Physical Activity Post-Neuromodulation Device Implant—Providing Guidance to Patients and Practitioners

Dear Editor, When patients are implanted with spinal cord stimulators, dorsal root ganglion stimulators, or intrathecal pumps, some of their first questions are when, or if, they can resume baseline physical activity. Guidelines regarding what physical activities and/or movements are considered safe for patients to resume post-implantation have not been established, nor are there any suggestions provided by the Neuromodulation Appropriateness Consensus Committee [1]. This is a common issue for other implantable devices and surgical procedures, with significant variation noted in recommendations of types of physical activity and when they can be performed post-procedure [2]. We propose that the interventional pain community creates consensus recommendations on physical activity post-neuromodulation device implantation. These guidelines would allow the pain medicine community to broadly adapt evidence-based, consensus guidelines regarding safety of physical activity post-implant to reduce the rate of hardware-related complications, improve the therapeutic success of neuromodulation for chronic pain, and allow the community to continually refine these recommendations with addition of new clinical studies. The complication rate from technical problems post-neuromodulation device implant, such as lead failure, migration, or fracture, ranges between 8.3% and 42.8%, with these complications potentially attributed to falls or excessive activity [3]. Estimates on how long it takes epidural electrodes to heal into place have not been corroborated by any literature, with patient handouts quoting between 6 and 12 weeks. In addition, many neuromodulators recommend limiting rotational movement for some time after implant, but there is no consensus within the interventional pain community on optimal length of time to refrain from these activities, and there is no peer-reviewed literature to guide these instructions. This topic has been studied in spinal fusion, with multiple studies suggesting majority of patients return to activities such as recreational sports within one year of cervical or lumbar fusion surgery [4, 5]. Another important guideline for interventionalists is how to advise patients for postimplantation activity depending on region of lead placement, as there are variable rates of recovery and activity after injury or intervention to the various spinal regions [4]. Clinical and radiological investigations of the degree of thoracic spine extension with arm movement also demonstrate the thoracic spine can extend up to 20 degrees, however, it is unclear if this is significant enough to contribute to lead dislodgment or fracture [6]. In addition to practitioner’s perceptions of unsafe activities, it is also important to consider patient’s perceptions of which postprocedure activities are safe, and advise accordingly. Surveys of cardiac pacemaker patients’ perceptions of unsafe activities reveal that they perceive many routine activities as unsafe, potentially leading to disabling lifestyle modifications [7]. It is essential for pain practitioners and device implanters to provide specific and clear instructions for patients on how to safely increase their physical activity after implantation, as resuming physical activity is a cornerstone of the patients’ pain management and increase in functionality. These recommendations would help patients proceed with physical activity in a safe way that prevents device complications, such as lead fractures or migration. We believe consensus recommendations focused on physical activity post-neuromodulation device implant should be developed that would ideally incorporate prior experiences and outcomes with neuromodulation, data from surgical postoperative studies, patient perceptions of physical activity, and physical therapy and occupational therapy best practices. This would help optimize safety and functionality for our neuromodulation patients. Funding sources: There are no funders to report for this submission. Disclosures: Dr. Varshney and Dr. Ghosh have no disclosures to report. Dr. Deer is a consultant for Abbott, Vertos, Axonics, Flowonix, SpineThera, Saluda Medical, Nalu, Medtronic, Nevro, SI Bone, Stimgenics, SPR Therapeutics, Cornerloc, Boston Scientific, PainTeq, and Vertiflex. Dr. Deer is a member of the advisory board for Abbott, Vertos, Flowonix, Nalu, SPR Therapeutics, and Vertiflex. Dr. Deer has equity options in Bioness, Vertiflex, Axonic, Vertos, SpineThera, Saluda Medical, Nalu, Cornerloc, PainTeq, and SPR Therapeutics. He is a research consultant for Abbott, Vertos, Mainstay Medical, Saluda, SPR Therapeutics, Boston Scientific, and Vertiflex. Dr. Deer has a patent pending for the DRG paddle lead with Abbott.

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