D. G. Weekes, R. E. Campbell, E. D. Wicks, C. J. Hadley, Z. S. Chaudhry, A. H. Carter, M. D. Pepe, B. S. Tucker, K. B. Freedman, F. P. Tjoumakaris, The Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
R. E. Campbell, The University of Virginia Medical Center, Charlottesville, VA, USA.
Clin Orthop Relat Res. 2021 May 1;479(5):870-884. doi: 10.1097/CORR.0000000000001723.
Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair.
QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function?
During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures.
There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups.
The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage.
Level II, therapeutic study.
肩袖修复术后的疼痛通常采用阿片类药物进行管理；然而，这些药物会引起严重的不良反应。放松练习是一种潜在的非药物性疼痛管理方法，易于实施且不会产生严重的不良反应；然而，在关节镜肩袖修复术后，放松练习的效果尚未在实际可重复的方案中进行研究。
问题/目的：（1）与标准疼痛管理药物相比，关节镜肩袖修复术后进行放松练习是否会减轻疼痛？（2）关节镜肩袖修复术后进行放松练习是否会减少阿片类药物的使用？（3）使用放松技术的患者中有多少比例认为他们减轻了疼痛程度，以及有多少比例在 2 周后继续使用这些技术？（4）关节镜肩袖修复术后进行放松练习是否会影响肩部功能？
在研究期间，有 563 名患者符合纳入标准；然而，仅招募、随机分组并在术后随访的患者有 146 名（放松组：74 名，对照组：72 名）；由于患者和研究人员的可用性，有 68%（563 名中的 384 名）的患者未联系。由于手术程序的改变（如仅清创术）或患者要求，有 33 名患者在术前或术后即刻未入组或未进行术后数据收集；这些患者没有术后数据。放松组和对照组的随访比例相似（放松组：80%，对照组：81%；p = 0.90）。放松组接受并复习了包含 5 分钟视频和解释放松呼吸技术教育小册子的教育材料，而对照组未接受放松教育材料。患者在关节镜肩袖修复术后的 5 天内记录他们的疼痛水平和阿片类药物的使用量。患者还在术前以及术后 2、6、13、18 和 26 周时完成美国肩肘外科医生肩部评分。线性混合模型用于分析术后疼痛、以吗啡毫克当量（MME）衡量的阿片类药物使用量和肩部功能结果。采用方案治疗方法纠正了那些入组但随后接受其他手术的患者。
在术后的前 5 天，放松组和对照组之间的疼痛评分没有差异。在术后 2 周时，放松组和对照组之间的疼痛评分也没有差异（3.3 ± 3 与 3.5 ± 2，平均差异 -0.22[95%置信区间-1.06 至 0.62]；p = 0.60）。在术后的前 5 天，放松组和对照组之间的阿片类药物使用量没有差异。与对照组相比，放松组在术后 2 周时使用的放松练习导致阿片类药物的使用量减少（309 ± 241 MME 与 442 ± 307 MME，平均差异 -133[95%置信区间-225 至-42]；p < 0.01）。在放松组中，有 62%（66 名中的 41 名）的患者认为放松练习减轻了他们的疼痛程度。在术后 2 周时，仍有 52%（66 名中的 34 名）的患者在进行锻炼。在 6 个月的随访期间，放松组和对照组之间的肩部功能没有差异。
术前给予快速、基本的放松练习可以使患者在关节镜肩袖修复术后的前 2 周内使用明显较低剂量的阿片类镇痛药物，而不会增加疼痛评分。我们认为这一结果很有希望，但还需进一步研究；更强烈的正念干预——我们在这里研究的是仅通过 5 分钟的视频来传播——可能会减轻疼痛并进一步减少阿片类药物的使用。
二级，治疗性研究。
