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Multimodal Analgesia Techniques Benefit Shoulder Replacement Patients

A multimodal approach to pain relief for patients undergoing shoulder replacements used at Hospital for Special Surgery (HSS) has been linked to positive pain relief outcomes, results of a study presented at the 2018 World Congress on Regional Anesthesia and Pain Medicine indicate.

"We find that our current departmental protocol appears to give good pain control while patients are in the hospital, but we have limited information about their pain experience in the subacute time frame (two weeks after surgery)," explained co-author and anesthesiologist Jacques T. YaDeau, MD, PhD, and director of the Clinical Research Division within the Department of Anesthesiology, Critical Care & Pain Management. "There is a concern that early discharge may leave some patients vulnerable to excessive pain at home."

To measure pain outcomes in patients who underwent total shoulder arthroplasties using this specific multimodal approach to analgesia, a team of HSS researchers examined outcomes in 100 patients enrolled in a prospective cohort trial. This study presented at the 2018 World Congress used interim findings on the first 50 patients enrolled.

Before surgery, each patient answered questions about their pain levels. During surgery, patients received an interscalene block, a type of peripheral nerve block that desensitizes pain in the shoulder, using local anesthetic in combination with clonidine, dexamethasone and buprenorphine. These medications, when used as part of the interscalene block, are associated with superior pain relief in shoulder replacement patients and are part of the multimodal analgesia plan for many patients at HSS. After surgery, researchers measured patients’ pain scores on days 1, 3, 7, 14 and three months following surgery.

Post-operative pain, both at rest and with movement, was consistently less than pre-operative pain, reported the researchers. While opioid use peaked on day 1, the use of intravenous opioid was minimal – only 24 percent of patients used  more than four doses.

"We found most patients did not make extensive use of intravenous opioids, there was a steep decrease of opioid consumption per 24-hour period over the first two weeks, and a number of patients did not take any oral opioids after leaving the hospital," said Dr. YaDeau.

Patients reported minimal side effects and high satisfaction with their post-operative pain treatment on both 1 and 14 days after surgery.

"Overall, these benchmark results demonstrate excellent analgesia using our current multimodal analgesia pathway," concluded Dr. YaDeau. "These pain outcomes are much better than the published outcomes when patients are given opioids only. The outcomes in this preliminary study provide insight for future research into improving pain relief in patients undergoing shoulder replacements."


Schweitzer, A BA; Liu, S MD; Gordon M MD; Lin Y MD, PhD; Gulotta, L MD; Dines D MD; Field K MS; YaDeau, JT MD PhD. "Pain Trajectory after Total Shoulder Arthroplasty Conducted with Multimodal Analgesia." Presented at: 2018 World Congress on Regional Anesthesiology and Pain Medicine; April 19-21, 2018.