Saturday, May 8, 2021

Pain management after shoulder joint replacement and during rehabilitation

Shoulder replacement is a big surgery for the big problem of shoulder arthritis. From decades of experience partnering with patients during their recovery, we have learned some steps than can ease and speed the shoulder's recovery while working to maintain the range of motion achieved at surgery. To emphasize, "partnering" is the key word here: active interaction between the patient and surgical team before and after surgery is essential.

Optimal pain management starts before surgery, assuring that the patient understands both the magnitude of the procedure as well as his or her essential role in carrying through with the potentially uncomfortable rehabilitation program that is essential to recovery. It is important to recognize that much of the discomfort comes from regaining the lost flexibility and muscle function resulting from long standing arthritis. Being prepared for the postoperative rehabilitation before surgery goes a long way toward understanding and managing postoperative pain. Many patients find that becoming familiar with the exercise program before surgery makes it easier to get started after surgery. See a link to some of the commonly used exercises here.

We have learned that giving a combination of medications immediately prior to surgery can lessen postoperative discomfort. Medications such as acetaminophen (Tylenol), anti-inflammatory medications (such as Toradol, Celebrex, or Aleve), a narcotic, and possibly Gabapentin each operate on different aspects of the pain pathway so that they work collaboratively. Of course, patients who are taking narcotic medication before surgery may have a more difficult time with pain management after surgery and may require an individual analysis of their situation before surgery.

In contrast to some surgeons, we do not find that single shot or continuous infusion pain catheters are particularly helpful or cost effective (see this link). Instead we find that the rapid transition from intravenous medications to scheduled acetominophen+scheduled anti-inflammatory+low dose oral narcotics for break through pain is very effective in enabling patients to successfully execute their stretching exercises on the same day as their ream and run or total shoulder arthroplasty and be ready for discharge from the hospital the same day or the day following their surgery.


After discharge, patients have shared with us what they call the four "S"s as a key to success: (1) stretching regularly working up to a one minute hold at maximum stretch, (2) scheduled Tylenol and Aleve each day to keep the blood levels constant, (3) safe aerobic exercise (walking, stationary bike), and (4) staying in regular contact with the surgeon so that he or she can be aware of and help manage any issues that arise; photographs or videos of the range of motion being achieved (see example of table slide four days after surgery shown below) are particularly helpful for tracking progress.



The bottom line is that shoulder joint replacement is a "joint venture" between the patient and the surgical team. Working together before and after surgery optimizes the patient's ability to regain shoulder comfort and function.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).