Anecdotally, many patients experience extreme discomfort after shoulder surgery. The April 5, 2017 issue of JBJS features results from a randomized controlled trial comparing morphine consumption and pain during the 24 hours following shoulder arthroplasty among two groups. One group (n=78) received a preoperative interscalene brachial plexus blockade, while the other (n=78) received intraoperative infiltration of bupivacaine liposome suspension.
Mean total postoperative narcotic consumption during the 24 hours after surgery was not significantly different between the two groups, although intraoperative narcotic consumption was significantly lower in the blockade group. The mean VAS pain scores were significantly lower in the blockade group at 0 and 8 hours postoperatively, the same as in the infiltration group at 16 hours postoperatively, and significantly higher than those in the infiltration group at 24 hours postoperatively. That last finding in patients undergoing blockade represents the phenomenon known as “rebound pain.”
The authors, Namdari et al., conclude that the “optimal postoperative pain regimen for shoulder arthroplasty…require[s] further investigation.” But their analysis uncovered four demographic factors that were associated with higher pain scores at 24 hours after surgery, regardless of the analgesic technique used:
- Younger age
- History of depression
- Higher Charlson Comorbidity Score
- Higher preoperative VAS score
In his commentary on the study, Ranjan Gupta, MD notes that one downside of the block approach is “an inability to assess the patient’s neurologic function after the surgical procedure.” His own early clinical experience leads him to favor the admittedly “laborious” infiltration approach, partly because “both patients and orthopaedic nurses who take care of these patients in the immediate postoperative time period can readily appreciate the lack of rebound pain.”
Ask anyone who has had rotator cuff surgery, and they’ll tell you how painful the first three postop months can be. Electrical stimulation might make that time period easier for patients.
A recent randomized controlled trial in Orthopedics found that 32 patients who received pulsed electromagnetic stimulation (applied at home through a battery-operated device) six to eight hours daily for six weeks after arthroscopic rotator cuff surgery had lower VAS pain scores and better Constant-Murley scores three months after surgery, when compared to a placebo group of 34 patients who used identical devices with the batteries removed. Additionally, patients in the active-treatment group returned to work and daily activities after an average of 3.4 months after surgery, compared to an average of 5.3 months for those in the control group.
All participants had similar small-to-medium rotator cuff tears, received the same surgical single-row repair, and underwent virtually identical rehab protocols. Clinical and functional outcomes had continued to improve for all patients at the two-year follow-up, but by then the between-group differences seen at three months had disappeared. The authors did not conduct an economic analysis of the use of the electromagnetic treatment.
Although this study shows that benefits from electromagnetic stimulation are short-lived, they occur at a postsurgical point in time that is clinically difficult for many rotator cuff patients.