- Email: [email protected]
Postoperative pain management: Number-needed-to-treat approach versus procedure-specific pain management approach
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178
Letters to the Editor / PAIN 154 (2013) 175–180
using comprehensive assessments [9,18,24]. Cross-fertilization between these networks is highly desirable. We appreciate the prompt to be ‘‘back for good’’ that made us reconsider this topic. Conflict of interest The authors report no conflict of interest. Acknowledgement The authors’ work is supported by DFNS and IMI-EuroPain. CG is supported by the ‘‘Kalkhof-Rose-Stiftung’’. References [1] Ageberg E, Flenhagen J, Ljung J. Test–retest reliability of knee kinesthesia in healthy adults. BMC Musculoskelet Disord 2007;8:57. [2] Altman DG, Bland JM. Measurement in medicine: the analysis of method comparison studies. Statistician 1983;32:307–17. [3] Bartlett MS. The use of transformations. Biometrics 1947;3:39–52. [4] Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10. [5] Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res 1999;8:135–60. [6] Box G, Cox D. An analysis of transformations. J R Stat Soc Ser B 1964;26:211–52. [7] Duke J, McEvoy M, Sibbritt D, Guest M, Smith W, Attia J. Vibrotactile threshold measurement for detecting peripheral neuropathy: defining variability and a normal range for clinical and research use. Diabetologia 2007;50:2305–12. [8] Geber C, Klein T, Azad S, Birklein F, Gierthmuhlen J, Huge V, Lauchart M, Nitzsche D, Stengel M, Valet M, Baron R, Maier C, Tolle T, Treede RD. Test– retest and interobserver reliability of quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain (DFNS): a multi-centre study. PAINÒ 2011;152:548–56. [9] Hastie BA, Riley III JL, Robinson ME, Glover T, Campbell CM, Staud R, Fillingim RB. Cluster analysis of multiple experimental pain modalities. PAINÒ 2005;116:227–37. [10] Hirschfeld G, Zernikow B, Kraemer N, Hechler T, Aksu F, Krumova E, Maier C, Magerl W, Blankenburg M. Development of somatosensory perception in children: a longitudinal QST-study. Neuropediatrics 2012;43:10–6. [11] Klein M, Birch DG. Psychophysical assessment of low visual function in patients with retinal degenerative diseases (RDDs) with the Diagnosys fullfield stimulus threshold (D-FST). Doc Ophthalmol 2009;119:217–24. [12] Lauria G, Cazzato D, Porretta-Serapiglia C, Casanova-Molla J, Taiana M, Penza P, Lombardi R, Faber CG, Merkies IS. Morphometry of dermal nerve fibers in human skin. Neurology 2011;77:242–9. [13] Løseth S, Mellgren SI, Jorde R, Lindal S, Stalberg E. Polyneuropathy in type 1 and type 2 diabetes: comparison of nerve conduction studies, thermal perception thresholds and intraepidermal nerve fibre densities. Diabetes Metab Res Rev 2010;26:100–6. [14] Mackay AM, Bradnam MS, Hamilton R, Elliot AT, Dutton GN. Real-time rapid acuity assessment using VEPs: development and validation of the step VEP technique. Invest Ophthalmol Vis Sci 2008;49:438–41. [15] Magerl W, Krumova EK, Baron R, Tolle T, Treede RD, Maier C. Reference data for quantitative sensory testing (QST): refined stratification for age and a novel method for statistical comparison of group data. PAINÒ 2011;151:598–605. [16] Maier C, Baron R, Tolle TR, Binder A, Birbaumer N, Birklein F, Gierthmuhlen J, Flor H, Geber C, Huge V, Krumova EK, Landwehrmeyer GB, Magerl W, Maihofner C, Richter H, Rolke R, Scherens A, Schwarz A, Sommer C, Tronnier V, Uceyler N, Valet M, Wasner G, Treede RD. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): somatosensory abnormalities in 1236 patients with different neuropathic pain syndromes. PAINÒ 2010;150:439–50. [17] McArthur JC, Stocks EA, Hauer P, Cornblath DR, Griffin JW. Epidermal nerve fiber density: normative reference range and diagnostic efficiency. Arch Neurol 1998;55:1513–20. [18] Neziri AY, Scaramozzino P, Andersen OK, Dickenson AH, Arendt-Nielsen L, Curatolo M. Reference values of mechanical and thermal pain tests in a painfree population. Eur J Pain 2011;15:376–83. [19] Rolke R, Baron R, Maier C, Tolle TR, Treede RD, Beyer A, Binder A, Birbaumer N, Birklein F, Botefur IC, Braune S, Flor H, Huge V, Klug R, Landwehrmeyer GB, Magerl W, Maihofner C, Rolko C, Schaub C, Scherens A, Sprenger T, Valet M, Wasserka B. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. PAINÒ 2006;123:231–43.
[20] Rolke R, Magerl W, Campbell KA, Schalber C, Caspari S, Birklein F, Treede RD. Quantitative sensory testing: a comprehensive protocol for clinical trials. Eur J Pain 2006;10:77–88. [21] Stevens SS. On the psychophysical law. Psychol Rev 1957;64:153–81. [22] Treede RD, Baron R. How to detect a sensory abnormality. Eur J Pain 2008;12:395–6. [23] Tukey J. On the comparative anatomy of transformations. Ann Math Stat 1957;28:602–32. [24] Walk D, Sehgal N, Moeller-Bertram T, Edwards RR, Wasan A, Wallace M, Irving G, Argoff C, Backonja MM. Quantitative sensory testing and mapping: a review of nonautomated quantitative methods for examination of the patient with neuropathic pain. Clin J Pain 2009;25:632–40. [25] Wöpking S, Scherens A, Haussleiter IS, Richter H, Schuning J, Klauenberg S, Maier C. Significant difference between three observers in the assessment of intraepidermal nerve fiber density in skin biopsy. BMC Neurol 2009;9:13. [26] Zinman LH, Ngo M, Ng ET, Nwe KT, Gogov S, Bril V. Low-intensity laser therapy for painful symptoms of diabetic sensorimotor polyneuropathy: a controlled trial. Diabetes Care 2004;27:921–4.
Christian Geber Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Germany E-mail addresses: [email protected] Rolf-Detlef Treede Walter Magerl Lehrstuhl für Neurophysiologie, CBTM, Medizinische Fakultät Mannheim der Universität Heidelberg, Germany 0304-3959/$36.00 Ó 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2012.10.012
Postoperative pain management: Number-needed-to-treat approach versus procedure-specific pain management approach
To the Editor: We read with great interest the article by McQuay et al. [11] that reported the use of number-needed-to-treat (NNT) league tables as a guide to measuring efficacy of various analgesic drugs. The authors present several benefits of using the league tables to guide analgesic choice. However, the authors did not discuss the limitations of using NNT as a guide to pain therapy in day-to-day clinical practice. We would like to point out some of the limitations of using NNT to guide pain therapy. The concept of NNT is dichotomous, as it sets a cutoff at 50% pain relief compared with placebo, which implies that gradual effects of analgesic cannot be considered. However, therapeutic objectives may vary based upon patient population and surgical procedures. Thus, although an analgesic providing 30% pain relief may be considered clinically relevant, it will be deemed to be ineffective based on NNT league tables. Furthermore, the clinical significance of a 50% reduction in pain scores may vary based upon the degree of pain at the time of measurement. For example, a reduction from a pain score of 8/10 to 4/10 has different clinical significance than a reduction from a pain score of 4/10 to 2/10. Another limitation is that the data used to calculate NNT values are derived predominantly from relatively minor surgical procedures (eg, dental procedures and minor peripheral procedures), which may not be valid for major surgical procedures. Because of differences in pathophysiology between different types of surgical procedures, the type of pain (eg, somatic vs visceral), location of pain, and intensity of pain vary significantly. Therefore, efficacy of an analgesic may vary based upon the type of surgical procedure. For example, the efficacy of paracetamol is higher for dental procedures
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Letters to the Editor / PAIN 154 (2013) 175–180
compared with orthopedic procedures [4]. Thus, it may be inappropriate to pool data from various different pain models (ie, multiple surgical procedures) to perform NNT calculations. Although the authors claim that their previous analysis found no consistent differences in NNT values between the different types of surgical procedures [1], they acknowledge the limitations of these analyses. Furthermore, the consequences of pain may vary based upon the type of surgical procedure. For example, pain after thoracic surgery may cause pulmonary dysfunction and influence postoperative morbidity. This requires consideration of the risk–benefit ratio of an analgesic technique, which may vary between different surgical procedures; although a neuraxial analgesic technique may be suitable for providing pain relief after thoracic surgery, it may not be appropriate for routine use after laparoscopic cholecystectomy. Also, the adverse effects of certain analgesics may prevent their use after selective surgical procedures (eg, use of nonsteroidal antiinflammatory drugs with tonsillectomy). Similarly, the consequences of opioid-related adverse effects may vary between surgical procedures. Overall, NNT represents a generalized approach to pain management, which may confuse a clinician who wishes to provide optimal analgesia for a specific surgical procedure. Similarly, the NNT league tables may not be relevant for certain situations such as acute pain therapy in patients with chronic pain and where analgesia is required for longer periods of time, as well as for settings not included in the studies used to determine the NNT values. This may be one of the reasons for a disparity between clinical practice and the available guidelines. The PROSPECT (Procedure-Specific Postoperative Pain Management) initiative is a Web-based clinical decision support program that aims to provide health care professionals with practical procedure-specific pain management recommendations formulated in a way that facilitates clinical decision-making across all the stages of the perioperative period (www.postoppain.org) [10]. The development of these recommendations is based on a rigorously defined methodological process [12], which includes systematic reviews of the literature (using the protocol of the Cochrane Collaboration to evaluate randomized controlled trials of analgesic, anesthetic, and surgical interventions affecting postoperative pain) in the specific type of surgery. The procedure-specific systematic reviews are supplemented with evidence from other similar surgical procedures (ie, transferable evidence) and clinical practice information (ie, practical guidelines from the PROSPECT Working Group). The availability of detailed information allows the readers to assess the evidence and make their own decisions based on their practice [2,3,5–9]. Thus, this approach may encourage practitioners to incorporate these recommendations into their practice and develop procedure-specific clinical pathways for pain management, which is relevant to their practice. Overall, although NNT league tables may have several advantages (eg, simplicity and easy comparison between drugs), the PROSPECT approach balances the evidence with clinical practice to provide procedure-specific pain management guidelines. However, this is not to suggest that a procedure-specific pain management approach is a substitute for NNT in every situation, because at times the NNT approach and procedure-specific pain management approach can be complementary. References [1] Barden J, Edwards JE, McQuay HJ, Andrew More R. Pain and analgesic response after third molar extraction and other postsurgical pain. PAINÒ 2004;107:86–90. [2] Fischer HB, Simanski CJ. A procedure-specific systematic review and consensus recommendations for postoperative analgesia after total hip replacement. Anaesthesia 2005;60:1189–202. [3] Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA, Rawal N, Joshi GP, Schug SA, PROSPECT Working Group. A procedure-specific systematic
[4]
[5]
[6]
[7] [8] [9]
[10]
[11]
[12]
179
review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 2008;63:1105–23. Gray A, Kehlet H, Bonnet F, Rawal N. Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence? Br J Anaesth 2005;94:710–4. Joshi GP, Bonnet F, Kehlet H, PROSPECT Group. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis (in press). Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, Neugebauer EA, Rawal N, Schug SA, Simanski C, Kehlet H. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026–40. Joshi GP, PROSPECT Collaboration. Evidence-based management of pain after haemorrhoidectomy surgery. Br J Surg 2010;97:1155–68. Joshi GP, Rawal N, PROSPECT Collaboration. Evidence-based management of pain after open hernia surgery. Br J Surg 2012;99:168–85. Kehlet H, Gray AW, Bonnet F, Camu F, Fischer HB, McCloy RF, Neugebauer EA, Puig MM, Rawal N, Simanski CJ. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy. Surg Endosc 2005;19:1396–415. Kehlet H, Wilkinson RC, Fischer HB, Camu F. PROSPECT: evidence-based, procedure-specific postoperative pain management. Best Pract Res Clin Anesthesiol 2007;21:149–59. McQuay HJ, Derry S, Eccleston C, Wiffen PJ, Andrew Moore R. Evidence for analgesic effect in acute pain – 50 years on. PAINÒ 2012;153: 1364–7. Neugebauer E, Wilkinson R, Kehlet H, PROSPECT Group. PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain. Surg Endosc 2007;21:1047–53.
Girish P. Joshi The PROSPECT Working Group Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA Address: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA E-mail addresses: [email protected] Stephan A. Schug School of Medicine and Pharmacology, University of Western Australia, Perth, Australia Francis Bonnet Department d’Anesthésie Reanimation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre & Marie Curie, Paris, France H.B.J. Fischer Department of Anaesthesiology, Alexandra Hospital, Redditch, Worcestershire, UK Edmund A.M. Neugebauer Institute of Research in Operative Medicine, University of Witten-Herdecke, Cologne, Germany Narinder Rawal Department of Anaesthesia and Intensive Care, University Hospital, Örebro, Sweden Christian J.P. Simanski Department of Trauma and Orthopaedic Surgery Cologne-Merheim, University of Witten-Herdecke, Cologne, Germany Henrik Kehlet Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark 0304-3959/$36.00 Ó 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2012.10.006
178
Letters to the Editor / PAIN 154 (2013) 175–180
using comprehensive assessments [9,18,24]. Cross-fertilization between these networks is highly desirable. We appreciate the prompt to be ‘‘back for good’’ that made us reconsider this topic. Conflict of interest The authors report no conflict of interest. Acknowledgement The authors’ work is supported by DFNS and IMI-EuroPain. CG is supported by the ‘‘Kalkhof-Rose-Stiftung’’. References [1] Ageberg E, Flenhagen J, Ljung J. Test–retest reliability of knee kinesthesia in healthy adults. BMC Musculoskelet Disord 2007;8:57. [2] Altman DG, Bland JM. Measurement in medicine: the analysis of method comparison studies. Statistician 1983;32:307–17. [3] Bartlett MS. The use of transformations. Biometrics 1947;3:39–52. [4] Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10. [5] Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res 1999;8:135–60. [6] Box G, Cox D. An analysis of transformations. J R Stat Soc Ser B 1964;26:211–52. [7] Duke J, McEvoy M, Sibbritt D, Guest M, Smith W, Attia J. Vibrotactile threshold measurement for detecting peripheral neuropathy: defining variability and a normal range for clinical and research use. Diabetologia 2007;50:2305–12. [8] Geber C, Klein T, Azad S, Birklein F, Gierthmuhlen J, Huge V, Lauchart M, Nitzsche D, Stengel M, Valet M, Baron R, Maier C, Tolle T, Treede RD. Test– retest and interobserver reliability of quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain (DFNS): a multi-centre study. PAINÒ 2011;152:548–56. [9] Hastie BA, Riley III JL, Robinson ME, Glover T, Campbell CM, Staud R, Fillingim RB. Cluster analysis of multiple experimental pain modalities. PAINÒ 2005;116:227–37. [10] Hirschfeld G, Zernikow B, Kraemer N, Hechler T, Aksu F, Krumova E, Maier C, Magerl W, Blankenburg M. Development of somatosensory perception in children: a longitudinal QST-study. Neuropediatrics 2012;43:10–6. [11] Klein M, Birch DG. Psychophysical assessment of low visual function in patients with retinal degenerative diseases (RDDs) with the Diagnosys fullfield stimulus threshold (D-FST). Doc Ophthalmol 2009;119:217–24. [12] Lauria G, Cazzato D, Porretta-Serapiglia C, Casanova-Molla J, Taiana M, Penza P, Lombardi R, Faber CG, Merkies IS. Morphometry of dermal nerve fibers in human skin. Neurology 2011;77:242–9. [13] Løseth S, Mellgren SI, Jorde R, Lindal S, Stalberg E. Polyneuropathy in type 1 and type 2 diabetes: comparison of nerve conduction studies, thermal perception thresholds and intraepidermal nerve fibre densities. Diabetes Metab Res Rev 2010;26:100–6. [14] Mackay AM, Bradnam MS, Hamilton R, Elliot AT, Dutton GN. Real-time rapid acuity assessment using VEPs: development and validation of the step VEP technique. Invest Ophthalmol Vis Sci 2008;49:438–41. [15] Magerl W, Krumova EK, Baron R, Tolle T, Treede RD, Maier C. Reference data for quantitative sensory testing (QST): refined stratification for age and a novel method for statistical comparison of group data. PAINÒ 2011;151:598–605. [16] Maier C, Baron R, Tolle TR, Binder A, Birbaumer N, Birklein F, Gierthmuhlen J, Flor H, Geber C, Huge V, Krumova EK, Landwehrmeyer GB, Magerl W, Maihofner C, Richter H, Rolke R, Scherens A, Schwarz A, Sommer C, Tronnier V, Uceyler N, Valet M, Wasner G, Treede RD. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): somatosensory abnormalities in 1236 patients with different neuropathic pain syndromes. PAINÒ 2010;150:439–50. [17] McArthur JC, Stocks EA, Hauer P, Cornblath DR, Griffin JW. Epidermal nerve fiber density: normative reference range and diagnostic efficiency. Arch Neurol 1998;55:1513–20. [18] Neziri AY, Scaramozzino P, Andersen OK, Dickenson AH, Arendt-Nielsen L, Curatolo M. Reference values of mechanical and thermal pain tests in a painfree population. Eur J Pain 2011;15:376–83. [19] Rolke R, Baron R, Maier C, Tolle TR, Treede RD, Beyer A, Binder A, Birbaumer N, Birklein F, Botefur IC, Braune S, Flor H, Huge V, Klug R, Landwehrmeyer GB, Magerl W, Maihofner C, Rolko C, Schaub C, Scherens A, Sprenger T, Valet M, Wasserka B. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. PAINÒ 2006;123:231–43.
[20] Rolke R, Magerl W, Campbell KA, Schalber C, Caspari S, Birklein F, Treede RD. Quantitative sensory testing: a comprehensive protocol for clinical trials. Eur J Pain 2006;10:77–88. [21] Stevens SS. On the psychophysical law. Psychol Rev 1957;64:153–81. [22] Treede RD, Baron R. How to detect a sensory abnormality. Eur J Pain 2008;12:395–6. [23] Tukey J. On the comparative anatomy of transformations. Ann Math Stat 1957;28:602–32. [24] Walk D, Sehgal N, Moeller-Bertram T, Edwards RR, Wasan A, Wallace M, Irving G, Argoff C, Backonja MM. Quantitative sensory testing and mapping: a review of nonautomated quantitative methods for examination of the patient with neuropathic pain. Clin J Pain 2009;25:632–40. [25] Wöpking S, Scherens A, Haussleiter IS, Richter H, Schuning J, Klauenberg S, Maier C. Significant difference between three observers in the assessment of intraepidermal nerve fiber density in skin biopsy. BMC Neurol 2009;9:13. [26] Zinman LH, Ngo M, Ng ET, Nwe KT, Gogov S, Bril V. Low-intensity laser therapy for painful symptoms of diabetic sensorimotor polyneuropathy: a controlled trial. Diabetes Care 2004;27:921–4.
Christian Geber Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität, Mainz, Germany E-mail addresses: [email protected] Rolf-Detlef Treede Walter Magerl Lehrstuhl für Neurophysiologie, CBTM, Medizinische Fakultät Mannheim der Universität Heidelberg, Germany 0304-3959/$36.00 Ó 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2012.10.012
Postoperative pain management: Number-needed-to-treat approach versus procedure-specific pain management approach
To the Editor: We read with great interest the article by McQuay et al. [11] that reported the use of number-needed-to-treat (NNT) league tables as a guide to measuring efficacy of various analgesic drugs. The authors present several benefits of using the league tables to guide analgesic choice. However, the authors did not discuss the limitations of using NNT as a guide to pain therapy in day-to-day clinical practice. We would like to point out some of the limitations of using NNT to guide pain therapy. The concept of NNT is dichotomous, as it sets a cutoff at 50% pain relief compared with placebo, which implies that gradual effects of analgesic cannot be considered. However, therapeutic objectives may vary based upon patient population and surgical procedures. Thus, although an analgesic providing 30% pain relief may be considered clinically relevant, it will be deemed to be ineffective based on NNT league tables. Furthermore, the clinical significance of a 50% reduction in pain scores may vary based upon the degree of pain at the time of measurement. For example, a reduction from a pain score of 8/10 to 4/10 has different clinical significance than a reduction from a pain score of 4/10 to 2/10. Another limitation is that the data used to calculate NNT values are derived predominantly from relatively minor surgical procedures (eg, dental procedures and minor peripheral procedures), which may not be valid for major surgical procedures. Because of differences in pathophysiology between different types of surgical procedures, the type of pain (eg, somatic vs visceral), location of pain, and intensity of pain vary significantly. Therefore, efficacy of an analgesic may vary based upon the type of surgical procedure. For example, the efficacy of paracetamol is higher for dental procedures
Ò
Letters to the Editor / PAIN 154 (2013) 175–180
compared with orthopedic procedures [4]. Thus, it may be inappropriate to pool data from various different pain models (ie, multiple surgical procedures) to perform NNT calculations. Although the authors claim that their previous analysis found no consistent differences in NNT values between the different types of surgical procedures [1], they acknowledge the limitations of these analyses. Furthermore, the consequences of pain may vary based upon the type of surgical procedure. For example, pain after thoracic surgery may cause pulmonary dysfunction and influence postoperative morbidity. This requires consideration of the risk–benefit ratio of an analgesic technique, which may vary between different surgical procedures; although a neuraxial analgesic technique may be suitable for providing pain relief after thoracic surgery, it may not be appropriate for routine use after laparoscopic cholecystectomy. Also, the adverse effects of certain analgesics may prevent their use after selective surgical procedures (eg, use of nonsteroidal antiinflammatory drugs with tonsillectomy). Similarly, the consequences of opioid-related adverse effects may vary between surgical procedures. Overall, NNT represents a generalized approach to pain management, which may confuse a clinician who wishes to provide optimal analgesia for a specific surgical procedure. Similarly, the NNT league tables may not be relevant for certain situations such as acute pain therapy in patients with chronic pain and where analgesia is required for longer periods of time, as well as for settings not included in the studies used to determine the NNT values. This may be one of the reasons for a disparity between clinical practice and the available guidelines. The PROSPECT (Procedure-Specific Postoperative Pain Management) initiative is a Web-based clinical decision support program that aims to provide health care professionals with practical procedure-specific pain management recommendations formulated in a way that facilitates clinical decision-making across all the stages of the perioperative period (www.postoppain.org) [10]. The development of these recommendations is based on a rigorously defined methodological process [12], which includes systematic reviews of the literature (using the protocol of the Cochrane Collaboration to evaluate randomized controlled trials of analgesic, anesthetic, and surgical interventions affecting postoperative pain) in the specific type of surgery. The procedure-specific systematic reviews are supplemented with evidence from other similar surgical procedures (ie, transferable evidence) and clinical practice information (ie, practical guidelines from the PROSPECT Working Group). The availability of detailed information allows the readers to assess the evidence and make their own decisions based on their practice [2,3,5–9]. Thus, this approach may encourage practitioners to incorporate these recommendations into their practice and develop procedure-specific clinical pathways for pain management, which is relevant to their practice. Overall, although NNT league tables may have several advantages (eg, simplicity and easy comparison between drugs), the PROSPECT approach balances the evidence with clinical practice to provide procedure-specific pain management guidelines. However, this is not to suggest that a procedure-specific pain management approach is a substitute for NNT in every situation, because at times the NNT approach and procedure-specific pain management approach can be complementary. References [1] Barden J, Edwards JE, McQuay HJ, Andrew More R. Pain and analgesic response after third molar extraction and other postsurgical pain. PAINÒ 2004;107:86–90. [2] Fischer HB, Simanski CJ. A procedure-specific systematic review and consensus recommendations for postoperative analgesia after total hip replacement. Anaesthesia 2005;60:1189–202. [3] Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA, Rawal N, Joshi GP, Schug SA, PROSPECT Working Group. A procedure-specific systematic
[4]
[5]
[6]
[7] [8] [9]
[10]
[11]
[12]
179
review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 2008;63:1105–23. Gray A, Kehlet H, Bonnet F, Rawal N. Predicting postoperative analgesia outcomes: NNT league tables or procedure-specific evidence? Br J Anaesth 2005;94:710–4. Joshi GP, Bonnet F, Kehlet H, PROSPECT Group. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis (in press). Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, Neugebauer EA, Rawal N, Schug SA, Simanski C, Kehlet H. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026–40. Joshi GP, PROSPECT Collaboration. Evidence-based management of pain after haemorrhoidectomy surgery. Br J Surg 2010;97:1155–68. Joshi GP, Rawal N, PROSPECT Collaboration. Evidence-based management of pain after open hernia surgery. Br J Surg 2012;99:168–85. Kehlet H, Gray AW, Bonnet F, Camu F, Fischer HB, McCloy RF, Neugebauer EA, Puig MM, Rawal N, Simanski CJ. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy. Surg Endosc 2005;19:1396–415. Kehlet H, Wilkinson RC, Fischer HB, Camu F. PROSPECT: evidence-based, procedure-specific postoperative pain management. Best Pract Res Clin Anesthesiol 2007;21:149–59. McQuay HJ, Derry S, Eccleston C, Wiffen PJ, Andrew Moore R. Evidence for analgesic effect in acute pain – 50 years on. PAINÒ 2012;153: 1364–7. Neugebauer E, Wilkinson R, Kehlet H, PROSPECT Group. PROSPECT: a practical method for formulating evidence-based expert recommendations for the management of postoperative pain. Surg Endosc 2007;21:1047–53.
Girish P. Joshi The PROSPECT Working Group Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA Address: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA E-mail addresses: [email protected] Stephan A. Schug School of Medicine and Pharmacology, University of Western Australia, Perth, Australia Francis Bonnet Department d’Anesthésie Reanimation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris, Université Pierre & Marie Curie, Paris, France H.B.J. Fischer Department of Anaesthesiology, Alexandra Hospital, Redditch, Worcestershire, UK Edmund A.M. Neugebauer Institute of Research in Operative Medicine, University of Witten-Herdecke, Cologne, Germany Narinder Rawal Department of Anaesthesia and Intensive Care, University Hospital, Örebro, Sweden Christian J.P. Simanski Department of Trauma and Orthopaedic Surgery Cologne-Merheim, University of Witten-Herdecke, Cologne, Germany Henrik Kehlet Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark 0304-3959/$36.00 Ó 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2012.10.006