Joined: September 15, 2004
I have been referred a pt post sternotomy for a CABG who is having on going post op pain. The physician want us to put a TENS unit on to help control the pain. I have never used a TENS for this problem and wonder if anyone has suggestions for: the cause of the ongoing pain, and if TENS has been effective. I have not seen him yet so I do not have any objective findings yet. Thanks for your input.
Ed Check the T spine for mechanical restriction there. They hog open the chest, T spine and ribs get torqued, sternal c/o due to stuff in back. Have seen quite a few of these at our University based Pain Clinic over the years. MAY be the sternum, but I'd look in back first, fix that however appropriate for the duration post-op, then re-assess.
Joined: September 15, 2004
Saw the pt today. He is 2 years post CABG. The scar has very thick keloid that is painful to touch through the entire length. The scar is mobile and not adhered to the sternum. He does have moderate thoracic restrictions with significant tenderness and increased tension at T4-5 on the right. He was referred back to his surgeon who offered no options to address the scarring. The scar was injected by a "pain" specialist and pt thinks this has helped a little. Any thoughts on how to address the keloid tissue? He has had other surgical procedures without any abnormal thickening of the incisional scar.
I have had a similar patient. My best suggestion using what I know is to test his twisting motion left side versus right side. See if it is not equal to both sides. Equal does not just mean range of motion. I prefer to think of it as is one side 30% or more less comfortable than the other side. Also do a forward flexion of the arm as high and far back as he can raise his arm. See too if these show differences. If they do, your treatment will simply be to perform 2 exercises to the GOOD side for 20 seconds. That means - go further and further into the twist, go further and further into the arm raise (Reaching up higher and pushing back). Repeat the 2 sets cycle until no longer seeing improvement. IF improvement slows down try doing one set of 40 seconds and see if this drops it even further. If not, go to the next exercise. Very simple exercises and if they work, I can suggest a few more.
The problem with scars is they need to be addressed early :( 2 years is quite far. I suggest you have a look at some of the literature for burns patients especially children who get a lot of this scarring. It is usually managed by pressure garments and pressure dressings, there may be some dressings for burns that may help if they are properly applied over the scar
ehanso I can tell you that silicone dressings like Mepiform are effective for these scars, in juvenile burns patients at an early stage. Whether this would extend to your patient, I am not sure, but I think it is likely there would be some benefit. One of the problems is cost, especially if you want to maintain the Rx for a few months (which is probably indicated). There is also some evidence behind silicon gel.
I would consider pressure dressings aswell, perhaps on top of a silicone dressing.
I have also come across some websites that suggest 'pulsed dye laser Rx' for these scars, I am unsure the quality of evidence but they do quote "there is some evidence for it for post-sternotomy keloid scarring"