Transcutaneous electrical nerve stimulation for postoperative pain relief after arthroscopic rotator cuff repair: a prospective double-blinded randomized trial

Effect of Transcutaneous Electrical Nerve Stimulation on Patients with Total Knee Replacement: A Randomized Controlled Trial

PURPOSE

The aim of this study was to determine the effect of transcutaneous electrical nerve stimulation (TENS) on pain, functionality, quality of life, and analgesic consumption in patients undergoing TKR.

DESIGN

A single center, randomized controlled trial.

METHODS

A total of 52 participants were randomly assigned to the intervention (n = 26) and control (n = 26) groups. The intervention group was exposed to conventional TENS. Data were collected with a Patient Identification Form, the Visual Analogue Scale (VAS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Quality of Life Scale (SF-36), and the Analgesic Tracking Form.

RESULTS

VAS and WOMAC scores significantly decreased in the intervention group, over time, while they increased in the control group. SF-36 scores significantly increased in the intervention group over time. It was determined that analgesic consumption was significantly lower in the intervention group than in the control group.

CONCLUSIONS

TENS significantly reduced pain and increased functionality and quality of life. Our findings suggest that TENS may be an effective adjunctive analgesic therapy in patients receiving TKR; however, more testing is needed in larger and more heterogeneous populations.

CLINICAL IMPLICATIONS

Nurses can provide effective postoperative pain control in patients undergoing TKR, increase functionality, accelerate the healing process, and improve their quality of life by using TENS, a non-pharmacological treatment method, in the perioperative period.

Effect of Gabapentin on Tendon-to-Bone Healing in a Rat Model of Rotator Cuff Repair

BACKGROUND

Gabapentin is often used as an analgesic after rotator cuff repair surgery and is recommended as an additional analgesic for arthroscopic rotator cuff repairs. However, evidence of its effects on biological healing mechanisms is lacking. The objective of this study was to investigate the potential of gabapentin in improving tendon-to-bone healing after rotator cuff repair using a rat model.

MATERIALS AND METHODS

A total of 20 male rats were randomly allocated to one of two groups: group 1 (repair only, n=10) or group 2 (gabapentin injection, n=10). The rats in the experimental group (group 2) were administered 80 mg/kg of gabapentin subcutaneously 30 minutes before surgery, followed by 80 mg/kg subcutaneously every 24 hours for 48 hours. We used the left shoulder of every rat, while for biomechanical analysis, we used the right shoulder.

RESULTS

There was no significant difference in the load to failure, ultimate stress, or elongation between the groups. Collagen continuity, orientation, and density were better in group 2 than group 1.

CONCLUSION

In a rat model of rotator cuff repair, gabapentin had a positive impact on the quality of collagen organization at the junction between the tendon and bone, while preserving the biomechanical properties. We propose the use of gabapentin as a supplementary analgesic agent for postoperative pain relief after arthroscopic rotator cuff repair; however, further studies of the effect of gabapentin on biological healing mechanisms are required. [Orthopedics. 202x;4x(x):xx-xx.].

The Impact of Transcutaneous Electrical Nerve Stimulation (TENS) on Acute Pain and Other Postoperative Outcomes: A Systematic Review with Meta-Analysis

This study aimed to investigate the efficacy and safety of transcutaneous electrical nerve stimulation (TENS) in postoperative acute pain control. PubMed, Scopus, and Cochrane Library were searched on 1-8 December 2022, for randomized controlled trials on the analgesic effects of TENS. The outcomes were pain intensity and opioid use (primary), and postoperative (PO) adverse events, blood pressure, and the duration of hospital stay (secondary); PROSPERO CRD42022333335. A total of 40 articles were included in the meta-analysis. Pain intensity at rest and during coughing for all types of surgeries combined was lower in the TENS group (standardized mean difference (SMD) = -0.51 [-0.61, -0.41], p < 0.00001, 29 studies, and -1.28 [-2.46, -0.09], p-value = 0.03, six studies, respectively). There was a statistically significant decrease in morphine requirements, as well as in the incidence of postoperative nausea and vomiting, dizziness, and pruritus. There was no difference between the groups in postoperative pain intensity during walking, in blood pressure, and only a borderline difference in the length of hospital stay. The subgroup analysis by surgery type did not show significant differences between the groups in pain severity at rest. Thus, TENS has a potential for pain control and postoperative recovery outcomes.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery

Background

Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications.

Purpose

This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery.

Study Design

Position statement.

Methods

The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated.

Results

A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption.

Conclusion

A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

Online Videos Regarding Relevant Postoperative Patient Information and Postoperative Rehabilitation After Arthroscopic Rotator Cuff Repair Provide Poor Information Quality, Accuracy, and Reliability

PURPOSE

To evaluate the information quality, accuracy, and reliability of YouTube videos regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair.

METHODS

By use of The Onion Router (TOR) software and predefined search terms, 102 videos were assessed. Four scoring systems were used to evaluate included videos: (1) Journal of the American Medical Association (JAMA) benchmark criteria score; (2) Global Quality Score (GQS); (3) DISCERN score; and (4) a newly developed score, the Rotator Cuff Score (RCS). The RCS (0-30 points) was built based on the latest published evidence and guidelines from the American Academy of Orthopaedic Surgeons. Videos that scored up to 9 points were regarded as poor-quality videos.

RESULTS

Most of the included videos provided poor information quality, accuracy, and reliability. Videos that were uploaded by medically trained professionals showed significantly better results for all scores compared with commercial or personal-testimony videos (JAMA benchmark criteria score, P < .001; GQS, P < .001; DISCERN score, P = .001; and RCS, P = .001). Multivariate linear regression showed that the involvement of medically trained professionals was a significant predictor of better results for all scores (JAMA benchmark criteria score, β = 1.496 [P < .001]; GQS, β = 1.105 [P < .001]; DISCERN score, β = 11.234 [P < .001]; and RCS, β = 5.017 [P < .001]). Surprisingly, the like ratio was significantly higher for videos that were uploaded by non-medically trained individuals (P = .041).

CONCLUSIONS

The average information quality, accuracy, and reliability of YouTube videos regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair are poor. Videos from medically trained professionals provide significantly higher information quality; however, even these videos lack important information for a better understanding of arthroscopic rotator cuff repair.

CLINICAL RELEVANCE

Because of the lack of a peer-review process, available videos on YouTube regarding relevant postoperative patient information and postoperative rehabilitation after arthroscopic rotator cuff repair are of low quality, accuracy, and reliability. However, patients increasingly visit YouTube to gather medical knowledge. Physicians should enlighten patients about these findings and should be able to provide alternative sources of high-quality information.

Comparing the effect of transcutaneous electrical nerve stimulation and massage therapy on post laparoscopic shoulder pain: a randomized clinical trial

BACKGROUND

Shoulder pain is a common clinical problem after laparoscopic surgeries. The use of non-pharmacological massage and transcutaneous electrical nerve stimulation (TENS) as an adjunct to routine treatment is increasing to provide optimal pain relief. Therefore, we aimed to determine the effect of TENS and massage therapy on post laparoscopic shoulder pain (PLSP).

METHODS

This study was conducted on 138 patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into three groups: massage plus conventional pharmacological treatment (n = 46), TENS plus conventional pharmacological treatment (n = 46), and conventional pharmacological treatment (n = 46). Massage and TENS were performed three consecutive times after the patients regained consciousness in the inpatient wards. The intensity of Shoulder pain was evaluated using a visual analog scale before and 20 min after each treatment.

RESULTS

Both massage therapy and TENS led to a significant reduction in the intensity of PLPS compared to the control group in all three measured times (p < 0.001). However, no significant difference was observed between TENS and massage at any of the three-time points.

CONCLUSIONS

This study's findings demonstrated that massage and TENS techniques could reduce PLSP.

TRIAL REGISTRATION

Registered in the Iranian registry of clinical trials ( www.irct.ir ) in 05/02/2022 with the following code: IRCT20200206046395N1.

Opioid-Sparing Strategies in Arthroscopic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Opioid overprescription is a problem in orthopaedic surgery. Arthroscopic surgery, given its minimally invasive nature, represents an opportunity to minimize opioid prescription and consumption by using effective pain management adjuncts. Thus, the primary question posed in this study was which noninvasive pain management modalities can effectively manage pain and reduce opioid intake after arthroscopic surgery.

METHODS

The databases PubMed, MEDLINE, EMBASE, Scopus, and Web of Science were searched on August 10, 2022. Randomized controlled trials (RCTs) evaluating noninvasive pain management strategies in arthroscopy patients were evaluated. Eligible studies were selected through a systematic screening process. Meta-analysis was performed for pain scores and opioid consumption at time points which had sufficient data available.

RESULTS

Twenty-one RCTs were included, with a total of 2,148 patients undergoing shoulder, knee, and hip arthroscopy. Meta-analysis comparing nonopioid, oral analgesic regimens, with or without patient education components, with the standard of care or placebo demonstrated no difference in pain scores at 24 hours, 4 to 7 days, or 14 days postoperatively. Nonopioid regimens also resulted in significantly lower opioid consumption in the first 24 hours postoperatively (mean difference, -37.02 mg oral morphine equivalents, 95% confidence interval, -74.01 to -0.03). Transcutaneous electrical nerve stimulation (TENS), cryotherapy, and zolpidem were also found to effectively manage pain and reduce opioid use in a limited number of studies.

CONCLUSIONS

A range of noninvasive pain management strategies exist to manage pain and reduce opioid use after arthroscopic procedures. The strongest evidence base supports the use of multimodal nonopioid oral analgesics, with some studies incorporating patient education components. Some evidence supports the efficacy of TENS, cryotherapy, and nonbenzodiazepine sleeping aids. Direction from governing bodies is an important next step to incorporate these adjuncts into routine clinical practice to manage pain and reduce the amount of opioids prescribed and consumed after arthroscopic surgery.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of RCTs. See Instructions for Authors for a complete description of the levels of evidence.

Present situation and development prospects of the diagnosis and treatment of rotator cuff tears

Rotator cuff tears are an important cause of shoulder pain and are caused by degeneration or trauma of the shoulder tendon at the anatomical neck of the humeral head. The understanding and research of rotator cuff tears have a history of hundreds of years, and their etiology, diagnosis, and treatment have a complete system, but some detailed rules of diagnosis and treatment still have room for development. This research paper briefly introduces the diagnosis and treatment of rotator cuff tears. The current situation and its valuable research direction are described.

Perioperative Management in the Collegiate Athlete: An Integrated Approach

Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.

Use of Opioids in the Early Postoperative Period After Arthroscopic Rotator Cuff Repair: A Systematic Review

Background:

Postoperative treatment plans after orthopaedic procedures frequently include opioids for pain relief.

Purpose:

To evaluate opioid use in the early postoperative phase after arthroscopic rotator cuff repair (ARCR) to develop a procedure-specific understanding of the current role of opioids in pain management for this procedure.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A PubMed search was used to identify eligible studies. Data on patient demographics, visual analog scale pain scores, and opioid use patterns (in morphine milligram equivalents [MMEs]) were collected and assessed. Cumulative MMEs were reported on postoperative day (POD) zero, and mean MMEs were reported on subsequent PODs (days 1, 2, 3, 5, 7, and 14). Metaregression, I² indices, and Cochran Q tests were used to evaluate study variation, heterogeneity, and variance.

Results:

A total of 1487 patients in 22 studies were included in the analysis. An estimated 51% (95% CI, 31%-70%) of patients with nerve blocks (NBs) were opioid-free through POD-0 versus 40% (95% CI, 1.2%-97%) of patients without NBs, which increased to 65% (95% CI, 55%-74%) versus 25% (95% CI, 1.7%-86%) by POD-1. Opioid requirements were highest in the first 72 hours after ARCR. NB use reduced opioid requirement on POD-0 compared with no NB use (15.8 vs 45.0 MMEs, respectively; P < .001) but did not reduce requirements after that. In addition, NB use led to a statistically significant increase in opioid requirements on POD-7 (28.6 vs 9.5 MMEs, respectively; P < .001). Using a model that assumes stable opioid requirements between our time points, weighted mean cumulative opioid consumption was 163 MMEs in the first week and 273 MMEs in the first 2 weeks (150 and 287 MMEs in patients with NB; 180 and 261 MMEs in patients without NB, respectively).

Conclusion:

Opioid use is relatively common in the early postoperative period after ARCR. Pain scores and opioid requirements may spike on POD-1; however, patients should be educated and reassured that they will gradually decrease usage over the initial 2-week postoperative period.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Neurostimulation as an Efficacious Nonpharmacologic Analgesic following Arthroscopic Rotator Cuff Repair

This case highlights the importance of pursuing nonpharmacologic analgesic modalities in orthopedic surgery to combat the current opioid epidemic. Presented is a patient who underwent an arthroscopic rotator cuff repair and biceps tenodesis operation and through the use of neurostimulation (in the form of auricular electrostimulation), fully recovered from surgery without the usage of any opioid or nonsteroidal anti-inflammatory medications. The patient was fitted with a novel auricular electrostimulation device (DyAnsys Primary Relief) in the immediate postoperative period that provided constant neurostimulation for 10 days, this neurostimulator was the only analgesic modality used in this case, and the patient reported minimal postoperative pain. The utility of this case centers around the lack of postoperative opioid use, presenting the idea that postsurgical orthopedic pain can be managed in a nonpharmacologic capacity, combatting the fields' ongoing opioid epidemic.

Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review

OBJECTIVE

Transcutaneous electrical nerve stimulation (TENS) is a minimally invasive method for treating pain. In the most recent review published in 2012, TENS was associated with increased pain relief following cardiothoracic surgery when compared to standard multimodal analgesia. The purpose of this systematic review and meta-analysis is to determine if adding TENS to current pain management practices decreases pain and analgesic use and improves pulmonary function for postcardiothoracic surgery patients.

MATERIALS AND METHODS

CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, PubMed, and ClinicalTrials.gov were searched using specific keywords. Covidence was used to screen, select studies, and extract data by two independent reviewers. The Cochrane Risk of Bias tool assessed risk of bias. Visual analog scale (VAS) and pulmonary function data were exported for meta-analysis using a random effects model.

RESULTS

The search yielded 38 articles. Eight randomized controlled trials met inclusion criteria for the literature review. Five studies were included in the meta-analysis of pain at 24, 48, and 72 hours postoperatively. Data were analyzed using the standard mean difference (SMD). TENS had a significant impact on VAS at rest (-0.76 SMD [95% confidence interval, CI = -1.06 to -0.49], p < 0.00001) and with coughing (-1.11 SMD [95% CI = -1.64 to -0.56], p < 0.0001). FEV1 improved after 72 hours (1.00 SMD [95% CI = 0.66-1.35], p < 0.00001), as did forced vital capacity (1.16 SMD [95% CI = 0.23-2.10], p = 0.01).

CONCLUSION

The addition of TENS therapy to multimodal analgesia significantly decreases pain following cardiothoracic surgery, increases the recovery of pulmonary function, and decreases the use of analgesics.

The effect of magnesium added to bupivacaine for arthroscopy: a meta-analysis of randomized controlled trials

Introduction

The analgesic efficacy of magnesium sulphate added to bupivacaine for arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the efficacy of magnesium sulphate in combination with bupivacaine for arthroscopy.

Methods

We searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through July 2020 for randomized controlled trials (RCTs) assessing the effect of magnesium sulphate plus bupivacaine versus bupivacaine for arthroscopy. This meta-analysis is performed using the random-effect model.

Results

Six RCTs were included in the meta-analysis. Overall, compared with bupivacaine for arthroscopy, combination analgesia using magnesium plus bupivacaine was associated with significantly prolonged duration of analgesia (SMD=0.93; 95% CI=0.27 to 1.60; P=0.006) and first time to analgesic requirement (SMD=196.57; 95% CI=13.90 to 379.24; P=0.03), reduced pain scores (SMD=-1.71; 95% CI=-2.96 to -0.46; P=0.007) and analgesic consumption (SMD=-1.04; 95% CI=-1.49 to -0.60; P<0.00001), but showed no remarkable influence on nausea or vomiting (OR=1.54; 95% CI=0.60 to 3.97; P=0.37).

Conclusions

Magnesium sulphate added to bupivacaine may significantly improve the analgesic efficacy for arthroscopy.

Immediate effects of TENS and HVPS on pain and range of motion in subacromial pain syndrome: A randomized, placebo-controlled, crossover trial

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is one of the most common methods for managing shoulder pain, and high voltage pulsed currents (HVPS) may be used for reducing pain. However, their immediate effects on resting pain and pain-free active range of shoulder motion (pfROM) in patients with subacromial pain syndrome (SAPS) have not been studied comparatively, yet.

OBJECTIVES

The aim of this study was to compare the immediate effects of TENS, HVPS and placebo stimulation on shoulder resting pain and pfROM in patients with SAPS.

METHODS

Randomized, placebo-controlled, double-blind, crossover study. One hundred and six patients with SAPS received placebo (predetermined 1st day application), TENS and HVPS with 1-day interval, in a random sequence. Before and after each application, resting pain and pfROM were evaluated by 0-10 cm visual analogue scales and a digital inclinometer, respectively.

RESULTS

Intensity of pain decreased significantly after TENS, HVPS and placebo interventions (p< 0.05). While pfROMs increased significantly after TENS and HVPS (p< 0.05), remained unchanged after placebo, except for internal and external rotations (p> 0.05). The most obvious effects on pain and pfROMs occurred after HVPS (p< 0.05).

CONCLUSION

In patients with SAPS, both HVPS and TENS, but preferably HVPS can be used effectively to decrease pain and increase pfROM.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Pain Control After Shoulder Arthroscopy: A Systematic Review of Randomized Controlled Trials With a Network Meta-analysis

BACKGROUND

Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year.

PURPOSE

To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate.

RESULTS

Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores (P < .05). No benefit was found in any of the studies evaluating subacromial infusions.

CONCLUSION

Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

Postoperative Rehabilitation of Rotator Cuff Repair: A Systematic Review

Rotator cuff tears are the most common cause of shoulder disability and can cause significant pain and dysfunction. This systematic review summarizes the latest research on rehabilitation following arthroscopic rotator cuff repair. Studies were eligible for inclusion if they pertained to postoperative rehabilitation following arthroscopic rotator cuff repair and were published between 2003 and 2019 with a level of evidence of 1 or 2. Two blinded reviewers screened, graded, and extracted data from articles and recommendations on various aspects of rehabilitation were summarized. A total of 4067 articles were retrieved from the database search and 22 studies were included for data extraction. We noted similar outcomes between early and delayed mobilization following surgery. Reviewed articles support the use of supervised physical therapy, bracing in 15 degrees external rotation, and adjunctive transcutaneous electrical nerve stimulation for pain management. Early isometric loading improved outcomes in 1 study. Evidence is lacking for exercise prescription parameters and postoperative rehabilitation of the subscapularis.

Prevalence of Prescription Opioids for Nonoperative Treatment of Rotator Cuff Disease Is High

Purpose

To quantify the prevalence of opioid and benzodiazepine prescriptions for patients with rotator cuff disease across a large health care system and to describe evidence-based risk factors for opioid use within this population.

Methods

We conducted a retrospective cohort study at a major health care system of all patients with qualifying diagnostic codes. Emergency department, urgent care, and outpatient encounters between January and December 2016 for an acute rotator cuff tear, listed as the primary diagnosis, were included. Encounters with prescriptions for opioids or benzodiazepines were identified using the Prescription Reporting With Immediate Medication Utilization Mapping (PRIMUM) system. Descriptive statistics and the rate of controlled-substance prescribing were calculated for the population as a whole and among subgroups.

Results

We identified 9,376 encounters meeting the inclusion criteria. Of these encounters, 1,559 (16.6%) resulted in 1 or more prescriptions for an opioid or benzodiazepine that were issued during the visit. A total of 2,007 opioid and/or benzodiazepine prescriptions were issued for the 1,559 encounters (rate of 1.29 prescriptions per prescribing encounter). This represented 5,310 patients, of whom 1,096 (20.6%) received a prescription for an opioid or benzodiazepine during at least 1 of their encounters. Of patients who received a prescription, 20.9% had at least 1 risk factor for prescription misuse; 3.6% of patients had more than 1 risk factor. There were no demographic differences between patients with risk factors and patients without them.

Conclusions

The prescribing of opioids for the treatment of pain in patients with rotator cuff disease remains high across multiple locations and specialties within a large health care system. Using alternative pain management pathways as primary prevention for opioid misuse and abuse in high opioid-prescribing locations-and especially for patients identified as having a high risk of opioid misuse-is an important practice to continue in our shift away from opioid use as a health care system.

Level of Evidence

Level IV, case series.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Rehabilitation Management of Rotator Cuff Injuries in the Master Athlete

Rotator cuff (RTC) injuries are common in master athletes, especially overhead athletes. Risk factors include aging and degeneration as nonmodifiable and volume of activity, muscle weakness, and loss of motion as modifiable. The clinical presentation involves limited range of motion (ROM), pain at rest and at night. Injury classification into traumatic versus nontraumatic and tendinopathy, partial or full-thickness tears helps to establish a treatment plan. RTC injury rehabilitation protocols are criteria-based, multimodal, and divided into four phases. The acute phase addresses pain, inflammation, ROM, and RTC protection. The recovery phase addresses kinetic chain abnormalities, flexibility, and strength, and the functional phase involves exercises directed toward specific sport activities. Return to sports is based on clinical recovery, kinetic chain principles, and adequate sports technique. Nonsurgical management is recommended in most cases, and surgical management is considered if symptoms progress, especially for full-thickness tears.

Confronting the Opioid Crisis: Practical Pain Management and Strategies: AOA 2018 Critical Issues Symposium

The United States is in the midst of an opioid crisis. Clinicians have been part of the problem because of overprescribing of narcotics for perioperative pain management. Clinicians need to understand the pathophysiology and science of addiction to improve perioperative management of pain for their patients. Multiple modalities for pain management exist that decrease the use of narcotics. Physical strategies, cognitive strategies, and multimodal medication can all provide improved pain relief and decrease the use of narcotics. National medical societies are developing clinical practice guidelines for pain management that incorporate multimodal strategies and multimodal medication. Changes to policy that improve provider education, access to naloxone, and treatment for addiction can decrease narcotic misuse and the risk of addiction.

Effects of Electrical Muscle Stimulation for Preventing Deltoid Muscle Atrophy after Rotator Cuff Repair: Preliminary Results of a Prospective, Randomized, Single-blind Trial

Background

This study investigates the effects of neuromuscular electrical stimulation (NMES) in preventing deltoid atrophy during the first 12 weeks after arthroscopic rotator cuff repair.

Methods

Eighteen patients undergoing arthroscopic repair of a medium-sized rotator cuff tear by a single surgeon, were randomized into two groups: NMES and transcutaneous electrical nerve stimulation (TENS). Each group used the respective device for 6 weeks after surgery. Pain was measured at baseline, 6, and 12 weeks postoperatively, using the visual analogue scale (VAS); range of motion (ROM), abduction strength and functional scores were measured at baseline and 12 weeks postoperatively. Deltoid thickness and cross-sectional areas were measured using magnetic resonance imaging at 12 weeks postoperatively.

Results

At 12 weeks post-surgery, no statistically significant difference was observed between the NMES and TENS groups in the pain VAS, the Disabilities of the Arm, Shoulder and Hand score, ROM, and abduction strength. Postoperative decrease in the thickness of the anterior, middle, and posterior deltoid, at the level just below the coracoid, was -2.5%, -0.7%, and -6.8%, respectively, in the NMES group, and -14.0%, -2.6%, and -8.2%, respectively, in the TENS group (p=0.016, p=0.677, and p=0.791, respectively). At the level of the inferior glenoid tubercle, postoperative decrease in area of the deltoid was -5.4% in the NMES group and -14.0% in the TENS group, which was significantly different (p=0.045).

Conclusions

NMES has the potential for reducing deltoid atrophy after arthroscopic rotator cuff repair, suggesting that NMES might help minimize postoperative atrophy after various shoulder surgeries.

Effects of transcutaneous electrical nerve stimulation (TENS) on acute postoperative pain intensity and mobility after hip fracture: A double-blinded, randomized trial

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality which may be used to reduce acute postoperative pain. Intense perioperative pain within the first few days after hip fracture surgery is common and is related to negative consequences such as restricted and delayed ambulation.

OBJECTIVE

The objective of the present study was to examine the effect of incorporating TENS treatment on pain intensity, and mobility, with standard rehabilitation care during the acute post-operative phase following Gamma-nail surgical fixation of extracapsular hip fractures.

MATERIALS AND METHODS

Forty-one patients were randomly assigned to a supplement of 30 mins of active TENS or sham TENS. The standard rehabilitation care included five daily 30 mins physical therapy treatments beginning 24 hrs after surgery. Outcome measures were: pain intensity at rest, at night and during ambulation (assessed with the Numeric Rating Scale; Functional Ambulation Classification instrument; time to complete five sit-to-stand tests; and two-minute walk test). Data were analyzed with Wilcoxon score rank tests. Significance was set at p≤0.05.

RESULTS

Significantly greater pain reduction during walking was noted in the active TENS group compared to sham TENS group (differences between the fifth and the second days: 2.55±1.37 vs 1.06± 1.11, respectively; p=0.0011). Additionally, advantage of active TENS was demonstrated in greater increase in walking distance on the fifth day and higher level of mobility compared to the sham TENS group. No additional effects of active TENS were noted on pain intensity at rest and at night and on five times sit-to-stand performance.

CONCLUSION

Addition of TENS to the standard care of elderly patients in the early days following Gamma nail surgical fixation of extracapsular hip fracture is recommended for pain management while walking and functional gait recovery. The effect of TENS on long-term functional outcomes should be explored in future studies.

TRIAL REGISTRATION

The trial was registered at the ISRCTN registry: ID ISRCTN32476360.

Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 2: Surgeon as Prescriber

A multimodal pain management strategy combines complementary medications and techniques, targeting unique pathways, to improve overall analgesic effect and reduce opioid requirements. In this 2-part review, we examine the literature identifying nonopioid analgesic modalities and their targets in the pain pathway as well as anesthetic techniques found to be opioid sparing in the practice of upper extremity surgery. Part 1 focused on operative anesthesia and analgesia. In part 2, we discuss the nonopioid options available after surgery and explore areas for future investigation specific to upper extremity surgery.

PROSPECT guideline for rotator cuff repair surgery: systematic review and procedure-specific postoperative pain management recommendations

Rotator cuff repair can be associated with significant and difficult to treat postoperative pain. We aimed to evaluate the available literature and develop recommendations for optimal pain management after rotator cuff repair. A systematic review using procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in English from 1 January 2006 to 15 April 2019 assessing postoperative pain after rotator cuff repair using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. Out of 322 eligible studies identified, 59 randomised controlled trials and one systematic review met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase-2 inhibitors, intravenous dexamethasone, regional analgesia techniques including interscalene block or suprascapular nerve block (with or without axillary nerve block) and arthroscopic surgical technique. Limited evidence was found for pre-operative gabapentin, perineural adjuncts (opioids, glucocorticoids, or α-2-adrenoceptor agonists added to the local anaesthetic solution) or postoperative transcutaneous electrical nerve stimulation. Inconsistent evidence was found for subacromial/intra-articular injection, and for surgical technique-linked interventions, such as platelet-rich plasma. No evidence was found for stellate ganglion block, cervical epidural block, specific postoperative rehabilitation protocols or postoperative compressive cryotherapy. The analgesic regimen for rotator cuff repair should include an arthroscopic approach, paracetamol, non-steroidal anti-inflammatory drugs, dexamethasone and a regional analgesic technique (either interscalene block or suprascapular nerve block with or without axillary nerve block), with opioids as rescue analgesics. Further randomised controlled trials are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Rehabilitation Therapy in Perioperative Pain Management

Physical agent modalities can be effective in the perioperative period for controlling pain and inflammation. This article presents research-based evidence to support the use of these modalities in pain management and to reduce the use of pain medications, including opioids. The mechanism of action, applications, contraindications, and adverse effects of cryotherapy, pulsed electromagnetic field therapy, transcutaneous electrical nerve stimulation, and laser therapy are reviewed. Incorporation of 1 or more of these therapies in anesthesia pain management protocols can improve outcomes and reduce potential drug side effects.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Transcutaneous Electrical Nerve Stimulation (TENS) in the Emergency Department for Pain Relief: A Preliminary Study of Feasibility and Efficacy

Introduction

Given the high rates of opioid addiction and overdose in the United States, non-opioid means of treating pain are increasingly needed. Transcutaneous electrical nerve stimulation (TENS) therapy is an effective non-opioid modality for treating pain, but has not yet been routinely used in emergency department (ED) settings. In this study we asked the following questions: Are TENS units a feasible treatment for pain in the ED? How effective are TENS units for the management of pain in a general ED population?

Methods

At our institution, we performed a pilot study using TENS units for pain. Patients in the ED were given, at the discretion of the ED provider, TENS units for the treatment of pain. Patients could be included for acute or chronic pain on whatever part of the body that was safe to use with TENS.

Results

A chart review of patients receiving TENS units in the ED (n=110) revealed that TENS was useful in relieving pain, along with other treatments, in 99% of cases. When surveyed, 83% of patients reported a functional improvement while using the TENS, and 100% of patients would recommend a TENS unit to a family or friend. When surveyed, 100% of ED staff observed that TENS units were effective in treating pain for patients, and 97% would want to use them if they themselves were patients.

Conclusion

Overall, in this small pilot study, TENS units appeared to be effective in our ED for reducing pain, when added to standard treatment. Additional studies are needed to determine which conditions are most responsive to TENS therapy, and the magnitude of pain reduction when used alone.

Electroactive biomaterials: Vehicles for controlled delivery of therapeutic agents for drug delivery and tissue regeneration

Electrical stimulation for delivery of biochemical agents such as genes, proteins and RNA molecules amongst others, holds great potential for controlled therapeutic delivery and in promoting tissue regeneration. Electroactive biomaterials have the capability of delivering these agents in a localized, controlled, responsive and efficient manner. These systems have also been combined for the delivery of both physical and biochemical cues and can be programmed to achieve enhanced effects on healing by establishing control over the microenvironment. This review focuses on current state-of-the-art research in electroactive-based materials towards the delivery of drugs and other therapeutic signalling agents for wound care treatment. Future directions and current challenges for developing effective electroactive approach based therapies for wound care are discussed.