Use of continuous interscalene brachial plexus block and rehabilitation to treat complex regional pain syndrome of the shoulder

Interventional pain blocks in Ontario: a population-based cross-sectional study on 2019 procedural volumes, clustering, and physician billings

PURPOSE

Multidisciplinary chronic pain management includes pharmacologic, psychological, and interventional strategies. In Canada, the use of interventional pain blocks (PBs) has increased in recent years. We sought to determine the distribution and clustering of PBs among physicians in Ontario, and to examine differences in the patient and physician characteristics by volume of PBs administered.

METHODS

We conducted a population-based cross-sectional study of PBs administered for chronic pain to Ontario residents between 1 January and 31 December 2019. Our primary outcome was the total number of PBs administered in an outpatient setting for chronic pain by eligible physicians. We used Lorenz curves, overall and stratified by PB type and physician specialty, to examine clustering of PBs among physicians, and compared patient and physician characteristics using standardized differences.

RESULTS

Among physicians who provided PBs, provision was highly clustered, with the top 1% of physicians providing 39% of blocks. In these high-volume PB providers, the majority of whom were general practitioners (88.4%), PBs made up the vast majority (median [interquartile range (IQR)], 87% [84-89]) of their billings, with the majority of the patients in their practices (63.0%) receiving at least one PB in 2019. Patients who received a PB from a high-volume provider had a higher annual frequency of visit for PBs (median [IQR], 10 [3-23]) and number of PBs administered per visit (median [IQR], 5 [4-6]).

CONCLUSION

Pain block administration is highly clustered in Ontario, with many patients receiving PBs in ways that are not supported by best evidence. Further research is required to determine whether the Ontario fee-for-service model of billing has created a suboptimal use of these health care resources.

Evaluation of intensive rehabilitation under continuous suprascapular nerve blockade for the treatment of refractory adhesive shoulder capsulitis. Case series

INTRODUCTION

Treatment of refractory adhesive shoulder capsulitis is a challenge. This observational retrospective study evaluated the long-term effectiveness of intensive physiotherapy protocol under a continuous peripheral blockade of the suprascapular nerve (cSSNB).

METHOD

We reviewed 29 medical records of patients suffering from adhesive capsulitis and treated with intensive physiotherapy under cSSNB during 10 days. The "disabilities of the arm, shoulder and hand" outcome questionnaire (DASH score) and shoulder movements were recorded at the beginning, 10 days after local anesthetic infusion and three months after.

RESULTS

Twenty six patients significant improved shoulder movements after 10 days of treatment. Sixteen patients were followed completely until 3 months after rehabilitation program. Range of four shoulder motion compatible with a normal daily life was acquired in nine patients at three months. There is no significant difference in shoulder motion between the end of LA infusion and at three months. At the end of infusion, DASH score is significantly decreased to 59.3 (n = 26), and persists three months 42.1 (n = 16). At three months, 33% of the initial population objectively reach the 4 goals, compatible with a correct quality of life.

CONCLUSION

Rehabilitation under cSSNB is associated with a significant long term improvement in shoulder motion and quality of life in patients with adhesive capsulitis. Randomized controlled trials will be necessary to demonstrate our encouraging results.

Unexplained pain after scheduled limb surgery

Orthopedic surgery can lead to pain that is poorly if at all explicable, both in the immediate postoperative period and at longer term, impairing the surgical result and necessitating a multidisciplinary approach of multimodal analgesia throughout the patient's care pathway. Preoperatively, patients at high risk of postoperative pain need to be identified and referred to a pain specialist to optimize pain management. Surgical and anesthesiological measures then need to be taken intraoperatively to limit the risk of pain. Finally, and most importantly, when pain does occur postoperatively, the surgeon needs to be able to treat any obvious cause and then rapidly to call in a pain specialist to identify the underlying causes and treat them effectively.

Short- and long-term results of an inpatient programme to manage Complex Regional Pain Syndrome in children and adolescents

The aim of this retrospective study was to determine whether an inpatient approach and the use of regional anaesthesia techniques can accelerate the recovery to normal functions in children with Complex Regional Pain Syndrome (CRPS). This study looked at the data of patients admitted to the rehabilitation unit with a diagnosis of CRPS from January 2010 to April 2015. Variables such as hospital stay, medications administered, regional anaesthesia procedures, changes in functional status prior to treatment and at the time of discharge, psychological evaluation and diagnosis were evaluated. A total of 31 patients (21 females and 10 males) were admitted with a diagnosis of CRPS 1 and 2. In all, 97% of the patients received a peripheral or central nerve catheter for an average of 4 days with pain scores of Verbal Numeric Scale (VNS) score = 1.0 ± 0.7 and an average length of hospital stay of 8.2 ± 2.6 days. The modified Functional Independence Measure for Children (WeeFIM) scores and Canadian Association of Occupational Therapists tests significantly improved at the time of hospital discharge, as well as their pain scores, which decreased from 8.2 ± 2 to 1.6 ± 3. In conclusion, these data suggest that the use of regional anaesthesia techniques and an intensive inpatient rehabilitation programme could accelerate the recovery of children with CRPS.

Ultrasound-Guided Continuous Superficial Radial Nerve Block for Complex Regional Pain Syndrome

Although there are many potentially effective therapeutic options for complex regional pain syndrome (CRPS), no definitive treatment exists. Therefore, patients often exhaust both medical and surgical treatment options attempting to find relief for their symptoms. As pain control and restoration of physical movement are primary treatment goals, strategies that include regional anesthesia techniques are commonly employed, but potentially underutilized, treatment modalities. The authors present a patient with refractory CRPS that had significant improvement in both pain control and the ability to tolerate intensive physical therapy following the placement of a superficial radial nerve catheter and an infusion of local anesthetic for 6 days as part of a multimodal analgesic regimen. This treatment approach also assisted in the decision-making process related to future treatment options. Although the use of regional anesthesia and perineural infusions of local anesthetic have previously been described as viable treatment options for CRPS, this case report represents the first known use of a superficial radial nerve catheter for treating CRPS as well as the first description of a technique for placing a superficial radial nerve (SRN) catheter using ultrasound guidance.

The value of nerve blocks in the diagnoses and treatment of complex regional pain syndrome type 1: a series of 14 cases

OBJECTIVES

Complex regional pain syndrome type 1 (CRPS-1) can progress to joint stiffness, which may be related to pain and/or capsule-ligament contracture. In this context, it is difficult to distinguish the respective causative roles of pain and contractures. Nerve blocks (NBs) can be used to determine the aetiology of joint stiffness. Subsequent treatment will depend on whether contractures are present or not. The objective of the present study was to evaluate the diagnostic and therapeutic value of the nerve blocks in the management of joint stiffness caused by CRPS-1.

DESIGN OF THE STUDY

A retrospective case series.

METHODS

Implementation of NBs in subjects with joint stiffness caused by CRPS-1. Primary efficacy criterion: an increase in the range of joint movement. Secondary criteria: pain level, treatment decision, duration of therapeutic NBs, return to work.

RESULTS

Fourteen patients with joint stiffness underwent 17 NBs. Ten NBs (59%) were associated with the normalization of the range of joint movement (i.e. the absence of contractures and the presence of an isolated pain component), prompting the implementation of physical therapy during NBs ("therapeutic NBs") in 90% of these cases. Three NBs (18%) were associated with a partial increase in the range of joint movement (i.e. a background of joint stiffness due to a combination of pain and contracture), prompting the implementation of a therapeutic NB in all of these cases. Four NBs (23%) were not associated with any increase in the range of joint movement (i.e. pure contractures), prompting consultation with a surgeon in all of these cases. Forty-three percent of the patients have since returned to work.

CONCLUSIONS

Nerve block is a valuable diagnostic and therapeutic option in the management of joint stiffness caused by CRPS-1.

[Association of physiotherapy under continuous brachial plexus analgesia and shoulder arthrographic-distension for treatment of resistant shoulder-hand syndrome]

OBJECTIVE

Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter.

MATERIAL AND METHODS

It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later.

RESULTS

After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment.

CONCLUSION

After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.

[Chronic pain and regional anesthesia in children]

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

The use of a continuous brachial plexus catheter to facilitate inpatient rehabilitation in a pediatric patient with refractory upper extremity complex regional pain syndrome

BACKGROUND

 The goal of interventional management of refractory pediatric complex regional pain syndrome is to facilitate early restoration of function to the affected extremity. These interventions are more complicated in children, as most do not tolerate these procedures without sedation.

CASE REPORT

 We report the first detailed description of a pediatric patient with complex regional pain syndrome refractory to medical management who had complete resolution of symptoms after brief inpatient rehabilitation involving continuous brachial plexus blockade and a multidisciplinary apaproach.

CONCLUSION

 Repeated interventional therapy for refractory, severe complex regional pain syndrome may not be feasible in children owing to the requirement for deep sedation or general anesthesia. A multidisciplinary apaproach of brief inpatient rehabilitation and continuous blockade via an indwelling pain catheter may provide a safer, more cost-effective means of restoring function in children with advanced disease.

Management of the stiff shoulder. A prospective multicenter comparative study of the six main techniques in use: 235 cases

INTRODUCTION

Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined.

PATIENTS AND METHODS

This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements).

RESULTS

Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05).

DISCUSSION

The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.