideline Subcommittee on Low Back Pain. American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. J Am Osteopath Assoc. 2010 (Nov);110(11):653-666.
Description: Low back pain is commonly treated by osteopathic physicians, frequently as a complement to conventional therapy. The focus of treatment is manipulation of the framework of the body — including skeletal, joint, and myofascial structures — when somatic dysfunction is a contributing or causative factor of low back pain. An analysis of existing guidelines and the results of 6 randomized trials provided the basis for a synthesis of the evidence for manipulative therapy. The combined results demonstrate a statistically significant reduction in low back pain with OMT when compared with active treatment alone, placebo control, or no treatment. An algorithm for OMT decision-making in patients with low back pain is presented. The appendix includes a glossary of osteopathic terminology. Access checked December 14, 2010.
The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline Revision
Access PDF: http://www.acfas.org/uploadedFiles/.../Clinical_Practice_Guidelines/HeelPainCPG.pdf
Source: American College of Foot and Ankle Surgeons
Date: 2010 (original version published in 2001)
Print Reference: Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain. J Foot Ankle Surg. 2010 (May-Jun);49(3 Suppl):S1-S19.
Description: The pathophysiology of heel pain tends to be primarily mechanical but diagnostic considerations must include neurologic, traumatic, arthritic, vascular, neoplastic, and infectious etiologies. This revised, 20-page guideline includes algorithms for the diagnosis and treatment of plantar and posterior heel pain, plus other etiologies of heel pain. Guidance on significant findings from patient history, clinical examination, and radiographic evidence are provided as an aid to diagnosing each type of pain. Many useful radiographic and photographic examples are included. A 3-tier treatment ladder for plantar heel pain begins with conservative measures and progresses to more aggressive options with grades of recommendation for each type of therapy. Treatment recommendations vary, depending on the origin of the pain, but can range from a change in footwear or analgesic therapy to injection modalities or surgery. Access checked August 27, 2010.
EULAR Recommendations for the Management of RA with DMARDS
Access PDF: http://ard.bmj.com/content/early/2010/05/04/ard.2009.126532.full.pdf
Source: European League Against Rheumatism (EULAR)
Date: 2010
Print Reference: Smolen JS, Landewe R, Breedveld FC, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Annals of the Rheumatic Diseases. 2010(Jun);69(6):964-975.
Description: Based on a review of the published evidence showing varied outcomes for different treatment strategies, experts within the European community of rheumatologists have established a consensus on the management of rheumatoid arthritis (RA) with biological and synthetic DMARDs and glucocorticoids. The resulting 15 recommendations cover general disease management as well as treatment considerations like: 1) therapy preferences, 2) patients with a history of tumor necrosis factor inhibitor (TNF-inhibitor) therapy failures, and 3) treatment during remission. The guidelines include an assessment of cost-effectiveness plus a discussion of the graded levels of evidence that support each recommendation. An easy-to-read algorithm showing 3 phases of treatment aimed at achieving clinical remission is included. Access checked June 18, 2010.
International Consensus Recommendations on Methotrexate Therapy
Canadian Recommendations for Use of Methotrexate in Patients with Rheumatoid Arthritis
Access PDF: http://www.jrheum.org/content/early/2010/05/27/jrheum.090978.full.pdf+html
Source: Canadian Rheumatologists, Canadian 3E Initiative Consensus Group
Date: 2010
Print Reference: Katchamart W, Bourré-Tessier J, Donka T, et al. Canadian Recommendations for use of methotrexate in patients with rheumatoid arthritis. Journal of Rheumatology. 2010(Jun). [Epub ahead of print].
Description: This Canadian guideline contains 9 additional recommendations that complement the 10 international recommendations on the administration of methotrexate (MTX) in RA published in 2009 (see immediately below). Using an evidence-based approach toward answering key disease management questions, guidance is offered for the assessment of variations in clinical response, prognostic factors for MTX response, strategies for non-serious adverse effect reduction, drug interactions, and patient treatment preferences. Access checked June 18, 2010.
Multinational Evidence-Based Recommendations for the Use of Methotrexate in Rheumatic Disorders With a Focus on Rheumatoid Arthritis
Access: http://ard.bmj.com/content/68/7/1086.full.pdf
Source: International 3E Initiative in Rheumatology Consensus Group
Date: 2009
Print Reference: Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E initiative. Annals of the Rheumatic Diseases. 2009(Jul);68(7):1086-1093.
Description: Methotrexate prescribing practices vary greatly among rheumatologists and primary care practitioners. Following a systematic review of the literature and a high level of expert consensus, 10 graded recommendations for the use of methotrexate in clinical practice management of rheumatoid arthritis (RA) were developed. The practice guidelines include: patient assessment, optimal methotrexate dosing and routes, monotherapy versus combination use, clinical monitoring, long-term safety, the protective effects of concurrent folic acid administration, and methotrexate administration in special situations. Access checked June 18, 2010.
Treating Rheumatoid Arthritis to Target: Recommendations of an International Task Force
Access PDF: http://ard.bmj.com/content/69/4/631.long
Source: European League Against Rheumatism (EULAR) T2T Expert Committee
Date: 2010
Print Reference: Smolen JS, Aletaha D, Bijlsma JWJ, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Annals of the Rheumatic Diseases. 2010;69:631-637.
Description: The committee’s goal was to assess available evidence and develop recommendations for achieving optimal therapeutic outcomes for patients on drug therapy for rheumatoid arthritis (RA). Following a review of published literature to identify treatment targets for RA, the evidence was evaluated by the task force and a consensus resulted in 10 recommendations for optimal outcomes in the treatment of RA. While the committee agreed that low disease activity may be acceptable for some patients, it was determined that the ultimate goal for most patients should be remission. Additionally, measures of disease activity within affected joints should be assessed every 3 months and changes in therapy are recommended until the treatment target is reached. Individual patient targets should be influenced by various patient factors, including comorbidities and drug-related risks. Follow-up evaluations are recommended on an ongoing basis and further treatment decisions should be based on structural changes, functional impairment, and health-related quality of life. Access checked April 9, 2010.
Symptomatic Treatment for Muscle Cramps
Access PDF: http://www.neurology.org/cgi/reprint/74/8/691
Source: American Academy of Neurology (AAN).
Date: 2010
Print Reference: Katzberg HD, Khan AH, So YT. Assessment: Symptomatic treatment for muscle cramps (an evidence-based review) Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010;74;691-696.
Description: This AAN assessment systematically reviews available evidence on the symptomatic treatment of muscle cramps. Conclusions are that, although they are likely to be effective, quinine derivatives should be avoided except in select patients because of potential toxicity. Vitamin B complex, Naftidrofuryl [not available in U.S.], and calcium channel blockers such as diltiazem are possibly effective and may be considered in the management of muscle cramps. Limited data regarding the use of magnesium preparations and gabapentin show that these agents are probably not effective NOTE: This guideline did not evaluate treatments for muscle cramps due to muscle diseases, kidney diseases, menstruation, pregnancy, or excessive exercise, heat or dehydration. Access checked February 27, 2010.
Guidelines for the Management of Polymyalgia Rheumatica
Access: http://rheumatology.oxfordjournals.org/cgi/content/full/49/1/186
Source: British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR)
Date: 2010
Print Reference: Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR Guidelines for the Management of Polymyalgia Rheumatica. Rheumatology. 2010;49(1):186-190.
Description: Polymyalgia rheumatica (PMR) is a clinical syndrome characterized by severe aching and stiffness in the neck, shoulder girdle, and pelvic girdle. It is the most common inflammatory rheumatic disease in the elderly and is one of the biggest indications for long-term steroid therapy. It is classified as a rheumatic disease, although the etiology is undetermined and there are difficulties in diagnosis, with wide variations in presentation, response to steroids, and disease course. The aim of these guidelines is to provide a safe and specific diagnostic process for PMR, using continued assessment, and discouragement of hasty initial treatment. Their further scope is to provide advice for the management and monitoring of disease activity, complications and relapse. Management of the related inflammatory condition, giant cell arteritis (GCA), is not covered here. 5 pages. Access checked December 11, 2009
Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain
Access: http://www.painphysicianjournal.com/2009/july/2009;12;699-802.pdf
Source: American Society of Interventional Pain Physicians (ASIPP)
Date: 2009
Print Reference: Manchikanti L, Boswell MV, Singh V, et al. Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain. Pain Phys. 2009;12:699-802.
Description: This is the fifth revision of the ASIPP chronic spinal pain practice guidelines and replaces the previous 2007 version. Using an ongoing process to synthesize the evidence, these guidelines continue to represent the most current emerging techniques in interventional therapy for pain by examining results reported in systematic reviews, randomized trials, retrospective trials, and prospective trials. Expert opinion and consensus have also been used as needed to provide the best evidence available. Information is provided on the evaluation of spinal pain, the diagnosis of chronic back pain without disc herniation, the application of therapeutic interventional techniques in the management of chronic low back pain, and the diagnosis of chronic neck pain without disc herniation. 104 Pages. Access checked August 7, 2009.
Low Back Pain: Early Management of Persistent Non-Specific Low Back Pain.
Access: http://guidance.nice.org.uk/CG88
Source: National Institute for Health & Clinical Excellence (NICE), UK National Health Service.
Date: 2009
Description: This guideline focuses on the care of patients with persistent or recurrent non-specific low back pain, lasting from 6 weeks to 1 year. Recommended therapies include either a structured exercise program (8 sessions during up to 3 months), a course of manual therapy, including manipulation or massage (9 sessions during 3 months), a course of acupuncture (up to 10 sessions), or a combined physical and psychological treatment program (100 hours during up to 8 weeks). The guideline specifies that patients should not have X-rays taken or be offered therapeutic ultrasound, lumbar supports, or injections of therapeutic substances into their backs. Patients with spinal malignancy, infection, fracture, cauda equina syndrome, or ankylosing spondylitis or another inflammatory disorder are not covered by this guideline. Access checked May 30, 2009.
Guideline: Diagnosis and Treatment of Forefoot Disorders
Access: http://www.acfas.org/HealthcareCommunity/content.aspx?id=367
Source: American College of Foot and Ankle Surgeons (ACFAS)
Date: 2009
Print Reference: Clinical Practice Guideline: Forefoot Disorders Panel. J Foot Ankle Surg. 2009;48(2):239-272.
Description: This 5-part guideline was developed for the diagnosis and treatment of 5 common painful foot disorders: digital deformities, pain in the ball of the foot, pain due to nerve compression, bunions, and traumatic forefoot injury. Forefoot pain and deformity can increase with age but an early diagnosis and appropriate treatment can halt or delay progression of the disorder. While it is common for some forefoot disorders to be caused by stress fractures or injury, it is important to note that arthritic conditions can be important etiologies. Furthermore, the prophylactic correction of toe deformities in patients with diabetic peripheral neuropathy is critical for the prevention of future ulceration. Treatment recommendations vary, depending on the cause of the condition, but can range from a change in footwear or analgesic therapy to injection modalities or surgery. Accessed 10/27/09.
British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis — After the First Two Years
Access to 4-page summary: http://rheumatology.oxfordjournals.org/cgi/reprint/ken450av1
Access to full guideline: http://rheumatology.oxfordjournals.org/cgi/data/ken450a/DC1/1
Source: British Society for Rheumatology, British Health Professionals in Rheumatology
Date: 2009
Print Reference: Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first two years). Rheumatology (Oxford). 2009(Jan); [Early online publication prior to print].
Description: This guideline was written as an extension of the first guideline (see below) on early management of rheumatoid arthritis (RA) and provides 20 evidence-based, graded recommendations for long-term management. The proposed model of patient care uses a multi-disciplined approach for ongoing assessment, treatment modification, and the monitoring of effectiveness. Ongoing measures of disease activity and damage are stressed as important components of long-term comprehensive care. 23 Pages. Access checked April 14, 2009.
British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Rheumatoid Arthritis -- the First Two Years
Access: http://rheumatology.oxfordjournals.org/cgi/data/kel215a/DC1/1
Source: British Society for Rheumatology, British Health Professionals in Rheumatology
Date: 2006
Print Reference: Luqmani R, Hennell S, Estrach C, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology (Oxford). 2006(Sep);45:1-16.
Description: This guideline provides 24 evidence-based, graded recommendations for the early management of rheumatoid arthritis. The patient care pathway uses a multi-disciplined approach for assessment, planning, treatment delivery, and the monitoring of effectiveness. 16 Pages. Access checked April 14, 2009.
Guideline on the Treatment of Osteoarthritis (OA) of the Knee
Access full guideline (278 pp); summary (5 pp) at: http://www.aaos.org/Research/guidelines/GuidelineOAKnee.asp
Source: American Academy of Orthopaedic Surgeons (AAOS)
Date: December 2008
Description: A multi-disciplinary AAOS workgroup developed evidence-based guidelines for the treatment of osteoarthritis of the knee in adult patients. The 22 recommendations were explicitly developed to include only treatments that are less invasive than knee replacement surgery. The guidelines recommend against performing an arthroscopic lavage if a patient only displays symptoms of osteoarthritis and no other problems like loose bodies or meniscus tears. Furthermore, overweight patients, with a Body Mass Index (or BMI) greater than 25, should lose a minimum of 5% of their body weight.
Patients should be encouraged to begin or increase their participation in low-impact aerobic fitness programs.
The guidelines authors recommend against using glucosamine and/or chondroitin sulfate or hydrochloride, needle lavage (aspiration of the joint with injection of saline), or custom made foot orthotics. For symptomatic relief of knee pain due to OA, the group recommends acetaminophen (not to exceed 4 grams per day), non-steroidal anti inflammatory drugs (NSAIDs), or intra-articular corticosteroids (for short term pain relief). Insufficient evidence was available to recommend for or against the use of bracing, acupuncture, or intra-articular hyaluronic acid. Access checked April 14, 2009.
 Certain elements of the above guideline are contradicted by guidelines from the Work Loss Institute (WLI) for knee/leg arthritis. The latter document recommends acetaminophen as a safer but less effective agent than NSAIDs for relief of knee pain. Therefore, acetaminophen should be the first line treatment, with NSAIDs reserved for those who do not respond. Glucosamine is recommended as providing effective symptomatic relief, and for modifying the progression of arthritis over a 3-year period, in patients with osteoarthritis of the knee. Glucosamine is noted as having a tolerability profile similar to that of placebo and is better tolerated than ibuprofen or piroxicam. Intra-articular (IA) injection of hyaluronic acid (eg, Synvisc) is suggested as decreasing symptoms of osteoarthritis of the knee. Furthermore, the WLI guideline notes that the short-term benefit of IA corticosteroids in treatment of knee osteoarthritis is well established and few side effects have been reported; however, longer-term benefits have not been confirmed. The guidelines conclude that total knee arthroplasties are well accepted as reliable and suitable surgical procedures to return patients to function.
Source: Work Loss Data Institute. Guideline: Knee & Leg (acute & chronic). 2008. [289 pages].
Access: http://www.guidelines.gov/summary/summary.aspx?doc_id=12673
OARSI Recommendations for the Management of Hip and Knee Osteoarthritis, Part II: OARSI Evidence-Based, Expert Consensus Guidelines
Access: http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf
Source: Osteoarthritis Research Society International (OARSI)
Date: 2008
Print Reference: Zhang W, Moskowitz RW, Nuki G, et al. Osteoarthritis Cartilage. 2008(Feb);16(2):137-162.
Description: Experts in 4 clinical disciplines from 6 countries evaluated existing guidelines on the management of hip and knee osteoarthritis. The evidence was evaluated and consensus recommendations were developed following a synthesis of expert clinical opinion and the strength of existing recommendations. The guidelines development team determined that optimal management of patients with hip or knee osteoarthritis requires a combination of non-pharmacological and pharmacological treatment modalities. The guideline includes 25 recommendations overall; 8 recommendations are related to the administration of non-opioid pain-relievers and 12 recommendations resulted following a review of the efficacy of non-pharmacological modalities from education to acupuncture. Five surgical recommendations are included. This guideline was developed in a manner that would allow adaptation for use in a variety of clinical settings and geographical regions. Access checked June 21, 2011.
2010 Update: Changes in Evidence Following Systematic Cumulative Update of Research Published
Through January 2009. Following the release of the recommendations approved in 2007 (published 2008), the OARSI Treatment Guidelines Committee analyzed the results of all relevant systematic reviews and randomized controlled trials published between 2006 and 2009. The committee reports on new research evidence related to the risk-benefit ratio for each osteoarthritis treatment recommendation. Access checked June 21, 2011.
Access: http://www.oarsi.org/pdfs/part_III_changes_in_evidence2010.pdf .
Print Reference: Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis Part III: changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis and Cartilage. 2010(Apr);18(4):476-499.
Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Access: http://www.annals.org/cgi/reprint/147/7/478.pdf
Source: American College of Physicians (ACP), American Pain Society (APS)
Date: 2007
Print Reference: Chou R, Qaseem A, Snow V, et al. Annals of Internal Medicine. 2007(Oct);147(7):478-491.
Description: Low back pain is reported to be the fifth most common healthcare complaint in the United States. This evidence-based guideline for the evaluation and treatment of acute and chronic low back pain in primary care settings was developed through a collaborative effort of the ACP and the APS. The guideline focuses on adults presenting with low-back pain unassociated with major trauma, with and without referred leg pain. Two algorithms were developed: 1) diagnostic evaluations and interpretation which can aid clinicians in identifying a general back pain category during the patient’s first visit, and 2) pain management that includes drug and nonpharmacologic therapies. Clinicians are encouraged to use the 7 evidence-based recommendations to expand current treatment modalities and to explore the benefits and drawbacks of traditional treatment methods. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for the Management of Hand Osteoarthritis: Report of a Task Force
Access: http://ard.bmj.com/cgi/gca?allch=&SEARCHID=1&FULLTEXT=management+of+hand+oa...
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism (EULAR)
Date: 2007
Print Reference: Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007(Mar);66(3):377-388.
Description: The EULAR task force responsible for developing these guidelines included experts from 15 different European countries in specialty disciplines from rheumatology to allied health. These evidence-based management recommendations for hand osteoarthritis are the result of existing evidence, clinical expertise, and perceptions of patient preference. The task force explains their rationale for the development of separate treatment recommendations for osteoarthritis of the hand (in contrast to the treatment of other joints) and the resulting guidelines include 11 key recommendations involving 17 treatment modalities. 12 pages. Access checked April 14, 2009.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline
Access: http://www.annals.org/cgi/reprint/147/7/492.pdf
Source: American Pain Society (APS), American College of Physicians (ACP)
Date: 2007
Print Reference: Chou R, Huffman LH, American Pain Society, American College of Physicians. Annals of Internal
Medicine. 2007(Oct);147(7):492-504.
Description: Task force members of the APS and ACP examined systematic reviews and randomized trials on a wide range of nonpharmacologic therapies used to treat acute or chronic low back pain. Studies that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction were graded on methodological quality. In the final analysis, four modalities showed good levels-of-evidence for moderate efficacy in the treatment of chronic or subacute low back pain: cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. The only therapy that provided good evidence for effectiveness in acute low back pain was superficial heat. Access checked April 14, 2009.
EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/content/full/ard.2005.044354...
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism (EULAR)
Date: 2007
Print Reference: Combe B, Landewe R, Lukas C, et al. EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2007(Jan);66(1):34-45.
Description: Recent advances in rheumatology include the use of biological treatments which have demonstrated improved disease control when initiated early in the inflammatory process. Recommendations for the diagnosis, treatment, and continual monitoring of arthritis were developed by expert consensus following a review of the evidence-based literature. Each of twelve recommendations is supported by the level of evidence reflected in a review of 284 manuscripts. These guidelines represent the current knowledge base, available treatment, and present expert thinking on the most effective approach to managing early arthritis. 12 Pages. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for Gout. Part I: Diagnosis. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/reprint/65/10/1301?ijkey=7jOEXurujRa0k&keytype=ref&siteid=bmjjournals
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism
Date: 2006
Print Reference: Zhang W, Doherty M, Pascual E, et al. EULAR evidence based recommendations for gout. Part I: Diagnosis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006(Oct);65(10):1301-1311.
Description: Nineteen rheumatologists representing 13 countries evaluated gout management recommendations and present guidelines that include 10 evidence-based diagnostic tests. A strength of recommendation score is provided for each proposition; radiological testing, biochemical testing, urate crystal analysis, and patient risk factors are evaluated. 12 Pages. Access checked April 14, 2009.
EULAR Evidence Based Recommendations for Gout. Part II: Management. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)
Access: http://ard.bmj.com/cgi/reprint/65/10/1312?ijkey=uZK1Nk6Uq8MCs&keytype=ref&siteid=bmjjournals
NOTE: Access free after completing brief registration through link on login page.
Source: European League Against Rheumatism
Date: 2006
Print Reference: Zhang W, Doherty M, Bardin T, et al. EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006(Oct);65(10):1312-1324.
Description: Nineteen rheumatologists representing 13 countries evaluated gout management recommendations and present 12 important evidence-based treatment guidelines. Recommendations range from acute treatment to prophylactic therapy and include patient education and behavioral modification strategies. Pain management approaches are recommended according to the strength-of-evidence and urate lowering therapy is described in detail. 14 Pages. Access checked April 14, 2009.
Evidence-Based Management of Acute Musculoskeletal Pain
Access: http://www.nhmrc.gov.au/publications/synopses/cp94syn.htm
Source: Australian Acute Musculoskeletal Pain Guidelines Group
Date: 2003
Description: This comprehensive guide begins with a discussion of etiology, effective patient communication, and assessment. The multi-disciplinary review examines five specific symptoms, describes evidence-based interventions for each and provides recommendations; these include acute low back pain, acute thoracic spinal pain, acute neck pain, acute shoulder pain, and acute knee pain. Access checked November 2, 2009.
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Neurological/Neuropathic Pain
Guidelines on Neuropathic Pain Assessment [NeuPSIG]
Access: http://download.journals.elsevierhealth.com/pdfs/journals/0304-3959....pdf
Source: International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group (NeuPSIG)
Date: 2011
Print Reference: Haanpaa M, Attal N, Backonja M, et al. NeuPSIG guidelines on neuropathic pain assessment. PAIN. 2011(Jan);152(1):14-27.
Description: Effective neuropathic pain treatment requires thorough patient evaluation and assessment. The IASP Neuropathic Pain Special Interest Group has revised their 2004 guidelines on the assessment of neuropathic pain for the primary care clinician. Following a systematic review and evaluation of scientific literature, the group classified and graded the evidence for the use of specific pain and psychosocial screening tools as well as clinical examination methods that include sensory profiling. In addition, the guideline includes a review of recommendations based on studies evaluating the influence of psychological factors on neuropathic pain and those that assessed treatment efficacy. The use of assessment techniques such as microneurography, functional brain imaging, skin biopsy, and peripheral nerve blocks are also evaluated. Access checked April 28, 2011.
Evidence-based Guideline: Treatment of Painful Diabetic Neuropathy
Access: http://dx.doi.org/10.1212/WNL.0b013e3182166ebe (click on full text PDF)
Source: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation
Date: 2011
Print Reference: Bril V, England J, Franklin GM, et al. Evidence-based Guideline: Treatment of Painful Diabetic Neuropathy. Neurology. 2011(Apr 11);76 [Epub ahead of print].
Description: This goal of this guideline was an assessment of the evidence to support specific pharmacologic and nonpharmacologic therapies to reduce pain, increase physical function, and improve quality of life for patients with painful diabetic neuropathy. The evaluation included a systematic literature review of anticonvulsant, antidepressant, and opioid drugs — plus complementary therapies such as electrical stimulation, magnetic field treatment, low-intensity laser treatment, and Reiki massage. The authors provide a review of the evidence for each treatment type as well as their rationales for recommended therapies. Access checked April 16, 2011.
EFNS Guidelines on Pharmacological Treatment of Neuropathic Pain: 2010 Revision
Access: http://www.efns.org/fileadmin/...EFNS_guideline_2010_pharma._treatment_of_neuropathic_pain.pdf
Source: European Federation of Neurological Societies
Date: 2010
Print Reference: Attal N, Cruccu G, Baron R, et al. EFNS guidelines on pharmacological treatment of neuropathic pain. Eur J Neurol. 2010(Sep);17(9):1113-1123, appendix e67-e88.
Description: The management of neuropathic pain continues to provide challenges for the practitioner. This paper summarizes the evidence-based treatment for painful polyneuropathy (diabetic and non-diabetic), postherpetic neuralgia, trigeminal neuralgia, central neuropathic pain, and several conditions for which very few studies were available. The mechanism of action, efficacy and adverse effects were presented and recommendations were made for antidepressants, antiepileptics, opioids, and a combination regimen. 33 Pages. Access checked November 10, 2010.
EFNS Guidelines on Neuropathic Pain Assessment: 2009 Revision
Access: http://www.efns.org/fileadmin/...EFNS_guideline_2010_neuropathic_pain_assessment.pdf
Source: European Federation of Neurological Societies
Date: 2010
Print Reference: Cruccu G, Sommer C, Anand P, et al. EFNS guidelines on neuropathic pain assessment. Eur J Neurol. 2010(Aug);17(8):1010-1018.
Description: The assessment of neuropathic pain is crucial to an accurate diagnosis and the development of an effective treatment protocol. This guideline provides recommended testing methods that are the result of a systematic review of the evidence-based studies on neuropathic pain assessment. In addition, a description and graded evidence for effectiveness is provided for electrodiagnostic studies, microneurography, laser-evoked potentials, reflex testing, biopsy and functional neuroimaging studies. 9 Pages. Access checked November 10, 2010.
Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-Specialist Settings
Access: http://www.nice.org.uk/guidance/CG96
Source: National Institute for Health and Clinical Excellence (NICE)
Date: 2010
Description: The varied symptoms of neuropathic pain — manifested as continuous or intermittent pain or numbness — can be difficult to treat. This guideline was developed for non-specialist healthcare practices and begins by exploring the many causes of adult neuropathic pain from diabetic neuropathy and post-herpetic neuralgia to chemotherapy-induced neuropathies. The NICE web page link above offers access to 3 versions of the guideline: 1) the full 155-page guideline, 2) a 6-page quick-reference version, and 3) a 12-page patient edition. The full guideline takes a comprehensive look at therapeutic options and provides summaries of study outcomes by drug class and individual agent. Both versions for healthcare professionals emphasize good communication and include a 'Care Pathway' that makes recommendations for first-, second-, and third-line treatment approaches. The patient version offers a list of questions that may aid communication during the practitioner-patient office visit. Access checked April 9, 2010.
Practice Parameter: Evaluation of Distal Symmetric Polyneuropathy
Access – Role of laboratory and genetic testing (an evidence-based review): http://www.neurology.org/cgi/rapidpdf/01.wnl.0000336370.51010.a1v1.pdf
Access – Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review): http://www.neurology.org/cgi/rapidpdf/01.wnl.0000336345.70511.0fv1.pdf
Source: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation
Date: 2009
Print References: England JD, Gronseth GS, Franklin G, et al. Neurology. 2009(Jan); [Early online publication].
Description: Distal symmetric polyneuropathy (DSP), the most common type of neuropathy, can be difficult to diagnose due to the large number of existing etiologies. Published literature indicates that many patients with neuropathic pain may not be accurately diagnosed, and the correct selection of screening tests can become critical to an accurate diagnosis of DSP. These 2 reports provide graded, evidence-based recommendations to aid in the diagnosis of DSP as well as important assessment information for other etiologies of polyneuropathy. A discussion of hereditary neuropathies reviews the considerations for the appropriate use of genetic testing. 16 Pages (each report). Access checked April 14, 2009.
Clinical Practice Guideline on the Treatment of Carpal Tunnel Syndrome
Access: http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp
Source: American Academy of Orthopaedic Surgeons (AAOS)
Date: 2008
Description: AAOS provides guidelines for carpal tunnel syndrome treatment in 3 different formats, all of which are available in pdf format at the website listed above. A summary of the 13 evidence-based recommendations is available in a 3-page format at the link entitled “CTS Treatment Recommendations Summary“. The “CTS Treatment Guideline” offers an 84-page document that begins with a summary of the recommendations and continues with a review of the process used to evaluate evidence for each recommendation. The supporting documents entitled “Evidence Report” and “Evidence Table” are 188 pages and 236 pages in length, respectively, and provide a full accounting of all studies evaluated and the rationale for grading the evidence. Access checked April 14, 2009.
Practice Parameter: The Diagnostic Evaluation and Treatment of Trigeminal Neuralgia (an evidence-based review)
Access: http://www.neurology.org/cgi/reprint/71/15/1183
Source: American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS)
Date: 2008
Print Reference: Gronseth G, Cruccu G, Alksne J, et al. Neurology. 2008(Oct 7);71(15):1183-1190.
Description: The goal of experts from the AAN and the EFNS was to establish answers to 6 specific questions related to diagnosis and treatment of trigeminal neuralgia. Following a systematic review of published evidence-based studies, an analysis of each question resulted in a recommendation based on that evidence or a determination that there was insufficient evidence to support a decision. The final section of the paper makes recommendations for specific future research that can help improve practice guidelines. 52 Pages. Access checked April 14, 2009.
Pharmacologic Management of Neuropathic Pain: Evidence-Based Recommendations
Access: (National Guideline Clearinghouse summary) http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=11724&nbr=6049
Source: International Association for the Study of Pain, Independent Expert Panel of the Fourth International Conference on the Mechanisms and Treatment of Neuropathic Pain
Date: 2007
Print Reference: Dworkin RH, O’Connor AB, Backonja M, et al. Pain. 2007(Dec 5);132(3):237-251.
Description: Assessment considerations in neuropathic pain include an identification of the underlying disease process, the type of lesion, response to prior therapy, and any comorbid conditions. This guideline provides a stepwise pharmacologic management recommendations table and includes graded support for specific drug treatment based on available therapeutic evidence. Consideration is given to clinical efficacy, adverse effects, potential benefit to health-related quality of life, and treatment costs. 15 Pages. Access checked April 14, 2009.
EFNS Guidelines on Neurostimulation Therapy for Neuropathic Pain
Access: (National Guideline Clearinghouse summary) http://www.ngc.gov/summary/summary.aspx?ss=15&doc_id=11372&nbr=5909
Source: European Federation of Neurological Societies (EFNS)
Date: 2007
Print Reference: Cruccu G, Aziz TZ, Garcia-Larrea L, et al. Eur J Neurol. 2007(Sep);14(9):952-970.
Description: Neuropathic pain relief is oftentimes incomplete with drug therapy alone. The EFNS task force evaluated and classified the evidence for neurostimulation therapy in neuropathic pain conditions. The evidence for the effectiveness of spinal cord stimulation, transcutaneous electrical nerve stimulation, electro-acupuncture, repetitive transcranial magnetic stimulation, motor cortex stimulation, and deep brain stimulation was examined; recommendations were rated according to the evidence for efficacy in specific types of pain disorders. Access checked April 14, 2009.
Consensus Guidelines: Treatment Planning and Options. Diabetic Peripheral Neuropathic Pain
Access: http://www.paineducators.org/resource/resmgr/Docs/DPNPSuppl.pdf
(See page S12 in this document.)
Source: American Society of Pain Educators and the Johns Hopkins University School of Medicine
Date: 2006
Print Reference: Argoff CE, Backonja MM, Belgrade MJ, et al. Consensus guidelines: treatment planning and options. Diabetic neuropathic pain. Mayo Clinic Proceedings. 2006(Apr);81(Suppl 4):S12-S25.
Description: Diabetic peripheral neuropathic pain requires attention to many factors including existing comorbidities and potential adverse effects of treatment. A thorough evidence-based discussion of pharmacologic therapies includes antidepressants, anticonvulsants, opioids, and topical agents. Recommendations are made for 1st and 2nd tier therapeutic agents, including a table of factors to consider in drug selection. Guidelines are offered for monitoring the patient’s pain management and modifying therapy. 14 Pages. Access checked May 2, 2011.
Practice Parameter: Treatment of Postherpetic Neuralgia. An Evidence-Based Report of the Quality Standards Subcommittee of the American Academy of Neurology
Access: http://www.neurology.org/cgi/reprint/63/6/959.pdf
Source: Quality Standards Subcommittee of the American Academy of Neurology
Date: 2004
Print Reference: Dubinsky RM, Kabbani H, El-Chami Z, at al. Practice parameter: treatment of postherpetic neuralgia. An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.
2004(Sep 28);63(6):959-65.
Description: The recommendations derived from the evidence of 51 studies in this systematic review are categorized and summarized in 4 classes of pharmacological treatment. 7 Pages. Access checked April 14, 2009.
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Non-Opioid & Complementary Therapies
Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis
Access: http://ptjournal.org/cgi/reprint/85/9/907
Source: Ottawa Panel and the University of Ottawa, Canada
Date: 2005
Print Reference: Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. Physical Therapy. 2008;85(9):907-971
Description: For adult patients with osteoarthritis, exercise can improve health outcomes. This comprehensive guideline for therapeutic exercise and physical therapy includes graded recommendations for patients at all stages of the disease. Full details of evaluation methodology and the quality of available studies is provided. The results contain 16 positive recommendations—primarily strengthening exercises and general physical activity—that show clinical benefit in the management of pain and improvement of functional status for patients with osteoarthritis. While the panel stated that more research is needed for a recommendation of manual therapy alone, one study reported benefits when combined with exercise. 65 Pages. Access checked April 14, 2009.
Antiepileptic Drugs Guideline for Chronic Pain
Access: http://lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/NeuropathicPain.pdf
Source: Washington State Department of Labor and Industries
Date: 2005
Description: Based on expert opinion and a systematic review of the literature, these guidelines make a summary statement about the lack of evidence for several antiepileptics and primarily focus on the use of Gabapentin for neuropathic pain. A dosing plan is recommended and adverse effects are stated. 2 Pages. Access checked April 14, 2009.
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Opioid Therapy & Safety
Opioid Analgesics in the Treatment of Cancer Pain: Evidence-based Recommendations from EAPC
Access: http://www.eapcnet.eu/LinkClick.aspx?fileticket=i-bB4cvZyzg%3d&tabid=1794
Source: European Association for Palliative Care (EAPC)
Date: 2012
Print Reference: Caraceni A, Hanks G, Kaasa S, et al and the European Palliative Care Research Collaborative. Lancet Oncology. 2012(Feb);13:e58-e68.
Description: These guidelines represent an update of previous EAPC guidelines following a systematic review of the literature and an analysis of other current guidelines on the use of opioids for the treatment of cancer pain. The review focuses on high-quality trials that contained data on efficacy, adverse effects, and outcomes in adult patients. The resulting guidance includes 16 evidence-based recommendations on opioid administration — including alternative systemic routes — and the management of adverse effects. The investigators openly describe the weaknesses in study quality and the lack of evidence or consensus in many of the published trials. Access checked January 24, 2013.
American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain
Access – Part 1 - Evidence Assessment: http://painphysicianjournal.com/2012/july/2012;15;S1-S66.pdf (66 pp)
Access – Part 2 - Guidance: http://painphysicianjournal.com/2012/july/2012;15;S67-S116.pdf (50 pp)
Source: American Society of Interventional Pain Physicians
Date: 2012
Print Reference: Manchikanti L, Abdi S, Atluri S, et al. Pain Physician. 2012(Jul);15(3 Suppl):S1-S116.
Description: The ASIPP guidelines for the use of opioids in the treatment of chronic non-cancer pain have been updated following an evaluation of evidence-based treatment in randomized clinical trials, systematic reviews, and observational trials since the last guidelines were published in 2008. Part 1 provides a detailed review of the current evidence related to the complex issues of opioid prescribing, efficacy, and safety, as well as misuse. The investigators state that their primary objectives are: 1) the improvement of patient access to opioids while avoiding diversion and abuse, and 2) an improvement in the consistency in practitioner philosophy and treatment of chronic non-cancer pain. Part 2 provides guidance for responsible opioid prescribing for non-cancer patients with chronic pain who require pain management for 90 days or longer. General and specific principles of opioid use are reviewed and the pharmacology and efficacy of specific opioids is described in detail. A 10-step approach for the overall management of individual long-term opioid therapy is described. Helpful features include an algorithm for evaluation and treatment, two algorithms to aid screening decisions, and a table that provides interpretations of unexpected results of urine drug screening. Access checked August 14, 2012.
ASPMN Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression
Access: http://www.aspmn.org/...Opioid-InducedSedationandRespiratoryDepression.pdf
Source: American Society for Pain Management Nursing
Date: 2011
Print Reference: Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression. Pain Management Nursing. (Sep 2011);12(3):118-145.
Description: Nurses play an important role in monitoring patients receiving opioid analgesics. In addition to variations in the health status of each patient, pain management can become complex due to differences in the dosage and route of opioid administration, combination therapy, and individual treatment goals. Based on an extensive review of existing literature, this expert-developed guideline specifically examines patient risk factors for advancing sedation and respiratory depression. Recommendations focus on effective assessment and monitoring practices, as well as appropriate interventions aimed at reducing the impact of adverse events. Additional recommendations include nurse education and the use of technology in patient monitoring. The authors review patient conditions — like functional status, preexisting disease, and a history of sleep-disordered breathing — that have been shown to increase the occurrence of opioid-induced adverse effects. Access checked December 6, 2011.
VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain
Access: http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp
Source: Department of Veterans Affairs and the Department of Defense (VA/DoD)
Date: 2010 (Version 2.0); Version 1.0 published in 2003
Description: Designed for use in an ambulatory care setting, the guideline provides all levels of pain management guidance from assessment to patient education. This guideline has a wider focus than the original version and includes treatment considerations for all patients who could benefit from chronic opioid therapy (defined as more than one month). The goal of this comprehensive set of recommendations is education and guidance for primary care practitioners and researchers who must assess and treat patients with persistent pain. Each best-practice recommendation is goal-focused and the treatment algorithm is designed to guide the clinician through assessment, a discussion of patient treatment goals, trial therapy, treatment evaluation, maintenance therapy, and treatment challenges. Tables that address drug interactions and contraindications are included; separate sections provide specific considerations for methadone use, titration challenges, managing adverse effects, and referral strategies. Two PDF versions of the guideline are available at the web address listed above: a 74-page summary and the 159-page full-text guideline. Both of these versions include the full 3-page algorithm. Access checked July 20, 2010.
Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain
Access: http://nationalpaincentre.mcmaster.ca/opioid/
Source: McMaster University; National Pain Center; Ontario, Canada
Date: April 30, 2010
Reference: Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain©. 2010. National Opioid Use Guideline Group (NOUGG).
Description: This extensive guideline is based on a systematic review to identify evidence from the literature regarding use of opioids for chronic noncancer pain. It was developed by a multidisciplinary National Advisory Panel that included 49 individuals from across Canada who provided medical expertise in family medicine, pain and addiction, patient perspectives, and views of other healthcare providers. The guideline includes 24 recommendations organized within 5 clusters; however, the vast majority of recommendations are based on consensus opinion (Grade C) rather than being derived from a higher level of published clinical-study evidence (Grade A or B). Access checked May 6, 2010.
Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain
Access: http://health.utah.gov/prescription/guidelines.html
Source: Utah Department of Health
Date: 2009
Description: This evidence-based Utah State guideline for opioid prescribing in acute and chronic pain was developed to provide practitioner guidance in the important balance between treatment and safety. Evidence and recommendations contained in previously developed guidelines — from government, state, and professional organizations — were used as a foundation for this guide; most of these documents are available for free access in this Pain-Topics.org ‘Guidelines’ section, including:
- ASIPP’s Opioid Guidelines in the Management of Chronic Non-Cancer Pain (2008).
- Washington State Guidelines on Opioid Dosing for Chronic Non-cancer Pain (2007).
- FSMB (Federation State Medical Boards) Model Guidelines for the Use of Controlled Substances for the Treatment of Pain (2004).
- VA/DOD Clinical Practice Guidelines for the Management of Chronic Non-Cancer Pain (2003).
- CPSO Evidence-based recommendations for medical management of chronic non-malignant pain. College of Physicians and Surgeons of Ontario (2000).
- ACOEM Occupation Medicine Practice Guidelines. American College of Occupational and Environmental Medicine (2008). This is only available for sale at the ACOEM website.
Recommendations for the management of acute pain include current evidence for assessment, prescribing, and monitoring. The section on chronic pain provides more detailed recommendations, including: the use of risk assessment tools, components of a comprehensive treatment plan, and methods for involving the patient and family members in the goals of treatment. Guidance for patient education is offered and the section on risk evaluation includes examples of many assessment tools currently in use. Because the need for adjustments during opioid treatment is common, recommendations are presented for the management of adverse effects, a change in pain management needs, and evidence of tolerance or misuse. Several discussion sections include contraindications to opioid prescribing, strategies for tapering opioids, and the appropriate use of methadone in pain management.
These guidelines are not proposed as being applicable to opioid prescribing on a nationwide basis, but they do offer potential value as a model for other state guidelines and practitioner training. Full guideline is 92 pages; summary 15 pages. Access checked April 20, 2009.
Also see the Pain-Topics.org book review: Responsible Opioid Prescribing: A Physician’s Guide (from the Federation of State Medical Boards) at: http://pain-topics.org/education_CME_locator/indexbkrv.php#ROP
QTc Interval Screening in Methadone Treatment: Clinical Guidelines
Access: http://www.annals.org/cgi/content/full/150/6/387
Source: Annals of Internal Medicine
Date: March 2009
Print Reference: Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MCP. QTc Interval Screening in Methadone Treatment: Clinical Guidelines. Ann Intern Med. 2009;150(6):387-395.
Description: An independent panel recommends that clinicians inform patients of arrhythmia risk when prescribing methadone, and assess history of heart disease. They also recommend that all patients have pretreatment and follow-up electrocardiography (ECG) at 30 days and annually thereafter. Clinicians are instructed to learn about interactions between methadone and other drugs that can prolong the QTc interval or slow elimination of methadone. Accessed 4/14/09.
NOTE: There has been controversy surrounding publication of these guidelines and the recommendation for ECG monitoring of all patients prescribed methadone. This publication is not a federal guideline. A government agency has forwarded draft recommendations related to QTc interval screening in methadone treatment for field review prior to finalization.
Also see the rebuttal editorial accompanying the guidelines….
Gourevitch MN. First Do No Harm ... Reduction? Ann Intern Med. 2009;150(6).
Available at: http://www.annals.org/cgi/content/full/150/6/417. Access checked 4/14/09.
APS/AAPM Clinical Guidelines For the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
Access: http://www.jpain.org/article/S1526-5900(08)00831-6/abstract
(As of 3/11/09 the publisher was offering free access to the full document, but this may change.)
Source: American Pain Society (APS), American Academy of Pain Medicine (AAPM)
Date: 2009
Print Reference: Chou R, Fanciullo GJ, Fine PG, et al. The Journal of Pain. 2009(Feb);10(2):113-130.
Description: This clinical practice guideline was developed by a multi-disciplinary panel of experts representing the American Pain Society and the American Academy of Pain Medicine. Based on a systematic review of the literature through November 2007, 25 recommendations were developed to guide the use of opioids for carefully selected and monitored patients with chronic non-cancer pain. However, the panel identified numerous research gaps and they did not rate any of the recommendations as supported by high-quality evidence. Only 4 recommendations were viewed as supported by moderate-quality evidence. Nonetheless, the panel came to a unanimous consensus on almost all of its recommendations. 17 pages + appendices. Access checked April 14, 2009.
Also of interest…
Two additional papers in this same edition of the Journal of Pain discuss important research limitations encountered during the development of the above guideline. Access to both checked 4/14/09; free access to full documents was available from the journal publisher as of 3/11/09.
- Research Gaps on Use of Opioids for Chronic Noncancer Pain (Chou R, et al. 2009) – concludes that clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to address these critical needs if the care of patients with chronic noncancer pain is to improve. 12 pages + appendices.
Access full document at: http://www.jpain.org/article/S1526-5900(08)00830-4/abstract
- Opioids for Chronic Noncancer Pain: Prediction and Identification of Aberrant Drug-Related Behaviors (Chou R, et al. 2009) – concludes that evidence on the prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments exist, evidence for their external validity is lacking. Further studies evaluating clinical outcomes associated with different assessment and monitoring strategies are needed. 15 pages + appendices.
Access full document at: http://www.jpain.org/article/S1526-5900(08)00832-8/abstract
[Washington State] Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain: An Educational Aid to Improve Care and Safety With Opioid Treatment
Access: http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf (59 pp)
Source: Washington State Agency Medical Directors’ Group
Date: 2010
Description: The development of this guideline — on the safe and effective administration of opioids in chronic non-cancer pain — was developed for the non-specialist primary care provider and is divided into 2 parts: Part 1 includes general patient assessment and opioid prescribing recommendations, and Part 2 provides guidance for treating patients who need high dose opioid therapy (specifically, >120 mg morphine-equivalent dose per day). It is important to note that this guideline provides recommendations that are specific to Washington State and further modifications are under consideration; therefore, they are not finalized are not necessarily appropriate or applicable on a nationwide basis. Access checked October 20, 2010.
Guidelines for the Use of Methadone in Office-Based Management of Chronic Non-Cancer Pain and A Review of the Use of Methadone for Treatment of Chronic Non-Cancer Pain
Access: http://cpsns.ns.ca/LinkClick.aspx?fileticket=A0AYQw_XvtQ%3d&tabid=92&mid=626
Source: College of Physicians & Surgeons of Nova Scotia
Date: 2006
Description: The use of methadone in cases where conventional opioid therapy is inappropriate or has failed is increasing and this guideline serves as a comprehensive guide to its use in chronic non-cancer treatment. The unique characteristics of methadone are reviewed, contraindications are discussed, and guidelines for initiating a trial regimen, including dosing and conversion ratios, are presented. Tables include 1) studies with varied protocols for opioid conversion to methadone, 2) a morphine to methadone dose conversion ratio, and 3) a list of potential drug-drug interactions. Costs listed in this paper are based on Canadian currency. 50 Pages. Access checked April 14, 2009.
Methadone for Pain Guidelines
Access: http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1986
Source: College of Physicians and Surgeons of Ontario
Date: November 2004
Description: These guidelines were developed to assist clinicians in the use of methadone to treat chronic pain. Due to increasing interest in methadone’s analgesic properties, this guideline attempts to provide sufficient information to clarify any potential confusion that may relate to its use. Pharmacology and duration of action are explained and the issue of variations in individual patient response to methadone is discussed. Prescribing options for acute and chronic pain in specific patient populations are presented; these include opioid naïve patients, individuals in methadone maintenance, patients who are being switched from another opioid, and others. Some of the information for pharmacists is based on Canadian standards of practice, but other clinical recommendations for methadone withdrawal and cautions regarding drug interactions are universally appropriate. 58 Pages. Access checked April 14, 2009.
FSMB Model Policy for the Use of Controlled Substances for the Treatment of Pain
Access: http://www.fsmb.org/pdf/2004_grpol_Controlled_Substances.pdf (45 KB, 5 pp)
Source: Federation of State Medical Boards of the United States, Inc. (FSMB)
Date: May 2004
Description: These Model Policy guidelines have been widely distributed and endorsed by the Drug Enforcement Administration, American Academy of Pain Medicine, American Pain Society, and National Association of State Controlled Substances Authorities. Many states have adopted pain policies using all or part of the Model Policy. Despite increasing concern in recent years regarding the abuse and diversion of controlled substances, pain policies have improved due to the efforts of medical, pharmacy, and nursing regulatory boards committed to improving the quality of and access to appropriate pain care.
Circumstances that contribute to the prevalence of undertreated pain include: (1) lack of knowledge of medical standards, current research, and clinical guidelines for appropriate pain treatment; (2) the perception that prescribing adequate amounts of controlled substances will result in unnecessary scrutiny by regulatory authorities; (3) misunderstandings of addiction and dependence; and (4) lack of understanding of regulatory policies and processes. Adding to this problem is the reality that the successful implementation of state medical board pain policy varies among jurisdictions. Access checked April 20, 2009.
Also see the Pain-Topics.org book review: Responsible Opioid Prescribing: A Physician’s Guide (from the Federation of State Medical Boards) at:
http://pain-topics.org/education_CME_locator/indexbkrv.php#ROP
CPSO Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain [including Opioids]
Access: http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1982
Source: College of Physicians and Surgeons of Ontario (CPSO)
Date: 2000
Description: The information in this Reference Guide for Clinicians was extracted from a longer guideline that is now only available in paper format from the publisher. Recommendations are limited to 4 types of chronic non-malignant pain: headache, neuropathic pain, musculoskeletal pain, and opioid use in chronic pain. Sections on the use of opioid therapy for chronic non-malignant pain consider the evidence according to pain type. Simple “Do’s and Don’t’s” of prescribing opioids (sometimes referred to in this older document as “narcotics”) for chronic noncancer pain of various types are provided, and there is helpful advice for patients. Several sample forms to aid in patient monitoring and risk management are provided. 32 Pages. (Note: It must be considered that this is a relatively old document on this subject and may not reflect more current thinking or research evidence.) Access checked April 22, 2009.
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Pain in Palliative Care
Opioids in Palliative Care: Safe and Effective Prescribing of Strong Opioids for Pain in Palliative Care of Adults
Access Guideline (also practitioner and patient summaries): http://guidance.nice.org.uk/CG140
Source: National Institute for Health and Clinical Excellence (NICE), UK
Date: May 2012
Description: This guideline was developed for the treatment of patients who have advanced progressive disease that requires pain management at the 3rd level of the WHO pain ladder. The authors state that these recommendations were designed with the goal of clarifying some of the misconceptions surrounding the use of strong opioids while also weighing issues of patient safety. A “Care Pathway” outlines recommendations for patient communication, dose titration, first-line treatment in all delivery modes, breakthrough pain, maintenance therapy, and the management of adverse effects. A glossary includes definitions of terms and acronyms. Access checked June 7, 2012.
Palliative Care for the Patient with Incurable Cancer or Advanced Disease
Part 2: Pain and Symptom Management
Access: http://www.bcguidelines.ca/pdf/palliative2.pdf
Source: British Columbia Ministry of Health
Date: 2011
Description: Pain is one of the most disabling symptoms associated with an advanced cancer diagnosis. While this guideline provides information on the management of 7 key symptoms overall, the first section provides a review of cancer pain assessment and therapeutic strategies for its management. An algorithm offers multiple recommendations for nociceptive and neuropathic pain, and several tables provide guidance on pharmacologic treatment options, including: opioids, nonopioid analgesics, adjuvant drugs for neuropathic pain and bone pain, antispasmodics, and muscle relaxants. Additional tables include opioid and fentanyl transdermal equianalgesic conversion tables as well as information on fentanyl transdermal dosing for the management of breakthrough pain. Another algorithm addresses the management of constipation which can be due to an adverse effect of opioid therapy or caused by multi-factorial issues in patients with advanced cancer disease. 44 pages. Access checked May 2, 2013.
NHPCO Statement [guideline] on Palliative Sedation in Terminally Ill Patients
Access: http://www.nhpco.org/sites/default/files/public/JPSM/NHPCO_Pall-Sedation-Ther_JPSM_May2010.pdf
Date: May 2010
Print Reference: Kirk TW, Mahon MM, et al. National Hospice and Palliative Care Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently Dying Terminally Ill Patients. J Pain Sympt Manage. 2010(May);39(5):914-923.
Description: This statement and commentary seek to clarify the position of NHPCO on the use of palliative sedation for patients at the end of life, recommend questions and issues to be addressed in each case for which palliative sedation is being considered, and assist health care organizations in the development of policies for the use of palliative sedation. This addresses the use of palliative sedation only for patients who are terminally ill and whose death is imminent. Access checked March 19, 2013.
EAPC Framework for the Use of Sedation in Palliative Care
Access: http://www.eapcnet.eu/LinkClick.aspx?fileticket=RKDokneiDJc%3d&tabid=38
Date: 2009
Print Reference: Cherny NI, Radbruch L, et al. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009;27(3):581-593.
Description: Sedation is considered to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution with attention to potential risks; problematic approaches can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions. This document provides procedural guidelines from the EAPC to help educate medical providers and set standards for best practice. Access checked September 25, 2011.
Clinical Practice Guidelines for Quality Palliative Care, Second Edition
Access: http://www.nationalconsensusproject.org/Guideline.pdf
Source: National Consensus Project for Quality Palliative Care
Date: 2009
Description: These guidelines for palliative care were developed to promote consistent high quality care in a variety of healthcare settings. Models of assessment and care that integrate multiple disciplines are presented. While pain management is not addressed on a treatment level, the guidelines emphasize the importance of pain assessment and relief. The integration of physical palliative care with psychological, social, spiritual, cultural and ethical components is discussed as an important aspect of good palliative care. 90 Pages. Access checked April 14, 2009.
Consensus Guideline on Parenteral Methadone Use in Pain and Palliative Care
Access (abstract only): http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=1885928
(Full document available for purchase.)
Source: Cambridge Journals Online
Date: 2008
Print Reference: Shaiova L, Berger A, Blinderman CD, et al. Palliat Support Care. 2008(Jun);6(2):165-176.
Description: Consensus guidelines were developed by expert practitioners from 8 palliative care facilities to assist clinicians with the use of parenteral methadone for patients with life-limiting illnesses. The authors provide recommendations for opioid conversion and methadone dosing that could allow the drug to be used as a first- or second-line therapy to benefit palliative care patients. 12 Pages. Access checked April 14, 2009.
Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians
Access: http://www.annals.org/cgi/reprint/148/2/141.pdf
Source: American College of Physicians (ACP)
Date: 2008
Print Reference: Qaseem A, Snow V, Shekelle P, et al. Annals of Internal Medicine. 2008(Jan);148(2):141-146.
Description: This guideline, written for all practitioners caring for patients who need end-of-life care, begins with a working definition for end-of-life. Based on the 2003 report from the Institute of Medicine on the weaknesses in palliative care as well as a synthesis of existing evidence for effective end-of-life care, 5 recommendations were developed. The guideline only presents interventions with strong to moderate evidence for the management or prevention of the symptoms of pain, dyspnea, and depression. It does not address many other important aspects of physical, psychological and social needs at the end of life. Access checked April 14, 2009.
Procedure Guideline for Palliative Treatment of Painful Bone Metastases
Access: http://interactive.snm.org/index.cfm?PageID=804&RPID=772
Source: Society of Nuclear Medicine
Date: 2003
Description: Radiopharmaceuticals are approved for the treatment of bone pain in patients with metastatic malignancy in multiple skeletal sites. This guideline is the result of a systematic review of the literature with a subsequent analysis and compilation of procedural recommendations for intravenous injection of radiopharmaceuticals by the Guideline Development Subcommittee and Task Force. The recommendations cover patient preparation, instructions for patients, precautions, guidelines for dosing, measurement of the agent activity, interventions reporting, quality issues and potential complications. 8 Pages. Access checked April 14, 2009.
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Pediatric Pain
WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses
Access: http://whqlibdoc.who.int/publications/2012/9789241548120_Guidelines.pdf
Source: World Health Organization (WHO)
Date: 2012
Description: This WHO guideline focuses on the pharmacological management of persistent pain in children with medical diseases that cause ongoing tissue damage. It addresses the treatment of cancer and noncancer pain, replacing the 1998 WHO guideline entitled Cancer Pain Relief and Palliative Care in Children. These recommendations use a new two-step approach based on pain severity which represents a move away from the WHO three-step analgesic ladder for pediatric patients. The primary focus is on pharmacological treatment and includes a discussion of the causes and characteristics of acute and persisting pain for many specific disease conditions. A two-page overview of the clinical recommendations includes a summary of the basic principles of pediatric pain management as well as the 23 recommendations developed in this initiative. Recommendations for the treatment of moderate to severe pain in certain situations may include non-pharmacological methods and the combination of non-opioid and opioid agents. WHO experts also identified specific concerns regarding geographic regions with overly restrictive provisions related to controlled drugs and have developed a list of policy change recommendations, some of which are covered in these guidelines. 172 pages. Access checked February 28, 2013.
Consensus Guidelines for Sustained Neuromuscular Blockade in Critically Ill Children
Access (abstract only): http://onlinelibrary.wiley.com/doi/10.1111/j.1460-9592.2007.02313.x/abstract
(Full document available for purchase.)
Source: United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group
Date: 2007
Print Reference: Playfor S, Jenkins I, Boyles C, et al. Paediatric Anaesthesia. 2007(Sep);17(9):881-887.
Description: This multidisciplinary consensus guideline was developed through multiple consensus conferences and a systematic review of the literature. The authors state that this is the first set of guidelines on sedation, analgesia and maintenance neuromuscular blockade in the critically ill pediatric patient (not including neonates). The guideline includes 6 key levels-of-evidence recommendations and the Working Group recommends the implementation of further trials in this area. Access checked December 13, 2010.
Guideline Statement: Management of Procedure-Related Pain in Children and Adolescents
Access (abstract only): http://dx.doi.org/10.1111/j.1440-1754.2006.00798_2.x
(Full document available for purchase.)
Source: Royal Australasian College of Physicians
Date: 2006
Print Reference: Guideline statement. Management of procedure-related pain in children and adolescents. Journal of Paediatrics and Child Health. 2006(Feb);42(Suppl 1):S2-S30.
Description: Based on the theory that children experience more pain that necessary during procedures, this guideline begins with an examination of the assessment of pain and anxiety and continues with a discussion of the consequences of under-treating pain. An evaluation of the child and an assessment of appropriate preparations prior to the procedure are important steps before implementing recommended environmental, behavioral, and pharmacological techniques. Levels of evidence recommendations are made for a very comprehensive list of procedures from suturing a laceration or biopsy site to tube insertion and removal. Special considerations for children with communication problems are discussed. 29 Pages. Access checked December 13, 2010.
Guideline Statement: Management of Procedure-Related Pain in Neonates
Access (abstract only): http://dx.doi.org/10.1111/j.1440-1754.2006.00799_2.x
(Full document available for purchase.)
Source: Royal Australasian College of Physicians
Date: 2006
Print Reference: Guideline statement. Management of procedure-related pain in neonates. Journal of Paediatrics and Child Health. 2006(Feb);42(Suppl 1):S31-S39.
Description: The guideline begins with a discussion of the consequences of neonatal pain and continues with pain assessment techniques. Strength of evidence recommendations for pain reduction from blood sampling to tube insertion and laser therapy are presented. Guidance is offered for preventive pain measures as well as environmental, behavioral, procedural, and pharmacological modifications for each procedure. 9 Pages. Access checked December 13, 2010.
Practice Parameter: Evaluation of Children and Adolescents With Recurrent Headaches
Access: http://www.neurology.org/cgi/reprint/59/4/490.pdf
Source: Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society
Date: Guideline re-affirmed in October 2005
Print Reference: Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches. Neurology. 2002(Aug);59(4):490-498.
Description: Diagnostic guidelines are based on 4 levels of evidence for recommendation. A discussion on the use of routine laboratory studies, lumbar puncture, EEG testing and neuroimaging is based on evidence of appropriateness following the clinical neurological examination. 9 Pages. Access checked April 14, 2009.
Clinical Report: Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems
Access: http://pediatrics.aappublications.org/cgi/reprint/114/5/1348
Source: American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
Date: 2004
Print Reference: Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2004(Nov);114(5):1348-56.
Description: Emergency department pain management can minimize distress and pain in children if a systematic approach is used. The environment, staff education, use of protocols, and new modalities of pain control can help manage this complex element of emergency care. Guidelines are provided for triaging oral analgesics, the use of EMLA/LMX4, the placement of topical anesthetics on open wounds, and the use of sucrose in neonates. This document is titled "clinical report"; however, it is included in the Clinical Guidelines section on the American Academy of Pediatrics website. 9 Pages. Access checked April 14, 2009.
Practice Parameter: Pharmacological Treatment of Migraine Headache in Children and Adolescents
Access: http://www.neurology.org/cgi/reprint/63/12/2215.pdf
Source: American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society
Date: 2004
Print Reference: Lewis D, Ashwal S, Hershey A, et al. Practice Parameter: Pharmacological treatment of migraine headache in children and adolescents. Neurology. 2004(Dec 28);63(12):2215-2224.
Description: The authors reviewed 166 articles on the acute and preventive pharmacological treatment of children and adolescents. Recommendations are made according to the strength of evidence. The authors state that "there is a paucity of controlled data regarding the treatment of primary headache disorders” in this population and make 7 recommendations for further study. 10 Pages. Access checked April 14, 2009.
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Perioperative Pain
Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management
Access: http://www.asahq.org/.../PracticeParameters/AcutePainManagementInThePerioperativeSetting.ashx
Source: American Society of Anesthesiologists - Medical Specialty Society
Date: 2012 (Update of 2004 published guideline; originally developed in 1995)
Description: This updated report was designed to review recent evidence-based studies and revise recommendations on acute pain management in the perioperative setting to improve efficacy and safety while reducing the risk of adverse outcomes. The guidelines address: 1) institutional policies, 2) preoperative patient evaluation, 3) preoperative preparation, 4) perioperative pain management including multimodal techniques, and 5) subpopulations at greater risk. 26 Pages. Access checked March 14, 2012.
ASPAN Pain and Clinical Comfort Guideline
Access: http://www.aspan.org/Portals/6/docs/ClinicalPractice/Guidelines/ASPAN_ClinicalGuideline_PainComfort.pdf
Source: American Society of PeriAnesthesia Nurses
Print Reference: ASPAN pain and comfort clinical guideline. J Perianesth Nurs. 2003(Aug);18(4):232-6.
Description: Guidelines for the perianesthesia environment begin with the pre-operative assessment and continue through postanesthesia phases I/II/III assessments, interventions, and expected outcomes. Complementary non-pharmacologic strategies are included in this nursing care plan protocol. 5 Pages. Access checked April 14, 2009.
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