Adding high-frequency transcutaneous electrical nerve stimulation to the first phase of post anterior cruciate ligament reconstruction rehabilitation does not improve pain and function in young male athletes more than exercise alone: a randomized single-blind clinical trial

Nitrous oxide analgesia for rehabilitation after anterior cruciate ligament reconstruction: A randomized controlled trial

BACKGROUND

Although there is increasing emphasis on rehabilitation training after ligament reconstruction, little is known about the pain induced by the procedure itself. Procedural success may be limited by pain and anxiety. Nitrous oxide is widely used to alleviate procedural pain. However, few studies have been conducted to show the efficacy and safety of nitrous oxide for rehabilitation training.

OBJECTIVES

To explore the short-term efficacy and safety of nitrous oxide for acute pain elicited by rehabilitation training.

METHODS

A double-blinded randomized placebo-controlled trial was conducted in the department of rehabilitation medicine. People willing to participate in the trial and sign informed consent, ≥18 years old, who had acute pain (self-reported pain score ≥4) caused by rehabilitation training after anterior cruciate ligament reconstruction were recruited. Participants undergoing rehabilitation training were randomized to receive either 65 % nitrous oxide or 100 % oxygen. The primary outcome was the pain score. Secondary outcomes were sedation score, range of motion, vital signs, physician and participant satisfaction, acceptance, and side effects.

RESULTS

120 people were enrolled; 60 received nitrous oxide and 60 received oxygen. The nitrous oxide group had a significantly lower pain score than the placebo group (P < 0.001, median difference -3, 95 % CI -4 to -2, effect size η2 = 0.369) and sedation scores (P < 0.001, median difference 1, 95 % CI 1 to 1, η2 = 0.263) during the procedure. Both physician (P < 0.001) and participant (P < 0.001) satisfaction were significantly higher in the intervention group than the placebo group. Acceptance (willingness to use the same gas next time) differed between groups (P < 0.001). No serious side effects occurred.

CONCLUSION

This study provides evidence supporting the efficacy and safety of self-administered nitrous oxide to reduce procedural pain during rehabilitation training after anterior cruciate ligament reconstruction.

Peripheral nerve stimulation for lower-limb postoperative recovery: A systematic review and meta-analysis of randomized controlled trials

Patients undergoing lower-limb orthopedic surgery may experience multiple postoperative complications. Although peripheral nerve stimulation (PNS) is a promising non-pharmacological approach that has been used in lower-limb postoperative recovery, the clinical efficacy of PNS remains inconclusive. This study systematically searched three databases (PubMed, Embase, and Cochrane Library) for randomized controlled trials (RCTs) that examined the treatment effects of PNSs in patients who underwent lower-limb orthopedic surgery up to September 29, 2023. Two investigators independently identified studies, extracted data, and conducted meta-analyses with Review Manager 5.4. The outcomes were pain relief (measured by reductions in pain intensity and analgesic consumption) and functional improvements (range of motion [ROM] and length of hospitalization [LOH]). A total of 633 patients including 321 in the experimental groups and 312 in the control groups from eight RCTs were included. PNS showed no significant effect on pain intensity, while analgesic consumption was marginally significantly reduced in the experimental group. Furthermore, no significant differences were observed regarding functional improvements in ROM or LOH after the intervention. Although PNS had no significant effect on pain relief or functional improvements, the intervention exhibited a marginally significant reduction in analgesic consumption. Future trials should be conducted with larger sample sizes, longer follow-up periods, and more varied stimulation parameters.

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.

Current Evidence-based Approaches to Multimodal Pain Control and Opioid Minimization After Arthroscopic and Knee Preservation Surgery

Nonarthroplasty knee procedures are common and may cause a wide spectrum of postoperative pain, ranging from minimal to severe, depending on the patient, pathology, and procedure. Procedures include ligament repair and reconstruction, especially anterior cruciate ligament reconstruction, meniscal débridement, repair and transplant, periarticular osteotomy, and cartilage restoration. Multimodal analgesia regimens have been implemented successfully, but notable variation characterizes current protocols. Increased public and physician awareness of the burden of opioid usage in the United States has encouraged the medical community to embrace opioid-minimizing and nonopioid techniques to mitigate the deleterious effects of these medications. Nonopioid medications; anesthesia techniques; surgical techniques; and postoperative nonmedication strategies, including physical therapy, transcutaneous electrical nerve stimulation, cryotherapy, cognitive techniques, and non-Western interventions, can form part of an effective multimodal approach. A multimodal approach can facilitate adequate analgesia without compromising patient satisfaction or outcome.

Analgesic effect of nitrous oxide during manual therapy after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial

BACKGROUND

Many patients during manual therapy after anterior ligament reconstruction will experience severe pain, which has a negative impact on their rehabilitation. However, there is rarely an analgesic method for these patients during rehabilitation. Nitrous oxide with rapid analgesic and sedative effects is often used to relieve pain in minor procedures. The purpose of this study is to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen during manual therapy after anterior ligament reconstruction.

METHODS/DESIGN

This single-center, randomized, double-blind and controlled trial will recruit 120 patients. Patients ≥ 18 years old undergoing manual therapy after anterior ligament reconstruction (1 month post-operative) with acute pain (VAS ≥ 4) are included. The main exclusion criteria included the following: pulmonary embolism, intestinal obstruction, pneumothorax. Patients will be randomly allocated to the intervention group (A) and the control group (B) in a ratio of 1:1. Doctors, therapists, patients, and data collectors are all blind to the study. The manual therapy will be performed by therapists. Nurses who implemented the intervention handed the doctors envelopes containing the patients' codes and allocation of A or B. Group A will receive a pre-prepared nitrous oxide/oxygen mixture plus conventional treatment (no analgesic) given as 30-min treatment sessions, once daily, and group B will receive oxygen plus conventional treatment (no analgesic) under the same conditions. Assessments will be taken 2 min before the intervention (T0), 5 min after the beginning of the intervention (T1), and 5 min after the intervention finished (T2). The primary outcome is pain score. Secondary outcomes include vital signs, side effects, joint range of motion, adjuvant analgesia need, therapist and patient satisfaction, and whether willing to receive the same gas again.

EXPECTED OUTCOMES

We expect nitrous oxide inhalation to have a beneficial effect on the pain of patients who receive manual therapy after anterior ligament reconstruction.

DISCUSSION

If this treatment appears beneficial, it could improve patients' satisfaction and quality of life potentially and even be implemented widely in hospital and rehabilitation settings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2200061175 (Version 2.0 June 15, 2022), https://www.chictr.org.cn .

Effect of TENS on Vacuum Pain in Acute Soft Tissue Trauma

BACKROUND

In the literature, the effect of TENS on acute pain has been investigated, and no study has been found on its effect on pain associated with VAC application. This randomized controlled trial was designed to assess the efficacy of TENS application in pain caused by vacuum applied in acute soft tissue trauma of the lower extremity.

DESIGN AND SETTINGS

The study included 40 patients: 20 in the control group, and 20 in the experimental group and was carried out in a university hospital's plastic and reconstructive surgery clinic. Data for the study were gathered using the Patient Information form and the Pain Assessment form. Conventional TENS lasting 30 minutes was applied to the experimental group patients 1 hour before vacuum (vacuum assisted closure [VAC]) insertion and removal by the researcher, and TENS was not applied to the control group. The "Numerical Pain Scale" was used to assess pain in both groups before and after TENS application. In the statistical analysis of the data, the SPSS 23.0 package program was used. In all tests, p < .005 was considered statistically significant.

RESULTS

The experimental and control groups of the patients included in the study were homogeneous in terms of demographic characteristics (p > .05). Furthermore, when the pain levels of the groups were compared over time, it was discovered that the pain levels of the control group were significantly higher than the experimental group at the times of VAC insertion (T3) and VAC removal (T6) (p < .05). Bonferroni test, one of the post hoc tests, was used to determine in-group significance in both the experimental and control groups, and it was discovered that the difference was between T6 and all other times (T6-T1, T2, T3, T4, T5).

CONCLUSIONS

The results obtained from our study showed that TENS reduced the pain caused by vacuum applied in acute soft tissue trauma of the lower extremity. It is thought that TENS may not replace traditional analgesics but may help reduce the level of pain and contribute to healing by increasing comfort during painful procedures.

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.

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.

Acupuncture-like versus conventional transcutaneous electrical nerve stimulation in the management of active myofascial trigger points: A randomized controlled trial

PURPOSE

Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. The transcutaneous electrical nerve stimulation (TENS) is a non-expensive, safe, feasible modality, used recently for the treatment of MPS with promising but limited results. The purpose of this study was to determine the efficacy of acupuncture-like TENS (AL-TENS) vs conventional TENS (C-TENS) in the treatment of active myofascial trigger points.

METHODS

This randomized controlled trial study was carried out with 60 consecutive patients with active trapezius trigger points referred to Physical Medicine and Rehabilitation Clinic. Participants randomly assigned to receive AL-TENS, C-TENS or sham TENS (S-TENS). The Visual Analogue Scale (VAS), Pressure Pain Thresholds (PPTs), and neck range of motion (ROM) were measured at baseline, after the first treatment sessions, after the final treatment session, and 3 months after the end of the last treatment session. Patients function was evaluated by Disabilities of the Arm, Shoulder, and Hand (DASH) at baseline, after the final treatment sessions, and 3 months after the end of intervention.

RESULTS

The interaction effect of time and group was significantly different when evaluating VAS (df = 4.65, F = 2.50, p = 0.038) and DASH (df = 2.63, F = 7.25, p < 0.001) in favor of active groups, as well as neck total lateral bending in favor of AL-TENS group compared other two groups (df = 4.16, F = 5.23, p = 0.001). Both VAS and DASH improved significantly at all follow-ups in AL-TENS and C-TENS groups. Of note, significant immediate improvement in all outcomes was observed only with AL-TENS.

CONCLUSIONS

According to the present study, both AL-TENS and C-TENS were superior to placebo in pain reduction and functional improvement. Although both TENS techniques have similar efficiency on pain reduction, functional and pain perception improvement, the AL-TENS was the superior approach when evaluating neck lateral bending ROM.

Reporte de caso de postcirugía de ligamento cruzado anterior

El ligamento cruzado anterior (LCA) es la lesión de la rodilla con mayor prevalencia en los atletas. Los avances en la técnica quirúrgica y la fijación de injertos han permitido a los pacientes participar en una rehabilitación funcional postoperatoria temprana. Este tratamiento está dirigido a lograr un mayor rango de movimiento, progresando hacia la movilización, fortalecimiento y control neuromuscular propioceptivo de la articulación. Existen varios protocolos de rehabilitación con variaciones en ejercicios específicos, progresión a través de fases y componentes claves que permiten la recuperación funcional. El objetivo final de la fisioterapia es devolver al paciente al nivel de rendimiento anterior a la lesión, incluidos el movimiento y la fuerza, sin dañar ni alargar el injerto. Presentamos el reporte de un caso con una lesión de LCA compleja, que recupero la funcionalidad de la articulación por aplicación de plan de tratamiento fisioterapéutico de forma inmediata a su intervención quirúrgica.

Postoperative Rehabilitation of Anterior Cruciate Ligament Reconstruction: A Systematic Review

Recent studies have investigated the various components of postoperative rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR). The objective of this article was to access and summarize the latest evidence for postoperative rehabilitation protocols following ACLR to evaluate common timeframes, number of phases, exercises, as well as the length of rehabilitation protocol. Common interventions include vibration training, open-chain and closed-chain exercises, electrical stimulation, postoperative bracing, and aquatic therapy. The eligibility criteria included English-language articles published from 2000 to 2019 pertaining to rehabilitation following ACLR, excluding addresses, commentaries, and editorials. Two blinded reviewers screened, graded, and extracted data from articles. Recommendations on various aspects of rehabilitation were summarized. A total of 3651 articles were retrieved from the database search, and 62 level 1 to 2 studies were available for extraction. On the basis of the evidence, vibration training can be safely incorporated into the postoperative rehabilitation protocol following ACLR. Accelerated rehabilitation may give patients short-term functional benefits. Open kinetic chain exercises may have additional strength and endurance benefits. Postoperative bracing does not confer additional benefits. Long-term use of neuromuscular electrical stimulation seems to be more beneficial than short-term use. Aquatic rehabilitation may be beneficial in the early phases of anterior cruciate ligament rehabilitation.