[Postoperative transcutaneous electrical nerve stimulation (TENS) in shoulder surgery (randomized, double blind, placebo controlled pilot trial)]

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.

The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair.

Factors that impact rehabilitation strategies after rotator cuff repair

Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.

[Perioperative pain therapy in interventions for elbow stiffness]

Conservative treatment and surgical release of a stiff elbow requires correct pain management which should be oriented to the individual needs of the patient. Regional anesthesia in combination with opioids is necessary postoperatively to obtain sufficient pain relief. There is a need for prospective randomized studies to develop an optimal pain therapy concept following operations for elbow stiffness.

Transcutaneous electrical nerve stimulation (TENS) for chronic pain

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a popular pain treatment modality but its effectiveness in chronic pain management is unknown. This review is an update of the original Cochrane review published in Issue 3, 2001.

OBJECTIVES

To evaluate the effectiveness of TENS in chronic pain.

SEARCH STRATEGY

The Cochrane Library, EMBASE, MEDLINE and CINAHL were searched. Reference lists from retrieved reports and reviews were examined. Date of the most recent search: April 2008.

SELECTION CRITERIA

RCTs were eligible if they compared active TENS versus sham TENS controls; active TENS versus 'no treatment' controls; or active TENS versus active TENS controls (e.g. High Frequency TENS (HFTENS) versus Low Frequency TENS (LFTENS)). Studies of chronic pain for three months or more which included subjective outcome measures for pain intensity or relief were eligible for evaluation. No restrictions were made to language or sample size. Abstracts, letters, or unpublished studies, and studies of TENS in angina, headache, migraine, dysmenorrhoea and cancer-related pain were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted and summarised on the following items: patients and details of pain condition, treatments, study duration, design, methods, subjective pain outcome measures, methodological quality, results for pain outcome measures and adverse effects, and conclusions by authors of the studies. Extracted data and methodological quality of studies were confirmed by the review authors.

MAIN RESULTS

Of 124 studies identified from the searches, 99 did not fulfil pre-defined entry criteria. Twenty-five RCTs involving 1281 participants were evaluated. Included studies varied in design, analgesic outcomes, chronic pain conditions, TENS treatments and methodological quality. The reporting of methods and results for analgesic outcomes were inconsistent across studies and generally poor. Meta-analysis was not possible. Overall in 13 of 22 inactive control studies, there was a positive analgesic outcome in favour of active TENS treatments. For multiple dose treatment comparison studies, eight of fifteen were considered to be in favour of the active TENS treatments. Seven of the nine active controlled studies found no difference in analgesic efficacy between High Frequency (HF) TENS and Low Frequency (LF) TENS.

AUTHORS' CONCLUSIONS

Since the last version of this review, new relevant studies have not provided additional information to change the conclusions. Published literature on the subject lacks the methodological rigour or robust reporting needed to make confident assessments of the role of TENS in chronic pain management. Large multi-centre RCTs of TENS in chronic pain are still needed.

Surgery for rotator cuff disease

BACKGROUND

This review is one in a series of Cochrane reviews of interventions for shoulder disorders.

OBJECTIVES

To determine the effectiveness and safety of surgery for rotator cuff disease.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006 unrestricted by date or language.

SELECTION CRITERIA

Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed methodological quality of each included trial and extracted data.

MAIN RESULTS

We included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months. Six trials that compared arthroscopic with open subacromial decompression reported no significant differences in outcome between groups at any time point although four trials reported a quicker recovery and/or return to work with arthroscopic decompression. Adverse events, which occurred in three trials and included infection, capsulitis, pain, deltoid atrophy, and reoperation, did not differ between surgical groups.

AUTHORS' CONCLUSIONS

Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease. There is "Silver" (www.cochranemsk.org) level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement. There is also "Silver" level evidence from six trials that there are no significant differences in outcome between arthroscopic and open subacromial decompression although four trials reported earlier recovery with arthroscopic decompression.