The Rebound Pain Phenomenon & The Physiotherapist

Introduction

The rebound pain phenomenon (RPP) presents a hurdle for physiotherapists’ and physical therapists’ in the acute care setting. Particularly for those therapists involved with early mobilisation and early exercise protocols, discharge planning, and emergency department presentations.

What is the Rebound Pain Phenomenon

The RPP is described as severe pain, usually reported as a burning-type pain, quantifiable by a significant difference in pain level between a functioning peripheral nerve block (PNB) and the acute pain experience once the block wears off. RPP can lead to a number of post operative negative outcomes such as increase reliance on opioid analgesia, decreased patient satisfaction and increased length of hospital stay.

What is PNB?

PNB’s are common and advantageous due to the subsequent decreased need for a general anaesthetic which allows a broad range of surgical procedures to be performed on an outpatient basis. This facilitates rapid recovery, decreases length of stay in hospital and decreases the need for opioid analgesics; particularly positive as this in turn results in reduced the risk of the adverse opioid side effects of nausea, vomiting & unwanted sedation.

Literature & Evidence

The RPP is a long way from being a well-researched condition. Current literature suggests that the intensity of the pain in RPP is higher post shoulder surgery than with knee surgery. However, it has not yet been proven whether RPP is procedure specific or patient specific which severely limits any pathophysiological understanding of the condition. Additionally, a lack of large prospective studies limits incidence percentages although preliminary studies predict around 40% of patients will experience RPP. Evidence to date also does not indicate any long-term impact to functional recovery or persistent pain pathology.

What Does This Mean for Physio’s?

The issue of RPP should be recognised as a negative side effect of a PNB. It poses a significant barrier to the role of physiotherapists’ in providing clinically indicated best care practices in the acute setting. More research is required surrounding this phenomenon to better understand the patient risk factors, effective analgesic adjuvant options and the impact of peri-operative education on the prevalence of the condition. Physiotherapists’ should be aware of the definition of RPP to assist in early identification of this patient group where possible.

References

  1. Joshi G, Gandhi K, Shah N, Gadsden J, Corman SL. Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities. Journal of clinical anesthesia. 2016 Dec 1;35:524-9.
  2. Ochroch J, Williams BA. Rebound Pain After a Nerve Block Wears Off. American Society of Regional Anaesthesia and Pain Medicine. 2018 May 1; 20-22.
  3. Malik OS, Kaye AD, Urman RD. Perioperative hyperalgesia and associated clinical factors. Current pain and headache reports. 2017 Jan 1;21(1):4.

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