Managing Pain in Pre- and Postsurgical Patients

by Glenn R. D’Addario, MSPT, DPT

Physical therapists know pain as physical suffering associated with bodily disorder; a sensation generated by harmful stimulus, characterized by physical discomfort and evasive action.¹ But, pain is so much more. It is a marker, a tool, a test, a scale, and a map that we can follow throughout the body. It is a window into our patient that allows us to learn about them, their lifestyle, their habits, their body mechanics, their past and current injuries, as well as an indicator of where they are at the moment, and where they want to go. It quantifies and qualifies progress and growth. Pain is one of the most valuable clues we have in generating an accurate diagnosis and determining a successful treatment plan.

But to our patients, pain “just hurts.” Pain is one of the primary reasons patients seek out physical therapists, whether from the actual discomfort or from the limitations secondary to their symptoms. Even though the therapist will assess their progress using a variety of measures, such as range of motion, strength, movement pattern assessment, and special testing, often the patient’s primary measure of progress is their perception of pain. It is our job to educate patients about pain management and appropriate expectations, while ultimately returning them to their desired level of function.

Pain and the Surgical Patient

An increasing trend in physical therapy is patients receiving preoperative, or prerehabilitative, care. Studies suggest getting rehab before surgery can lead to improved postoperative outcomes, reduced medical cost, increased quality of life, and improved mental status.^2,3,4 The Journal of Bone and Joint Surgery published an article that concluded, “Post-acute care utilization decreased if preoperative physical therapy was used, with only 54.2% of the preoperative physical therapy cohort using post-acute care services. However, 79.7% of the non-preoperative physical therapy cohort used post-acute care services. After adjusting for demographic characteristics and comorbidities, the use of preoperative physical therapy was associated with a significant 29% reduction in post-acute care use.”²

Another study from 2012 looked specifically at quality of life when preoperative programing was performed prior to total knee replacement. The study compared a preoperative group who performed exercises 2 days per week at a therapy facility and 1 additional day at home to a control group only participating in postoperative care. At 3 months post total knee arthroplasty, eight health-related quality of life domains were assessed with findings suggesting efficacy of preoperative care in facilitating quality of life.³

With more and more patients being referred to physical therapy, and many self-referring for prerehabilitative care, how do therapists manage preoperative patients’ pain, and how does that compare to postoperative pain management?

It is obvious that each patient we see is different and will present inversely regardless of his or her diagnosis. However, in general, the priority of preoperative care is to improve strength and range of motion prior to undergoing surgery. When pain is a barrier to achieving these goals, and the symptoms are preventing effective stretching and strengthening, the pain must be initially addressed. The college athlete with an ACL rupture reporting minimal pain and discomfort will require a different preoperative approach compared to an elderly patient who has suffered from progressive osteoarthritis. It is thus necessary to educate patients about their specific treatment plan and expected prerehabilitative outcomes.

Also, preoperative patients are often not seen in the clinic as often as postoperative patients. Therefore, establishing a comprehensive home exercise program from the beginning is crucial to achieving the prerehabilitation goals. Patient education about what they can do and expect postop is also beneficial to early rehabilitation success, as this can help with potential stress and anxiety associated with an upcoming surgical intervention and initiate a more proactive approach to the entire healing process.⁵

Pain management for the postoperative patient is critical for steady progression toward long-term goals and returning the patient back to their previous level of activity. Many postop protocols initially call for joint protection strategies, edema control, and pain management. Within these guidelines, there are still numerous treatment choices to make. A combination of manual interventions, modalities, and therapeutic exercise/activities may be used. As healing continues and the patient progresses, pain can still slow down functional gains. Frequently working on mobility strategies and strength and movement pattern correction can help reduce pain, while other times the pain is so great it can become limiting to certain types of rehabilitation interventions. The therapist may choose pain control modalities to help address symptoms and progress to a more active level of pain management.

Although prehabilitation is more commonly thought of as a method of improving orthopedic postsurgical outcomes, it has also been shown to be effective in complex medical cases involving cancer treatments and cardiovascular issues. Studies have shown positive outcomes for overall function as well as physiological outcomes.^6,7,8,9 When working with these complex medical patients, additional attention must be placed on pain control management, following the appropriate list of precautions and contraindications per each intervention. Common comorbidities such as diabetes and COPD are frequently present in the rehab setting, and further precautions must be taken when considering pain management options. Altered sensation to the extremities is to be considered when the patient has a medical history positive for diabetes. Blood pressure, respiratory, and heart rate should be monitored in patients with COPD, especially if the patient is undergoing therapeutic exercise.

Research about most pain modalities is varied and inconclusive, yet some of the most common forms are as follows:

Interferential Current (IFC):

IFC is an electro-therapeutic frequently used as a pain control modality. However, its clinical efficacy is debatable. A systematic review and meta analysis from 2010 concluded that, “interferential current as a supplement to another intervention seems to be more effective for reducing pain than a control treatment at discharge and more effective than a placebo treatment at the 3-month follow up. However, it is unknown whether the analgesic effect of IFC is superior to that of the concomitant interventions. Interferential current alone was not significantly better than placebo or other therapy at discharge or follow up.”¹⁰

Transcutaneous Electrical Nerve Stimulation (TENS):

Another article reviewed the use of TENS from articles published over a 3-year time span (2005-2008). Conclusions were that “one meta-analysis was able to show the positive treat effects of electrical stimulation for the relief of chronic musculoskeletal pain, and randomized controlled trials consistently demonstrate the effectiveness of TENS for acute, emergent, and postoperative pain conditions. However, the effectiveness of TENS on individual pain conditions, such as low back pain is still controversial, likely due to poor study designs and small sample size.”¹¹

Ultrasound (US):

Ultrasound has been used as a pain control tool for greater than 60 years, and its effectiveness for treating musculoskeletal pain has been questionable despite its longevity in the field. A review from 2001 looked at 35 random controlled trials focused on treating musculoskeletal conditions, concluding, “That there was little evidence that active therapeutic ultrasound is more effective than placebo for treating people with pain or a range of musculoskeletal injuries or for promoting soft tissue healing.”¹²

Elastic Therapeutic Tape:

The recent Olympic games have made taping very popular in physical therapy clinics. It is being used for pain control, improving range of motion, as well as for improved function. A systematic review looked at multiple studies with varying results. Two studies looked at musculoskeletal injuries in the lower extremity and reported that the use of tape did not affect outcome measures. Two other studies examined musculoskeletal injuries involving the spine (whiplash) and “treatment” with tape. They showed significant improvement in pain levels as well as range of motion both immediately and 24 hours postinjury. However, long-term results did not vary between the two groups.

Subjects with chronic low back pain treated with tape and exercise, tape alone, or exercise alone experienced significant improvement in short-term pain, while the exercise-only group also showed significantly less long-term disability. Two other studies examined musculoskeletal injuries in the shoulder. One of the studies found insufficient evidence to indicate that tape decreases pain and disability in patients with shoulder impingement/tendinitis, while the other study suggested that tape might provide short-term pain relief for patients with shoulder impingement. The systematic review as a whole concluded that there was “insufficient evidence to support the use of tape following musculoskeletal injury, although a perceived benefit cannot be discounted.”¹³

Photobiomodulation:

Low-level laser therapy (LLLT) is a medical technique in which exposure to low-level laser light, or light-emitting diodes, stimulate cellular function leading to potential beneficial clinical effects. A therapeutic laser is a device that emits light through a process of optical amplification based on the stimulated emission of photons. Evidence suggests that this light has an effect on mitochondria, which then results in increased ATP production. Injuries and trauma often lead to cell damage where ATP production becomes reduced, which can then slow the healing process. ATP is responsible for energy release, thus effecting physiological functions, some of which are directly related to injury repair and pain relief. Cells that become exposed to infrared light “at the right frequency” can improve mitochondrial function, thus leading to an immediate increase of ADP production. The ADP then links with free oxygen singlets to produce ATP, which then helps stimulate healing.¹⁴

Iontophoresis:

Iontophoresis is a technique that uses electric current to transfer a topical medication through the skin. A meta-analysis from 2012 looked for evidence with regard to iontophoresis for the treatment of inflammatory dysfunctions, acute soft tissue injuries, and pain. Data was collected about iontophoresis’ effect on pain when compared to a control or placebo intervention. Twenty-four studies were initially included, however, based on comparable statistical outcomes for pain; the results of 10 were then collected for meta-analysis. The study concluded that there is “quantitative evidence that iontophoresis is effective in the treatment of pain, however the lack of solid research design in studies on iontophoresis makes it difficult to ensure that the improvements observed can be explained by the iontophoresis technique in se.”¹⁵

Cryotherapy:

The use of ice to control pain and edema has been commonplace for years. Gabe Mirkin, MD, wrote The Sports Medicine Book in 1978 in which the acronym “RICE” initially appeared, referring to using rest, ice, compression, and elevation in treatment. The thought at that time, and for years to follow, was that the application of ice immediately after a sprain/strain injury would delay swelling and reduce pain. In an article written for Consumer Reports in October 2015, Dr Mirkin was quoted as stating, “Ice doesn’t increase healing – it delays it.” This was his response after reviewing a study published in 2014 by the European Society of Sports Traumatology, Knee Surgery & Arthroscopy that had found that applying ice on injured tissue shuts off the blood supply that brings in healing cells.¹⁶

Topical Analgesics:

Though not applied as a modality for postsurgical pain, topical analgesics are a common tool for treating pain symptoms associated with arthritis, low back pain, and musculoskeletal strains. In the physical therapy setting, topical analgesics can be useful for clients seeking temporary pain relief that is affordable, can be used in the clinic or at home, and is easy to apply. Topicals are manufactured as crèmes, gels, liquids, and sprays. Many use natural ingredients such as menthol and capsaicin that achieve pain relief via the gate control theory of pain described by Ron Melzack and Patrick Wall in 1965. The typical effect of topical analgesics is to produce an inhibitory effect at the nociceptor level on nerve transmission.¹⁷

A Balance: Evidence and Experience

Evidence-based medicine is the approach to medical care intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. However, when published research varies so vastly, therapists must rely on their personal and professional experience when rehabbing pre- and postsurgical patients. Choose the modality that you continually have the most success with. Integrate this knowledge and understanding, along with patient values, to generate the most successful outcomes possible for your patients. RM

Glenn R. D’Addario, MSPT, DPT, is president and co-founder of HD Physical Therapy, Wakefield, Mass. He earned a bachelor of science in biology from Notre Dame College, Manchester, NH, and a master’s degree in physical therapy from Franklin Pierce College, Concord, NH. D’Addario also holds a doctorate in physical therapy from Franklin Pierce University. He has extensive experience in orthopedics, sports medicine, and manual therapy, and was a physical therapist for the Nashua Pride professional baseball team. For more information, contact [email protected].

References

1. “Pain.” Merriam-Webster.com. Retrieved October 16, 2016, from http://merriam-webster.com/dictionary/pain.

2. Snow R, Granata J, Ruhil AV, et al. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. J Bone Joint Surg Am. 2014;96(19):e165.

3. Swank AM, Kachelman JB, Bibeau W, et al. Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. J Strength Cond Res. 2011;25:318–25.

4. Brown K, Topp R, Brosky JA, Lajoie AS. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study. Percept Mot Skills. 2012;115:765-774.

5. McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev. 2004;1:CD003526.

6. Silver JK. Cancer prehabilitation and its role in improving health outcomes and reducing healthcare costs. Semin Oncol Nurs. 2015;31(1):13-30.

7. Furze G, Dumville JC, Miles JN, et al. “Prehabilitation” prior to CABG surgery improves physical functioning and depression. Int J Cardiol. 2009;132(1):51-58.

8. Sawatzky JA, Kehler DS, Ready AE, et al. Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study. Clin Rehabil. 2014;28:648-657.

9. Gillis C, Li C, Lee L, et al. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014;121(5):937-947.

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11. DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Curr Rheumatol Rep. 2008;10(6):492-499.

12. Robertson VJ, Baker KG. A review of therapeutic ultrasound; effectiveness studies. Phys Ther. 2001;201;81:1339-1350.

13. Mostafavifar M, Wertz J, Borchers J. A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Phys Sportsmed. 2012;40:33-40.

14. Photobiomodulation, Low Level Laser Therapy, Cold Laser. (2008). Retrieved October 17, 2016, from http://panmedicahealth.com/photobiomodulation.shtml.

15. Clijsen R, Taeymans J, Baeyens J, Barel A, Clarys P. The effects of iontophoresis in the treatment of musculoskeletal disorders – a systematic review and meta-analysis. Drug Deliv Lett. 2012;2(3):180-194.

16. Byrne S. (nd). Why You Should Avoid Ice for a Sprained Ankle. Consumer Reports. Retrieved October 25, 2016, from http://www.consumerreports.org/health/avoid-ice-for-a-sprained-ankle/.

17. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov 19;150(3699):971-979.