Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial
Weekes DG, Campbell RE, Wicks ED, Hadley CJ, Chaudhry ZS, Carter AH, Pepe MD, Tucker BS, Freedman KB, Tjoumakaris FP. Clinical Orthopaedics and Related Research. May 2021. https://pubmed.ncbi.nlm.nih.gov/33835103/
Relaxation breathing techniques may decrease post-operative opioid consumption while providing similar pain relief and shoulder function after arthroscopic rotator cuff repair.
Physicians use multimodal pain management techniques to treat post-operative pain while minimizing opioid usage. Patients who perform relaxation exercises may see improvements in pain in the short- and long-term after orthopaedic surgeries. However, no randomized controlled trial has evaluated the effects of relaxation exercises after a sports medicine procedure.
The authors sought to determine whether educating patients with a rotator cuff repair about relaxation techniques can decrease pain and opioid consumption and improve shoulder function compared to controls.
The authors performed a randomized controlled trial with patients undergoing arthroscopic rotator cuff repair for full-thickness rotator cuff tears. They excluded patients if they had severe glenohumeral arthritis, revision shoulder surgery, pre-operative opioid usage or drug dependence, or were already practicing relaxation techniques. Among 563 eligible patients from June 2017-April 2018, the authors randomized 146 patients ̶ 74 in the relaxation group and 72 in the control group. Patients randomized into the relaxation group watched a 5-minute video explaining how to perform relaxation breathing techniques and received a pamphlet with these same instructions. The researchers instructed participants to perform the breathing exercises for ~2 minutes every 4 hours before taking pain medications during the first 5 days after surgery. They also urged the participants to continue the breathing exercises until they stopped using opioid medications. Participants kept track of their pain and medication use in a journal for the first 5 days after surgery. They then completed a survey two weeks after surgery to assess pain, opioid consumption (morphine milligram equivalents), and continued use of relaxation techniques. Lastly, patients completed the American Shoulder and Elbow Surgeons (ASES) score 2 weeks, 6 weeks, 3 months, 4.5 months, and 6 months post-operatively. Participants randomized to the control group received the same standard of care but were not given any relaxation education.
58 participants in the relaxation group and 61 participants in the control group completed the follow-up assessment. Participants averaged 60 years of age, and 55% were male. Participants that performed relaxation breathing techniques had similar post-operative pain and opioid consumption compared to controls. The two groups also had similar pain 2 weeks after surgery. However, participants in the relaxation group consumed fewer opioids 2 weeks after surgery than controls (similar to 20 vs. 29 tablets of 10-mg oxycodone). 52% of participants in the relaxation group continued to perform the breathing exercises 2 weeks after surgery. Furthermore, 62% thought that the relaxation techniques helped improve their post-operative pain. Finally, both groups had similar shoulder function (ASES scores) throughout the recovery timeline.
The authors found that relaxation techniques can decrease post-operative opioid consumption at 2 weeks after arthroscopic rotator cuff repair while providing similar pain relief and shoulder function. Since these relaxation techniques were easy to teach, minimal risk, and cheap, the potential for relaxation techniques to decrease post-operative opioid consumption is intriguing. However, the authors warn that these conclusions are not yet clinically applicable, as other literature shows mixed results. Future research should evaluate the effects of relaxation duration, intensity, and frequency before a clear clinical recommendation can be provided. The balance between duration, frequency, and patient compliance should be explored further to combat opioid dependence in the surgical population.
Clinicians may consider educating patients before surgery about relaxation breathing techniques to decrease post-operative opioid consumption.
Questions for Discussion
What can clinicians do to improve patient adherence to the relaxation breathing techniques? What type and duration of relaxation techniques work best to minimize post-operative opioid consumption? Which patients are most likely to benefit from performing relaxation techniques after surgery?
The American Society of Shoulder and Elbow Therapists’ Consensus Statement on Rehabilitation Following Arthroscopic Rotator Cuff Repair
Making a Comeback After Rotator Cuff Repair
American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: Optimizing the Management of Rotator Cuff Problems
Written by: Ryan Paul
Reviewed by: Stephen Thomas & Jeffrey Driban