Shoulder Function After Cardioverter-Defibrillator Implantation: 5-Year Follow-up

Efficacy of Shoulder Rehabilitation Post-Cardiac Implantable Electronic Device Implantation

Background/Objectives: Cardiac implantable electronic devices (CIEDs) can prevent ventricular arrhythmia-related sudden cardiac death but cause paradoxical discomfort that impairs daily living and quality of life. No management guidelines exist for reducing pain, improving motion around the CIED implantation site, or preventing shoulder contractures. We evaluated the impact of continuous successive shoulder rehabilitation programs for CIED patients on reducing shoulder pain, improving shoulder range of motion, and patient satisfaction in daily living. Methods: In this prospective observational study, patients who had received CIED implantation underwent shoulder rehabilitation therapy with education during hospitalization from the day post-CIED implantation. After in-hospital rehabilitation, patients chose to undergo successive shoulder rehabilitation from their home and after 4 weeks in the outpatient clinic (rehabilitation group, n = 68) or not (non-rehabilitation group, n = 33). Pain and shoulder function was assessed using the Visual Analog Scale (VAS) and Disability of the Arm, Shoulder, and Hand (DASH) scores, respectively, the day following CIED implantation and at 1-3 months postoperatively. Patient satisfaction was evaluated using the 36-item Short Form Survey (SF-36). Outcomes were compared between groups. Results: VAS pain scores significantly decreased, while DASH scores substantially improved in the rehabilitation group compared to the non-rehabilitation group. Although the SF-36 subdomains were similar between groups, the rehabilitation group showed a better health-related quality of life trend. No complications were observed following post-CIED rehabilitation. Conclusions: Shoulder rehabilitation therapy with successive education after CIED implantation significantly improved pain and shoulder function. Definitive guidelines and long-term outcomes should be investigated further.

A Randomized Trial of Lenient Versus Strict Arm Instruction Post Cardiac Device Surgery (LENIENT)

BACKGROUND

Arm restriction after cardiac implantable electronic device (CIED) placement is common practice despite minimal supporting evidence. Patients receive a range of restriction recommendations of variable durations with the goal of reducing complications such as wound dehiscence, infection, lead dislodgement, or hematoma formation. These movement limitations can lead to emotional stress and anxiety, complications such as frozen shoulder, and upper extremity venous thrombosis due to immobilization. There are no published clinical trials assessing the benefits and risks of arm restrictions post-CIED implant.

OBJECTIVES

The randomized trial of lenient vs strict arm and activity instruction post-CIED surgery (LENIENT trial; NCT04915261) is a single center nonblinded randomized prospective study designed to evaluate lenient compared to restrictive post-CIED care instructions. We hypothesize that there will be no significant difference in complications between the arms.

METHODS/DESIGN

All patients receiving a de novo CIED or those with upgrades and revisions requiring a new lead implant will be enrolled. Subjects are enrolled in a nonblinded randomized prospective trial with 6 randomly assigned 8-month periods, during which either a lenient or restrictive postoperative activity instructions will be given to all patients. Postoperative instructions are given at the time of discharge and further reinforced by recurrent interactive voice recognition (IVR) phone calls, text messages and emails. The requirement for individual consent has been waived. The primary end point is a composite of (1) lead dislodgement, (2) frozen shoulder, (3) upper extremity venous thrombosis, (4) clinically significant hematoma, and (5) infection occurring within 52 weeks of index surgery. The study is a noninferiority trial with a sample size of 1,250 per group.

DISCUSSION

This is the first large randomized clinical trial designed to establish an evidence-based postoperative standard of care for patients undergoing CIED implantation. This will improve the quality of care provided to patients and help guide implanting physicians providing postoperative care instructions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04915261.

Relationship between CIED extent of displacement toward the shoulder while in the supine position and shoulder impairment

BACKGROUND

Device-related shoulder impairment is a common complication in cardiac implantable electronic device (CIED) recipients. This study examined the relationship between the extent of device displacement toward the shoulder while in the supine position and ipsilateral shoulder impairment.

METHODS

This cross-sectional study included 142 consecutive patients with CIEDs. The effects of the extent of device displacement on functional limitations, muscle strength, pain-disability, and quality of life were evaluated. Range of motion (ROM), grip strength (GS), the Shoulder Pain and Disability Index (SPADI), and the 36-item Short-Form (SF-36) Health Survey were used.

RESULTS

The mean device displacement was greater in patients with than without device-related shoulder impairment (51 ± 19 vs. 38 ± 15 mm; p < .001). Female gender (p = .046), high body mass index (p = .008), and defibrillator implantation (p = .004) were significantly more frequent in patients with than without impairment. Patients with excessive device displacement had significantly higher ROM limitation rates (p = .003) and SPADI scores (p = .02) and significantly lower GS (p = .04) and SF-36 scores (p = .032). Defibrillator implantation (OR: 2.569, 95% CI: 1.216-4.681; p = .03) and the extent of device displacement (OR: 1.502, 95% CI: 1.186-1.852; p = .01) were independent predictors of shoulder impairment.

CONCLUSIONS

Excessive displacement of the device toward the shoulder while in the supine position causes shoulder impairment by contacting more muscle fibers. Obese female patients with defibrillators have the highest risk.

Efficacy and safety of different exercises in preventing cardiac implantable electronic device-related shoulder impairment

BACKGROUND

Shoulder impairment on the implant-side is common after cardiac implantable electronic device (CIED) implantation. The aim of this study was to compare the efficacy and safety of the pendulum exercise (PE) and stretching & strengthening exercises (SSE) in preventing postimplantation shoulder impairment.

METHODS

This prospective, randomized study collected data from 89 patients, including 30 in a control group, 31 in a PE group, and 28 in a SSE group. Shoulder functions on the implant-side were evaluated by grip strength (GS), range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and 36-Item Short-Form Survey (SF-36).

RESULTS

Shoulder median flexion and abduction ROM were significantly improved two-month postimplantation compared to two-week postimplantation in PE (156±11 vs. 146±10, p = .002; 147±9 vs. 136±9, p = .001, respectively) and SSE (158±13 vs. 147±11, p = .003; 149±13 vs. 138±9, p = .002, respectively) groups, but not in the control group. Two months after implantation, the two exercise groups showed no significant differences in any assessment. Compared with the PE and SSE groups, the control group had significantly lower GS (p = .012 and p = .002, respectively) and SF-36 physical component summary (p = .007 and p = .003, respectively) and significantly higher VAS (p = .003 and p = .001, respectively) and QuickDASH (p = .002 and p = .005, respectively) scores two-month postimplantation.

CONCLUSIONS

PE and SSE for the ipsilateral upper arm starting two-week after CIED implantation provided similar benefits in preserving shoulder girdle muscle strength, maintaining shoulder motion, relieving shoulder pain, preventing shoulder injury, and improving quality of life, without the risk of lead dislodgement. This article is protected by copyright. All rights reserved.

Predictors of shoulder limitations and disability in patients with cardiac implantable electronic devices: Importance of device size

BACKGROUND

Generator-induced shoulder impairment is a common complication of cardiac implantable electronic device (CIED) implantation. Although implantable cardioverter-defibrillators (ICDs) have become smaller in size, they are still bigger than pacemakers (PMs). This study aimed to investigate the effects of single-chamber PM and ICD sizes on shoulder function.

METHODS

This retrospective study included 200 consecutive patients, of whom 123 had PMs and 77 had ICDs. The CIED implantation effects on shoulder function, pain, disability, and quality of life (QoL) were evaluated. The range of motion (ROM), Visual Analog Scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and Short Form-36 (SF-36) Health Survey (Physical and Mental Component Summary [PCS and MCS]) were used.

RESULTS

The flexion and abduction range limitation rates were significantly higher in the ICD group than in the PM group (16.9% vs. 7.3%, p = .035 and 19.5% vs. 8.9%, p = .031, respectively). The two groups had similar VAS scores. The median QuickDASH score was significantly higher in the ICD group than in the PM group (8.2 [3.6-19.6] vs. 4.6 [2.6-17.9], p = .034). There were no significant differences in SF-36 components between the two groups. ICD implantation (OR: 1.642, 95% CI: 1.293-2.776; p = .001) and incision length (OR: 1.343, 95% CI: 1.194-2.064; p = .01) were independent predictors of shoulder ROM limitations.

CONCLUSIONS

Reduced device sizes with advancing technology can decrease shoulder functional limitations and disability after implantation. Healthcare professionals should not neglect shoulder evaluations during the pre- and postimplantation periods.