Moderate strength evidence supports the use of multimodal programs or non-opioid individual modalities to provide added benefit for postoperative pain management following rotator cuff repair.

Management of Rotator Cuff Injuries
Endorsed by: AANA, ASES, AOSSM, ASSET, APTA
Moderate Evidence MODERATE EVIDENCE
Rationale
A number of articles, of both high and moderate quality (Bain, G. I. 2001, Banerjee, S. S. 2008, Bang, S. R. 2010, Behr, A. 2012, Borgeat, A. 2010, Ciccone, Ii W. J. 2008, Clendenen, S. R. 2010, Coghlan, Ja 2009, Culebras, X 2001, Desmet, M. 2013, Desmet, M. 2015, Faria-Silva, R. 2016, Fredrickson, M. J. 2011, Hadzic, A. 2005, Hartrick, Ct 2012, Hoe-Hansen, C. 1999, Kim, Jy 2016, Klein, Sm 2000, Ko, S. H. 2017, Kraeutler, M. J. 2015, Lee, Ar 2012, Lee, Hj 2015, Lee, J. J. 2017, Lee, J-H 2011, Lee, Jj 2014, Lee, Jj 2015, Lin, Y. H. 2015, Liu, X. N. 2017, Mahure, S. A. 2017, Malik, T. 2016, Merivirta, R. 2012, Oh, J. H. 2009, Osti, L. 2015, Park, J. Y. 2016, Schwartzberg, Rs 2013, Shin, H. J. 2016, Sun, Z. 2018, Takada, M. 2009, Thackeray, E. M. 2013, Watanabe, K. 2016, Yamakado, K. 2014, Yun, M. J. 2012), addressed a variety of individual and multimodal pain management modalities. Based on this literature,  it is clear that any one of a variety of pain management non-opioid medications or modalities has a positive impact on patient pain control in the post-operative period. It should be noted that most of the literature validated a singular approach against a singular control group and did not perform a direct comparison against all other options, nor were indirect comparisons of the literature review findings using network meta-analysis statistically feasible. . This led to the inability to rank-order pain management modalities in a “most effective” to “least effective” manner. Because of this, the guideline development group framed the pain management recommendations as a more general list of pain management modalities, both singular and multimodal, which exhibited comparative efficacy, as compared to their within-study comparisons.

Defining multimodal therapy as using multiple but different modalities of pain management therapies simultaneously in the same post-operative period, the study group was able to arrive at the second multimodal pain management recommendation (recommendation B). The evidence assessing multimodal pain management supported the use of multimodal pain management treatment compared to a single modal approach. In particular, four high quality studies (Jo, 2014; Perdreau, 2015; Syed, 2018; Han, 2013) support the concept of multimodal therapy although the specifics of which mix of options is the most optimal requires further research.

Risks and Harms of Implementing this Recommendation
While the study group’s conclusion that there are various successful options of both singular and multimodal post-operative pain management has moderate strength of evidence, the analysis did not include a risk benefit comparison of options.  Each individual medication or modality carries its own inherent risks and benefits which should be taken into account by the health care provider prescribing the intervention.

Future Research
The analysis of this question has exposed the need for future research particular into the pros and cons of each medication, modality, and multimodal program as they are compared to each other.  The collective data and indirect comparisons from the high quality articles cited in this recommendation could be used to perform a network meta-analysis, providing valuable information to best guide future management.
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