Consensus on the preoperative management of patients with chronic moderate-severe shoulder pain to improve postoperative outcomes. Delphi results

Abstract

BackgroundAn appropriate preoperative management of patients with chronic moderate to severe shoulder pain who are candidates for surgery due to rotator cuff disease or glenohumeral osteoarthritis may improve surgery and patient outcomes, but published evidence in this regard is scarce. Therefore, the availability of recommendations on preoperative interventions based on expert consensus may serve as guidance. MethodsA Delphi study was conducted to develop a preoperative management algorithm based on a national expert consensus. A Delphi questionnaire was developed by a Scientific Committee following a systematic review using PRISMA criteria of the relevant literature published during the last 10 years. It consisted of 48 statements divided into five blocks (I. Assessment/diagnosis of preoperative pain; II. Preoperative function/psychosocial aspects; III. Therapeutic objectives; IV. Treatment; V. Follow-up/referral), and 28 experienced shoulder surgeons from across the country were invited to answer. ResultsAll participants responded to the Delphi questionnaire in the first round and 25 in the second round (89.3% of those invited). Overall, 46/49 final statements reached a consensus, based on which a final preoperative management algorithm was defined by the Scientific Committee. First, surgeons should assess shoulder pain intensity and characteristics, shoulder functionality and psychosocial aspects using specific validated questionnaires. Preoperative therapeutic objectives should include shoulder pain control, depression/nocturnal sleep improvement, opioid consumption adjustment and substance abuse cessation. Postoperative objectives regarding the degree of shoulder pain reduction or improvement in functionality/quality of life should be established in agreement with the patient. Treatment of preoperative chronic moderate to severe shoulder pain should comprise non-pharmacological as well as pharmacological interventions. Follow-up of shoulder pain levels, treatment adherence and mental health status of these patients may be carried out by the surgical team (surgeon and anesthesiologist) together with the Primary Care team. Patients with very intense shoulder pain levels may be referred to the Pain Unit, following specific protocols. ConclusionA preoperative management algorithm for patients with chronic moderate to severe shoulder pain who are candidates for surgery due to rotator cuff disease or glenohumeral osteoarthritis was defined based on a national expert consensus. Main points include a comprehensive patient management starting with an objective assessment of shoulder pain and function, quality of life, establishment of preoperative and postoperative therapeutic targets, prescription of individualized therapeutic interventions and multidisciplinary patient follow-up. Implementation of these recommendations to clinical practice may result in better preoperative shoulder pain management and more successful surgery outcomes and patient satisfaction.