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The Role Multimodal Pain Management Plays With Successful Total Knee and Hip Arthroplasty

Warren, Kevin G. Jr, BS, RN; Froehlich, Morgan, PharmD; Feldman, Daniel L., MD

Topics in Geriatric Rehabilitation: January/March 2019 - Volume 35 - Issue 1 - p 42–54
doi: 10.1097/TGR.0000000000000215
Pharmacology for the Older Adult: A Primer for the Fine Print

Approaching the best way to treat and manage a patient's surgical pain following total joint arthroplasty is a challenging task. To reduce the use of opioids, we utilize many different methods working together in a synergistic way. This is the true core of multimodal pain control. This task can be accomplished with a driven effort from the interdisciplinary team mostly comprising of but not limited to the surgeon, regional anesthesiologist, nurse, and physical therapist. The team addresses education of the patient, anesthesia type, medications, and nonpharmacological interventions within the development of the pain management plan. Achieving the goal of safe, effective pain management, in this population, will lead to improved outcomes, patient satisfaction, and enhanced functional life of patients.

St Charles Hospital of Catholic Health System, Port Jefferson, New York (Mr Warren); Northport Veterans Affairs Medical Center, Northport, New York (Dr Froehlich); and John T Mather Memorial Hospital, Port Jefferson, St Charles Hospital, Port Jefferson, Peconic Bay Medical Center, Riverhead, and Department of Anesthesiology, Long Island Anesthesia Physicians, Rocky Point, New York (Dr Feldman).

Correspondence: Kevin G. Warren Jr, BS, RN, St Charles Hospital of Catholic Health System, 2002 Belle Terre Rd, Port Jefferson, NY 1777 (kevin.warren@chsli.org).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Many issues and questions have been raised with today's surgical practice, which is heavily reliant on use of opioid pain relievers as the primary method of controlling postoperative pain.1 The current sentiment regarding the surging fear of opioid usage is not entirely justified when considering specific situations. These situations involve clinically relevant disease processes, surgical interventions, and other traumatic injuries, which can all warrant opioid usage.1 Opioids can be an effective tool for pain control, but also come with unfavorable side effects and the possibility of addiction, which may outweigh their potential benefits.2 , 3

Multimodal pain management is a method that has been discussed for years and recently gained widespread popularity, employing a safer approach to pain control.4 The goal of multimodal pain control is to use many different medications and techniques that will decrease opioid usage by attacking pain receptors from different methods and help deliver effective pain relief. Following total joint arthroplasty also known as replacement, effective pain management has a significant impact on recovery, outcomes, and the patient experience.5 , 6 Each phase of care for this patient population has different challenges and concerns, which warrants an interdisciplinary approach with standardized best practice protocols.7 These protocols need to have the ability to identify when variations in care are necessary for patient-specific care.8

The techniques employed during anesthesia are the cornerstone of these protocols. The surgeon's involvement and engagement sets the tone throughout the entire surgical process. The variety and timing of opioid and nonopioid medications plays a significant role during the postoperative phase.9 , 10 Education throughout the entire perioperative process is crucial to the patient and their support system to promote engagement and preparedness for surgery.10–12

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PAYORS INFLUENCE

Changes in health care clearly influence how care will be delivered. Payors such as the Centers for Medicare & Medicaid Services (CMS), private, and worker compensation insurances are all pushing for a shift toward grading performance of surgeons and hospitals on the quality of care for certain services.14 , 15 The CMS has begun bundle payment models with some voluntary and some mandatory areas.

The ultimate aim of these programs is to reduce the cost of care and increase the quality of the outcomes.16 Private insurers are reviewing data to designate facilities as Centers of Excellence (COE), which will become their preferred surgical sites/facilities and lead to only approving their patients to have surgery at a COE site. Other bundle payment models will be releasing information to the public on the quality of services provided by each hospital to assist the patient with making an informed decision about where to have elective surgery.17 The health care providers who have good outcomes, decreased complications, and cost-effective techniques will benefit financially. Those health care providers with the highest costs of care and poor outcomes may be penalized and need to pay back money based on their performance as compared with other providers in their region.14 , 18

In addition, in a final ruling beginning in 2018, the CMS has removed total knee arthroplasty (TKA) from the inpatient-only list.19 This will open the door for outpatient or ambulatory total knee replacement, which means Medicare will cover same-day TKA. This change has repercussions for all joint replacement programs across the country. Ambulatory surgical centers will be gearing up for this business. The ambulatory centers are preparing for these changes and need to consider obvious hurdles such as effective management of the continuum, monitoring, educating, and pain control for this population.20

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REGULATORY INFLUENCE

To complicate the issue, The Joint Commission (TJC), the regulatory body, has released guidelines effective January 1, 2018. These guidelines change the requirements related to pain assessment and management for inpatient care.21 Health care changes are heavily based directly on monetary drivers and regulatory requirements of care. Changes in the standards of care by TJC will push organizations to look for ways to address this requirement. Organizations need to review how pain is being managed currently across all inpatient hospital settings. During CMS and TJC onsite evaluations of performance, focused surgical tracers are performed. Organizations have their pathways, policies, evidence-based practice, competencies of staff, assessment of pain and interventions, orders from providers, and alternative approaches to pain management with nonpharmacological interventions reviewed and inspected.22

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APPROACH ACROSS THE CONTINUUM OF CARE

Standardized care protocols ensure proper coordinated care throughout the continuum.23 Each phase and member of the interdisciplinary team has specific responsibilities and focus points. One common trait of successful programs is effective communication and appreciation for each discipline making up the team.24 The continuum of care for total joint replacement is considered to start in the orthopedist's office, which is commonly referred to as the orthopedic consult phase. This is the time during which the surgery is suggested and the patient decides to move forward with joint replacement. A plan of care should be determined for pain management prior to surgery to address the patient's perceived needs. The patient's history and experience with opioids, not just in terms of addiction, will assist the physician's clinical decision-making with developing a pain management plan.5 If necessary, adjustments can be made after surgery to meet the patient's need.25

The next phase of the continuum involves preoperative assessment and risk stratification to mitigate inherent risk of surgery. The intraoperative and postoperative phases flow into the follow-up phase, when the patient is home continuing the necessary outpatient rehabilitation.25 , 26

Building order sets based on evidence-based research and practice with developed protocols is essential.7 , 27 Order sets need to be specific for both hip and knee replacement. The order sets for preoperative and postoperative phases of care should have targeted elements for each phase, ensuring that required standardized care is delivered consistently.28 Standardized care means that each total hip or knee replacement will receive the same exact care with every patient, despite numerous surgeons at a facility.29

Programs benefit greatly from having a surgeon as an advocate or champion to facilitate “buy-in,” encouraging other surgeons to become involved with the program. Involvement of all surgeons will help make future changes and improve adherence to best practice. Establishing critical elements from the clinical practice guidelines to achieve for all patients is important and can assist with the development and/or modification of existing pathways.30

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INDIVIDUALIZED CONSIDERATIONS

The protocol must be able to adjust for the needs of the individual patient. All patients should start within a standardized protocol to ensure consistency is achieved with this surgical population.31 The protocol should involve assessments for risk stratification to identify when a deviation from protocol is required. An individual's situation involves his or her medical history, ambulating status, social factors, and preoperative pain regimen.32 , 33

Patient preference can play a role in the course of their treatment plan.32 , 33 Their thoughts and opinions should be involved with the development of their pain management strategy. These preferences can have an effect on patients' ability to effectively self-manage their pain control during the follow-up phase of care.32 , 33

Care cannot be given like a “happy meal approach” with only 3 choices. Successful pain management that covers all situations cannot use a regimented approach. Once a program has standardized practice established, they can better address the individualized needs of each patient. Poor identification of these patients can lead to potential problems with impact on care, extending length of stay, and increasing the risk of complications. Patient-specific models of approach are not only helpful but critical to delivering high-quality care on a consistent basis.8 , 34 , 35

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AT-RISK POPULATION

This multimodal pain management method can focus benefits on the older population, who are typically receiving joint replacements. The elderly are highly susceptible to confusion and delirium following surgery. This confusion is multifactorial resulting from the anesthesia received during the procedure, postoperative narcotic medication usage, the slower rate at which drugs are metabolized, and simply being in the hospital, which can be considered a foreign place to the elderly, therefore increasing confusion.36–38 Monitoring for early signs of delirium from the interdisciplinary team is important. Delirium negatively impacts ambulating status, increases risk of injury, and delays needed care. A comprehensive assessment of the patient, cognitive screening, vital signs, laboratory work, involving kidney function, comprehensive blood count with differential, and urine analysis/culture sensitives are some of the tests needed to determine delirium.36 , 39 , 40 When delirium is determined, safety intervention measures must be considered with the degree of delirium to prevent injury. These interventions might include reduction in environmental stimuli, frequent rounding with reorientation, encouraging family members or support system visits, and usage of bed or chair alarm for safety. Adjusting pain management for the patient should include consideration of removing opioids or restricting their use. Delirium has been shown to contribute to longer length of stay, higher costs of care, and potentially lead to poor surgical outcome.37 , 41 , 42

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CHRONIC OPIOID POPULATION

The patient who has built up a tolerance to opioids preoperatively represents a major challenge. The chronic use opioid patient, or patient with a history of substance abuse, can be a difficult patient for pain management following surgery.3 , 43 , 44 Early identification of these patients is vital to direct patient-specific intervention and handling before surgery. It is imperative to create a pain plan before surgery with the involvement of anesthesia, the patient, and any other practitioners caring for the patient postoperatively.5 , 45 , 46 Maintaining a patient's current pain medication regimen before surgery and adding additional pain medications to their regimen in the postoperative phase will assist in controlling pain levels.4 , 47 Some research suggests that long-term usage of opioids leads patients to build up a tolerance, potentially causing a state of opioid-induced hyperalgesia. This state affects the body's relationship and interaction with opioids to cause the same amount of pain medication to not relieve pain, but in fact make pain worse.48 , 49 Understanding each condition of opioid sensitivity is important for clinical staff and the patient to effectively manage pain levels to have a positive outcome after surgery.8 , 50

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ANESTHESIA'S ROLE

One aspect of multimodal approach to pain involves administration of various combinations of analgesic medications at numerous time points during the course of surgery. Effective pain management after total joint replacement can be achieved with a mixture of medications used during the preoperative (nonsteroidal anti-inflammatory drugs [NSAIDs], cyclooxygenase-2 [COX-2] inhibitors, and gabapentinoids), intraoperative (opioids, local anesthetics, and antiemetic combinations), and postoperative phases of care (opioids, NSAIDs, COX-2 inhibitors, gabapentinoids, and acetaminophen).4 Nonpharmacological interventions will help supplement physical therapy interventions, achieve additional pain management options in conjunction with medications.21

“The biggest game changer in total joint replacement in recent years is anesthesia,” stated Dr Richard W. Cohen, of Trinity Health System of Georgia.

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Say hi to your anesthesiologist

The most important member of the orthopedic steering committee is the anesthesiologist.51 Orthopedic surgeons have an obvious impact on a patient's outcome. Their knowledge and skill in utilizing the latest advancements such as the use of minimally invasive incision, muscle-sparing surgical technique, improved computer imaging, patient-specific implants, and the use of robotic assisted surgery positively improve patient outcomes.51–55 However, the anesthesiologist is more than just the person “knocking you out during the procedure.” Rather your anesthesiologist is the person centralized on the interdisciplinary team to influence on a positive patient outcome. Effective anesthesia during the surgical case has immediate impact on decreasing pain, and minimizing adverse effects in the patient's first 24 hours.56 This is especially significant for the patient to achieve early mobilization with physical therapy on same day of surgery and into postoperative day 1, truly “starting on the correct foot.”57 , 58

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Impact from the operating room

For intraoperative anesthetic management of a total joint replacement, the patient will receive either general anesthesia or neuraxial anesthesia. Neuraxial anesthesia consists of a spinal anesthetic, an epidural, or a combination of spinal and epidural anesthesia.37 During a spinal anesthetic, the cerebrospinal fluid surrounding the spinal cord is accessed by placing a needle into the intrathecal space. A limited volume of local anesthetic is delivered through this needle. The anesthetic will inhibit the propagation of neural signals from those nerves that are surrounded with this medication. Clinically, the patient will experience motor weakness and lack of sensation below the level of injection. In contrast to the spinal anesthetic, the epidural anesthetic is performed by injecting local anesthetic into the space just outside of the dura. A catheter can also be threaded into this space, which allows for the continuous administration of local anesthetics, both intraoperatively and postoperatively.59

In addition to the local anesthetic, a dose of preservative-free morphine can also be injected into the intrathecal space, allowing for continued pain relief in the postoperative period.60 Side effects of this medication include increased nausea, vomiting, pruritus, respiratory depression, and urinary retention.

For patients receiving general anesthesia, an induction agent, such as propofol, is used in addition to neuromuscular blocking drugs, such as rocuronium. An endotracheal tube or similar device is most often placed and the patient is mechanically ventilated. If a neuraxial technique is employed, a local anesthetic, such as a bupivacaine, is injected into the cerebrospinal fluid, causing loss of motor and sensory function below the level of injection. This technique is most often combined with intravenous (IV) sedation throughout the procedure.9 , 59

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Breaking from tradition

Historically, general anesthesia has been the more common type of anesthesia employed during total joint arthroplasty surgery. A study by Memtsoudis et al,9 reviewed 528 495 entries of patients undergoing primary hip or knee arthroplasty between 2006 and 2010.9 Of those entries, 382 236 records included anesthesia-type used, 11% received neuraxial anesthesia, 14.2% had combined neuraxial-general anesthesia, and 74.8% of the patients received general anesthesia. This study found that patients receiving neuraxial anesthesia had significantly lower 30-day mortality (0.10, 0.10, and 0.18%; P < .001), as was the incidence of decreased length of stay, cost, and inhospital complications. This decrease with inhospital complications included reductions in pulmonary embolism, pulmonary compromise, pneumonia, cerebrovascular events, and acute renal failure.9 , 60

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Nerve block

The trend to use less narcotic medications to treat postoperative pain continues to increase, and multimodal analgesic regimens are increasingly becoming part of total joint replacement protocols (refer to the Figure). One component of these protocols includes the use of peripheral nerve blocks, typically performed with the use of ultrasound guidance. Under ultrasound guidance, a local anesthetic is delivered by injection so that the medication surrounds the nerve. The local anesthetic blocks the pain signals from traveling back to the brain. Benefits to the patient include less postoperative narcotic consumption, increased participation with physical therapy, fewer side effects including nausea and vomiting, and improved patient satisfaction. The 2 most commonly performed blocks are the femoral nerve block and the adductor canal nerve block.61

Figure

Figure

The femoral nerve supplies sensation to the anterior portion of the thigh as well as allows for knee extension by the 4 quadriceps muscles, sartorius and pectineus. Blockade of this nerve provides postoperative pain control following a TKA. It can however cause knee extensor mechanism weakness, which can lead to an increased risk of falls in the postoperative period.61 A similar block, often performed for postoperative pain management following TKA, is the adductor canal block. This nerve block targets the saphenous nerve, as it courses through the adductor canal. The saphenous nerve is a branch of the femoral nerve and provides sensation to the medial lower aspect of the leg and the superior pole of the patella. It is purely a sensory nerve and therefore decreases the risk of falls associated with the femoral nerve block.

One meta-analysis by Jiang et al62 included 11 randomized controlled trials for a total of 675 patients comparing an adductor canal nerve block to a block done with saline for patients undergoing TKA. Those patients whose block was performed with local anesthetic had statistically significant less postoperative narcotic consumption as compared with those patients with a saline block (P < .001) and had less pain at rest or during activity. Many studies have been performed to compare the femoral nerve block with the adductor canal nerve block. One such meta-analysis by Kuang et al63 included 9 randomized controlled trials with 609 patients. They found that, as compared with the femoral nerve block group, the adductor canal block group had no significant differences in pain scores at rest, with mobilization, rescue opioid consumption, patient satisfaction, and hospital length of stay. Patients in the adductor canal group also had better quadriceps muscle strength and mobilization ability. From this meta-analysis, it appears that both blocks provide equivalent postoperative pain control; however, the adductor canal block is better at preserving quadriceps strength.63

Peripheral nerve blocks can be performed as either single-shot injections or insertion of a catheter. The advantage of catheter placement is that it allows for the continuous administration of local anesthetics to the nerve and therefore continued pain control. One study by Hanson et al64 demonstrated reduced opioid consumption in patients receiving an adductor canal catheter and continuous local anesthetic infusion as compared with placebo. This study also showed benefits in terms of quadriceps strength, distance ambulated, and pain scores.65 Complications of placing a catheter are both minor and severe. Minor complications include catheter migration, obstruction, dislodgement, and leaking of local anesthetics. Major complications are rare but include infection, nerve injury, and hematoma.66

Another modality of pain control is local infiltration analgesia. This can be offered by itself or in combination with a peripheral nerve block. Local infiltration analgesia consists of injecting medications around or within the joint (periarticular or intra-articular, respectively). Medications that are commonly used include narcotics, NSAIDs, and local anesthetics. A meta-analysis performed by Seangleulur et al70 demonstrated that, when compared with placebo, patients who received a periarticular injection had lower pain scores, opioid consumption, and postoperative nausea and vomiting. They also had higher range of motion at 24 hours postoperatively and shorter length of stay as compared with placebo.70

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ORAL MEDICATIONS

NSAIDs and COX-2 inhibitors

NSAIDs are among the most commonly prescribed medications in the United States, with nearly 70 million prescriptions every year.71 NSAIDs provide their antipyretic, anti-inflammatory, and analgesic effects by limiting prostaglandin production in peripheral tissues. Traditional NSAIDs inhibit the activity of both COX-1 and COX-2 enzymes. COX-1 is ubiquitous in the body, therefore affecting body tissue. COX-2 enzyme is found more specifically in acute or chronic inflammatory tissue. Use of selective COX-2 inhibitors reduces the adverse effects of gastric mucosa and decreases inhibition of prostaglandin production in the gastrointestinal tract, therefore reducing the risk of stomach bleeding.72 Some surgeons are concerned about the use of NSAIDs prior to surgery due to a decrease in platelet aggregation and the potential increase in bleeding time.73 Consequently, NSAIDs are commonly discontinued 7 to 10 days before surgery to reduce perioperative bleeding.74 Currently, celecoxib is the only available FDA-approved COX-2 inhibitor in the United States. Despite inconsistent evidence of increases in cardiac morbidity with COX-2 usage, pain relief with improved gastric tolerance remains the foundation for the benefit of selective COX-2 inhibition75 (refer to the Table 72–75 , 77 , 78 , 83 , 85–88).

TABLE

TABLE

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Gabapentinoids (gabapentin and pregabalin)

Pregabalin and its predecessor gabapentin were first developed as anticonvulsant medications. They are thought to act on the alpha-2-delta subunit of the presynaptic voltage-gated calcium channels in the central nervous system, thereby decreasing neurotransmitter release.76 Neuropathic pain is found in approximately 12.7% of patients after TKA. Use of pregabalin in the perioperative period decreases neuropathic pain, minimizes opioid consumption, and lessens sleep disturbance. Pregabalin also demonstrates synergistic effects with COX-2 inhibitors.77 , 78 Side effects of gabapentinoids include dizziness and somnolence with long-term use.

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Opioids

Opioids bind to 3 opioid receptors (mu, kappa, and delta). They are located in the central nervous system, which causes inhibition of ascending pain pathways, altering the perception of and response to pain. Opioids also produce general central nervous system depression.79 , 80 Complications and side effects from opioid medications have been extensively studied. They affect numerous organ functions, including digestive, nociceptive, immune, hormonal, psychomotor, urinary, cardiac, respiratory, and musculoskeletal. As such, a wide array of adverse effects can occur including nausea, vomiting, constipation, sedation, dizziness, respiratory depression, physical dependence, tolerance, immunosuppression, fatigue, urinary depression, and hypotension.81

Compared with the IV route, oral opioids provide equivalent anesthesia and time to mobilization in total joint arthroplasty patients,82 but with fewer side effects.83 Oral opioids are available in immediate-release and controlled-release formulations. Immediate-release formulations tend to provide inconsistent pain relief due to delays in administration and failure to reach constant therapeutic plasma concentrations. Sustained-release preparations have more constant bioavailability,84 providing longer-lasting basal analgesia and minimizing the need for rescue IV narcotics. The Acute Pain Management Guideline Panel currently recommends a fixed dosing schedule for all patients requiring opioid medications for more than 48 hours postoperatively85 (refer to the Table).

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Tramadol

Tramadol is a synthetic centrally acting opioid agonist and inhibits the reuptake of serotonin and norepinephrine.86 Tramadol has gained popularity because of the low incidence of respiratory and gastrointestinal side effects compared with opioid medications.84 However, it is a less potent analgesic and reserved for mild to moderate pain.85

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Acetaminophen

Acetaminophen is one of the most common analgesics in the postoperative setting.87 Although its exact mechanism of action is not fully known, acetaminophen is thought to act predominately in the central nervous system through serotonin, opioid, eicosanoid, and nitric oxide pathways.88 While hepatotoxicity is the primary side effect, dosages with this complication have exceeded 4 g daily.85 , 88 Although the 650-mg dose is most common, the 1000-mg dose has been reported to be more effective in some patients.84 Since the Food and Drug Administration approval of IV acetaminophen in the United States, the safety and efficacy of 1-g IV acetaminophen every 6 hours in adult inpatients up to 5 days postoperatively has been shown85 , 87 (refer to the Table). However, the advantages of IV acetaminophen are offset by its high cost, which limits its wide use in multimodal analgesia.71 Based on available clinical and economic evidence, oral acetaminophen continues to be an essential component of multimodal analgesia, with the IV formulation limited to patients who are unable to tolerate oral medications.

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NONPHARMACOLOGICAL INTERVENTION

Nonpharmacological intervention can be an effective way to treat pain without taking more pain medication.50 , 89 The nature of the surgery and the inflammatory process immediately following can increase pain levels. Increased pain levels decrease the ability of the patient to ambulate, perform exercises, and function independently.90 , 91 Nonpharmacological means, in conjunction with medications, can decrease the effects of pain.5 , 21 , 56 If there is a focus on the treatment of the physiological pain, interventions toward treatment of the psychological pain should be used.92 , 93

Dealing with psychological pain through stress management and anxiety reduction can be controlled with the practice of meditation, guided imagery, and cognitive-behavioral therapy.94–96 While some of these techniques are not embraced by everyone, many find them effective. Realizing there is a mind-body connection can be a helpful tool in pain management protocols.97 , 98 Meditation following surgery is a low-touch, high-reward activity with a minimal amount of training needed to gain benefit.99 Conversations promoting this method should encompass the power of the body and its resilience and that meditation can help build up the natural internal pain relievers and activation of brain function toward controlling pain.99 , 100 Meditation can be quick and easy with the use of tools such as a smartphone application or through use of the Internet. Patients do not have to attend a class or go to a specialist; they simply sit back, relax and listen, and train their mind. Guided imagery is a method of distraction and refocusing of one's mind.101 This holistic approach has shown to help reduce pain levels and anxiety. This cost-effective modality can have positive impact on the outcome of patients with total joint arthroplasty with minimal effort and no possible negative side effect.101 , 102

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An oldie but a goodie

Quite simply, the longest and most conservative treatment of orthopedic injury was and still is RICE (rest, ice, compression, and elevation).36 Using ice, elevating, and perhaps using compression stockings and/or sequential compression devices all help with decreasing the negative effects of the inflammatory process.5 , 30 , 103 The impact of elevation and cold therapy has been found to reduce pain and swelling after arthroscopy and arthroplasty surgery.5 , 103 , 104 Promotion and use of this modality can and should begin in the hospital and continue after the transition to home. Some hospitals are requiring patients to purchase units and/or rent for home usage.

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Interventions to consider

The use of alternative means of managing patients' pain with nonpharmacological intervention, such as mind-body and tactile-base approaches, can be considered for reducing pain and anxiety postoperatively. Other nonpharmacological interventions to consider for pain management protocols could include acupuncture,105 , 106 massage therapy,107 transcutaneous electrical nerve stimulation,108–110 acupressure,98 and aromatherapy.111 These treatments depend on resources however and the specialists to provide care, patient preference, and the ability to fit or be added into existing protocols. Any means of decreasing pain in this population is key and should be considered with supporting clinical evidence.

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PATIENT EDUCATION

Patient education is imperative throughout the entire perioperative process for total joint replacement.12 Without education of the complete process, and promotion of self-management activities for this patient population and/or their support system, might lead to a patient being unprepared for surgery.12 , 13 , 112–114 An unprepared patient increases the chances of poor outcomes and possible complications.11 , 115

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Preoperative education

At St Charles Hospital, it is mandatory for all patients with total joint arthroplasty to attend a preoperative education class and encourage their support system or caregiver to attend as well.12 , 13 , 114 The class sets expectations of care, explains the process, the purpose for many activities and items used in the hospital, discharge planning, and encourages self-management behaviors to improve chances for a positive outcome while reducing fears of surgery.12 , 13 , 116 It is essential for patients to take responsibility for their involvement and care, self-management, to have a successful outcome after surgery.117 An area of focus should involve developing realistic expectations of surgical pain.21 , 118 The framework used to explain postoperative pain should be carefully crafted to avoid instilling fear, but to strengthen confidence of the comprehensive program and how patients can be involved, which is an element of cognitive-behavioral therapy.94 , 95 , 119 Explaining the protocol thoroughly will help prepare and create understanding of methods to control pain, and the reason why patients' involvement is necessary and at times crucial.3 , 119 , 120 Education addressed the approach for each phase of care and all elements involved with their special distinctions4 , 7 (refer to the Figure). Setting the foundation will help secure patient involvement and offer the understanding that is needed for each patient upon his or her discharge to home.16 , 18 , 112 Education should be delivered in a continuous progression to meet the individual needs of patients and where they are in the postoperative phase of rehabilitation. The teach-back method is one of the best forms of education for patient retention of information.112 , 121 , 123 In addition, nonpharmacological interventions need to be heavily encouraged.89 , 92 , 97

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Education is a continuous process

Following joint arthroplasty, patients have to move, but unfortunately pain can limit movement. This is a challenging new experience for most patients.90 , 91 The patients' surgeon, physical therapists, and nurses face this difficult part of the surgical journey daily with their patients, at times facing a steep learning curve on St Charles Hospital's Orthopedic Unit.25 , 36 Key to improving pain levels is educating patients to be proactive and not reactive to high pain levels.122 This leads to optimal management of pain.112 Understanding that pain medication is a tool to be used and the way to use this tool properly and safely is important.122 Walking patients through situations preoperatively and encouraging positive focus postoperatively keeps patients on the correct path.5 , 7 , 123

Without a certain degree of effective pain control, patients will not be able to fully participate with physical therapy or ambulate fully.4 , 6 After surgery, time is of the essence and plays a factor with determining success. Timeliness is important when it comes to acute postoperative total knees and gaining range of motion before adhesions (scar tissue) form and limit movement.6 , 90 , 91 , 124 The ability to control pain levels is a comfort measure, yet it is also a necessity to help improve ambulation status and successful surgical outcome.14 , 24 , 125 , 120

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Reduce the risk

In most cases joint replacement is an elective surgery, meaning there is time to optimize, and reduce risk for the patient. Optimization is a challenging aspect in today's total joint replacement world. Numerous programs are coming up with interesting ways to tackle risk factors.5 , 16 , 126 The first step is risk stratification, which determines the population that represents a higher risk of complications and could lead to poor outcomes.33 , 35 Using a standardized evidence-based assessment tool is important and this tool should begin prior to or during the orthopedic consultation phase regarding surgery.25 , 27 , 32 , 127 Modifiable risk factors should be targeted with specific interventions. Reduction with this at-risk population is a key to drive positive outcomes, reduce readmission, and complications of surgery.28 , 32 , 128 Direct referral into self-management education classes and/or referral into a perioperative medical evaluation can be a part of this effort.117

Prior to surgery an element of optimization is having the patient's home assessed by a health care professional to determine how safe patients' living environment is in order to reduce injury and to increase preparedness. At this time recommendations can be made to increase the safety of the living environment for the patient to return home quickly after surgery. The patient and support system can be educated on items of preparedness for all aspects of care, support, and areas to be concerns. There are a limited number of programs across the country utilizing this service in the preoperative phase of care to affect outcomes and safety.

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Other education focus points:

  • TJC's slogan of encouraging patients to Speak Up can be a useful motto, encouraging patients to voice concerns or opinions in all aspects of their care. Promoting the patient to be proactive with their concerns can help prevent poor or untimely care.129
  • Hourly rounding helps identify status of pain levels and the need for possible intervention, but the patient holds the keys in communicating accurate pain levels.130
  • Promoting healthy eating, preoperative and postoperative, can promote healing.27 , 131
  • Use of nonpharmacological intervention, such as ice therapy and elevation to decrease edema, helps to decrease pain and aid in ambulation.30 , 89
  • Reference materials, access to videos on general care topics, available on the Internet, can be low-touch educational support for patients at home.11 , 117 , 118
  • Patient navigation can be an effective approach in the follow-up phase of care to track patient progress, re-educate on important plan of care, use teach-back method of education and clarification, and a point of contact for questions or concerns in addition to the surgeon's office. Patients are encouraged to call the doctor with any questions or concerns; however, they can have very minor questions, for example, “how long should I leave ice on the surgical area?” Some patients might feel this is not a vitally important question to call the surgeon. Giving the patient a primary contact person or patient navigator at the hospital for support and guidance can be important for compliance to postoperative protocols.11 , 117 , 118 , 132
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DATA IS KING

Programs need to continuously assess the effectiveness of their standardized pathways, order sets, and the program's ability to identify when it is necessary to change the course of individualized care.16 , 18 , 25 Maintaining a grasp on research and best practice in the orthopedic field helps identify where improvement is needed, which helps ensure the best possible care. Understanding the performance improvement cycle will assist programs in always striving to provide the best care through the usage of data.133 , 134

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Track your progress

Tracking data is the true way to assess and determine performance, the effectiveness of measures, and overall quality of the program. Without using data all thoughts and concepts of performance are based on word and expert opinion.133 , 135 Simply stating that an organization does a great job with early mobilization does not prove how well patients are progressing with ambulating the same day of surgery. Without tracking this measure of success there is no validity in performance.

Electronic medical record systems have helped open the door to a possible gold mine of data to deepening understanding. Programs now need to use their data to their advantage. Some in the health care fields are under the misconception that finding out their facility is performing poorly, especially when they were under the impression that their performance was excellent, is detrimental.28 , 30 , 136 Data should be used to help identify barriers, correct and improve performance, and eliminate personal or administrative feelings of failure.

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Programmatic approach

Grasping a baseline of data on historical performance or a comparison baseline can build understanding of the current status or effectiveness as compared with other programs137; however outliers can skew the data.8 , 24 , 25 , 135 Every program should set aside 1 month every year as a review of current clinical practice guidelines and annual comprehensive data review for the previous year.25 Data should be tracked and used to drive interventions and should be discussed at each orthopedic meeting.25 , 112 , 137 Adherence to current evidence-based practice through chart reviews helps ensure there is no variation from protocol. Goals should be quarterly and yearly to push the program forward. Areas to track and trend, such as programmatic opioid usage, and the way the medication is administration (oral verses IV) should be identified in a goal to improve care for patients, stockholders, and engagement of all members of the team.22 , 138

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Other factors that influence a patient's perception of pain:

  1. Sleep: amount, consistency, quality, continuous positive airway pressure usage for sleep apnea patients.139
  2. IV fluid management to maintain proper hydration levels.140
  3. Postoperative nausea and vomiting.4 , 9
  4. Studies have shown that anxiety level and history of depression are indicators for possible poor outcomes and/or 30-day hospital readmissions. The emotional status of the patients affects their perception of pain levels.123 , 141 , 142
  5. Ethnic/religious/cultural background influence.142 , 143
  6. Social support surrounding the patient.114 , 143
  7. Higher body mass index affects the patient's ability to transfer and ambulate.33 , 35 , 144
  8. History of deformity/fracture (traumatic injury)/revision joint replacement.30 , 145 , 146
  9. Ambulating status, weakness/endurance.32 , 147 , 148
  10. Surgery to joint or surrounding joint—needing more surgical intervention during the joint replacement.32 , 149
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Limitations

Limitations of this article and issues that our program is currently addressing include different elements throughout each phase of care. Medication choices are constantly reviewed and new considerations frequently occur to improve care. Both Caldolor (ibuprofen) and Dyloject (diclofenac sodium), NSAID non-opioid pain relievers, are being considered for use with total joint arthroplasty and many other types of surgical procedures.73 There is apprehension with using these medications, for example, expense of the medications, limited research, no defined usage recommendations with timing and number of doses, and the choice of route for IV vs oral medications. An additional limitation comes from the patient's insurance coverage of medications. Postoperatively, the protocol calls for certain brand name nonopioid pain relievers to be prescribed. But often the insurance company limits or restricts the patients' options to having access to these nonopioids due to the expense of these drugs leaving the patients many times with the only option of choosing opioid pain relievers.

Orthopedics and analgesia are interdependent. Finding the best technique for analgesia plays an essential role in pain management. During the intraoperative phase of care, use of the peripheral nerve block allows 2 options with (1) a single shot or (2) continuous delivery of a numbing agent through a catheter surrounding a neurological region to decrease pain sensations, therefore having the most benefit to the total joint arthroplasty patient. Delivering medication into the body via a catheter can be an effective way of decreasing pain, but the potential risk of damage to tissue, making this method a concern.

Improvement of the patient's physical state can influence the pain management plan. Research involving the amount of preoperative exercise to optimize the patient's physical state, in order to assist in recovery after surgery, can help improve positive outcomes. Despite the lack of strong clinical research on defined protocols, experts have attempted to create a solution for preoperative total joint arthroplasty preparation with strength and endurance programs. A limitation to the strength and endurance program is patient's insurance coverage, which typically only covers a certain amount of physical therapy sessions for a calendar year. Further research is needed on developing a preoperative strength and endurance program to improve outcomes.

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CONCLUSION

Developing a comprehensive program to treat and manage patients' surgical pain following total joint arthroplasty is a challenging task. The utilization of many different methods resulting in the reduction of opioids, working together in a synergistic way, is the true core of multimodal pain control. The dedicated interdisciplinary team can accomplish this task through individualized focus on the development of the patient's pain management plan using the multimodal approach. Achieving the goal of safe, effective pain management, in this population, will lead to improved outcomes, patient satisfaction, and enhancing functional life of patients.

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        Keywords:

        anesthesia; multimodal pain management; opioids; patient education; regional anesthesia; total joint arthroplasty; total joint replacement

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