Overcoming Movement-Evoked Pain to Facilitate Postoperative Recovery

Abstract

Severe movement-evoked postoperative pain can be immobilizing, instilling fears that further movement will produce unbearable pain. This impedes healing and functional restoration while extending time to recovery. Therefore, it is critical to effectively manage movement-evoked pain (MEP) through comprehensive planning and timely evaluation. This article builds on recent calls to standardize MEP to inform care planning in a way that both reduces pain and improves functioning. Reassessment of MEP subsequently guides refinement of therapy. Although this seems intuitive, it challenges common practices that focus too heavily on overtreating, undertreating or not treating pain while ignoring or solely focusing on optional functioning. This has implications to nurse clinicians, educators, researchers and compliance professionals dedicated to enhancing the quality and safety of nursing practice.

INTRODUCTION

It is a natural human response to move less when experiencing strong pain. This is a protective mechanism employed in response to movement-evoked pain (MEP). Defined as pain that is initiated or exacerbated by active or passive movement of the involved tissues (Booker, Arnstein, & van Boekel, 2022; Fullwood et al., 2021), MEP is common with many acute (e.g., vaso-occlusive crisis, post-traumatic, postoperative) and chronic (e.g., low back pain, arthritis) forms of pain. Movement may have a low, moderate, or high impact on patient’s everyday functioning. In particular, after surgery, MEP often triggers fear and activity avoidance that impedes recovery and produces disuse and deconditioning-related problems regardless of the pain severity. Limited movement is sometimes expected and appropriate in the initial phase after surgery, but continued restricted movement slows recovery, initiates or worsened disability, and well-being (Butera, Fox, & George, 2016).

Postoperative MEP differs from pain provoked by an underlying pathology (e.g., angina, pathologic fracture) that requires rest until the underlying problem is evaluated and treated. After surgery, MEP consistently occurs with certain position changes or movements regardless of whether they require exertion or weight-bearing. It often interferes with standard recovery activities (e.g., turn, cough, deep breathe, mobilize out of bed), but is not captured in standard pain assessment documentation. Additionally, the common, yet suboptimal practice of selecting and dosing analgesics to pain intensity alone (Quinlan-Colwell, et al, 2022) may further impede functioning if the patient becomes over-sedated or experiences severe side effects from select medications. By evaluating MEP in addition to the traditional “pain at rest” or scheduled assessments, permitted activities that produce pain can be modified, while unaffected movements can be encouraged to help minimize pain, guarding, and immobility that impedes functioning. We assert that pain controlled only at rest is not well-managed in the absence of functional improvement, which has implications to how we educate, research and clinically manage postoperative pain. Our previous article, emphasized the methods of assessing MEP and its importance of MEP assessment as a standard practice. In this follow-up article, we delineate ways to manage post-operative MEP using a multimodal approach.

Postoperative pain is expected, especially during required movements the first days after surgery, making those with pre-existing MEP vulnerable to severe interference from postoperative pain, subsequent chronic pain and disability (Papadomanolakis-Pakis et al., 2021; van Boekel et al, 2021). Understanding MEP and promoting postoperative activities prevents complications related to pain, immobility and multiple medication use. In addition to multimodal analgesia, engaging patients to move despite transient discomforts can prevent the amplification and chronification of postsurgical pain (Gilmore, et al., 2019; Parrish, 2020).

Nurses should intervene to enhance pain tolerability and engagement in activities required for optimal recovery (Booker, et al., 2020). Nurses are in a key position to implement and evaluate safe, effective pain treatment plans while considering functional benchmarks, discharge criteria and patient-specific factors (Jones et al., 2020; Wainwright, Jakobsen, & Kehlet, 2022). Establishing a plan based on realistic, measurable goals will help maximize pain reduction, and functional improvement while avoiding treatment-related harm. All nurses can work collaboratively with the healthcare team, patient and caregivers to develop and implement a multi-modal plan of care to:

1. Educate about the occurrence and effects of postoperative MEP.

2. Develop individualized short- and long-term specific, measurable, achievable, realistic, timely (SMART) goals.

3. Engage in early mobility and frequent movement to prevent immobility-related complications.

4. Assess/manage expectations and psychosocial factors that may impede movement.

5. Proactively control pain with integrated non-pharmacologic and pharmacological strategies.

6. Evaluate the qualities of MEP to refine the efficacy of treatments.

7. Provide patients and caregivers with resources to reduce pain, enhance functional recovery and prevent complications secondary to prolonged pain or immobility.

This person-centered approach urges clinicians to assume a whole-person model of pain care (Yeung, Irwin, & Cheung, 2021) and not to simply treat the symptom or pathology of pain but to actively engage with patients and healthcare teams to promote recovery, wellness, mobility, and life balance.

PLANNING CARE

The preoperative assessment of pain, functional status and latent ways of coping with pain (drug and nondrug) forms a strong foundation for treatment planning. The tailored plan of care must mutually align acknowledging how pain or its treatment interferes with prescribed or valued activities, and the individual’s unique goals. Accurate assessment of MEP pinpoints the most relevant nursing diagnosis for treatment planning and refinement to progress towards functional benchmarks and postoperative goals. Currently, MEP is a not a nursing diagnoses or an ICD-11 code, but delineating the etiology and defining characteristics by considering biopsychosocial factors of MEP (e.g., comorbidities, activity tolerance, anxiety, fear, coping style, supports and resources) may shift the nursing focus of interventions, education and counselling. Preventing complications of immobility (see Box 1) is important to convey. Beyond preventing/treating pain, other interventions that safely promote mobility are a necessary part of the plan and may require expanding the treatment team (e.g. to include physiotherapists, psychologists, etc.) to best meet the needs of the individual.

Callout Box 1. Hazards of Immobility.

Effects on cardiovascular function	Effects on respiratory function	Effects on genitourinary function
Increased workload of the heart, including increased heart rate	Decreased respiratory vital capacity	Incomplete bladder emptying
Deep vein thrombosis	Decreased movement of secretions, pooling of mucous	Urinary tract infection
Orthostatic hypotension	Atelectasis	Formation of calculi in kidneys and infection
Loss of plasma volume	Pneumonia	Effects on Integumentary function
Venous stasis, venous insufficiency edema	Oxygen-carbon dioxide imbalance	Skin breakdown Pressure injury
Effects on gastro-intestinal function	Effects on musculoskeletal function	Effects on psychological function
Increased risk of aspiration	Weakness, increased risks of falls	Anxiety
Loss of appetite	Muscle atrophy, loss of muscle strength	Depression
Decreased peristalsis	Calcium loss from bones	Sensory deprivation, apathy
Constipation	Contractures	Learned helplessness
	Joint pain	Delirium

Goal Setting

Assessments and diagnoses provide a foundation for treatment planning, implementation and evaluation based on individualized goals, risks, capabilities and ordered restrictions. Develop goals so that all parties can identify potential areas of disagreement, and be confident they meet the SMART (Specific, Measurable, Achievable, Realistic and Timely) criteria for desired outcomes for comfort, function, and mood (Booker & Haedtke, 2016). For example, “control pain so that standing for 30 seconds within 12 hours and walking 10 steps within 24 hours is tolerable” meets these criteria for many patients after surgery. Establishing mutually aligned goals requires critical thinking, engaging dialog and at times challenging assumptions held by the patient, caregiver, or different treatment team members. Daily refinement of goals helps further individualize interventions, as there will be some patients who refuse to turn, cough or deep breathe the day after surgery, whereas others may want to resume activities that are restricted in the postoperative period.

A common but unrealistic assumption is that pain treatment will eliminate all postoperative pain during movement and rest. Pain may be minimized transiently with local anesthetics/multimodal therapies at rest, and be present with movement, or return when those therapies are stopped. Patient and caregiver-centered education should prepare them and primary caregivers to expect some postoperative pain and how to cope with it outside of the hospital setting. Educate on the importance of lessening the fear, anxiety and other emotions that can drive pain levels up, impeding functional progress after surgery. Unrealistic expectations that pain should be eradicated is counterproductive if it contributes to over-treatment or diminishes functioning (Harvey et al., 2018). Thus, frank conversations to develop realistic comfort-function goals are needed preoperatively and reinforced in the perioperative and postoperative phases when responses to pain control strategies are known (McEvoy, et al., 2017). Consistent messaging by the interprofessional team, striving to achieve realistic comfort-function goals is needed.

Realistic expectations include acknowledgement that anxiety, a sense of loss and pain are natural and by coping with them people can regain functioning and explore new ways of pursuing valued activities. The meanings ascribed to pain (e.g., “this is awful,” “I shouldn’t move”) are a better predictor of whether they will regain usual functioning after surgery than measures of pain intensity at rest (Campos, 2020). Hence, consider if MEP is causing impaired functional recovery or a consequence of a mindset or complication that demands attention. Removing pain as a barrier to early postoperative mobilization is essential to regaining full functional potential (Munter, 2018).

MANAGEMENT STRATEGIES

Multimodal Approach

MEP after a procedure may display altered peripheral ( sensation, inflammation, etc.) and/or central nervous functioning (intensification, spread, prolonged duration), increasing the risk of poor outcomes (Fullwood et al., 2021). Therefore, rather than increasing opioid doses based on pain intensity reports (which can impede functioning through oversedation), add different therapies to improve pain tolerance and functional capacity (Quinlan-Colwell, Rae & Drew, 2022). Multimodal analgesia can improve pain control and mobility while avoiding overreliance on one therapy. The best practice of multimodal therapy entails using multiple drugs in the lowest effective dose for the shortest time in addition to non-drug therapies (See Tables 1 & 2). Patient-centered interprofessional teamwork may be needed to balance concerns for pain reduction, therapeutic movement and avoidance of iatrogenic harm in complex cases. Evidence supports multimodal analgesia as a way to lower postoperative pain and opioid use, while improving patient functioning, satisfaction and other desirable clinical outcomes (Ntalouka, 2021).

Table 1.

Non-pharmacologic Pain Management Strategies that Facilitate Movement

Category	Strategies	Benefits	Risks	Effect on Mobility
Restorative modalities: Help restore optimum function, independence, and comfort.	Positioning Thermotherapy Therapeutic exercise Massage P.T./O.T. Orthotics; adaptive equipment	Builds strength, stamina, flexibility. Supports proper alignment the prevent secondary maladaptive changes. Expertise of P.T./O.T. establishes a specific program tailored to individual’s needs & risks.	Fatigue, overexertion, inflammation, injury or falls. Increase in pain or swelling may reinforce fear/avoidance pattern. Protect from thermal injury (don’t use in a person unable to feel or remove it).	Has an established activity/exercise plan appropriate to surgery/recovery needs. Start with imagining movements before doing them, then progress. Establish a routine. Thermotherapy and stretch after activity.
Example: Per a physician’s order, place TENS near location of pain for approximately 15 minutes twice a day, gradually increasing the intensity until the preferred or tolerated intensity is reached.” Offer thermotherapy (topical heat or cooling source) at least 15 minutes before or immediately after physical activity known to produce MEP.
Behavioral modalities: Activities that assist individuals in overcoming cognitive/affective barriers to movement and/or pain.	Relaxation/imagery mindful techniques Mental distraction Pacing activities Cognitive-Behavioral Therapy Technology guided therapy (e.g. Virtual Reality, Telehealth) Self-Management programs	Reduces pain, distress cognitive and affective barriers to movement. Benefits increase with practice. May reduce medication use.	Unresolved mental health problems may emerge requiring specialty attention. Guidance may be needed to master techniques if anxiety, frustration or intrusive thoughts prevent engagement. Require frequent (daily) practice. VR, RR, or videos may trigger motion sickness, unpleasant memories/thoughts/feelings.	Relaxation techniques may be better sitting upright, with eyes focus on 1 point. May need to challenge cognitive distortions or pessimism to motivate patients. Mastery takes time, need to practice even if no immediate benefit.
Example: Encourage slow diaphragmatic breathing before engaging in a painful activity to “breathe out” movement-related fear or anxiety. Counting (as distraction) during painful activity and resuming diaphragmatic breathing after MEP can aid in task persistence and recovery from MEP.
Complementary/integrative approaches: Unconventional activities that can be used in addition or with other non-pharmacological or pharmacological strategies.	Reiki, Healing Touch Electrical Nerve Stimulation (TENS) Humor, music Acupuncture Nutritional Supplement	Enhance blood flow, circulation, nutrition. Stimulates natural comfort (endorphins) and healing processes. Diminishes unhelpful stress responses.	Access to skilled personnel who understand postsurgical limitations is a limiting factor in many settings. Some nutritional supplements interact with drugs.	Nutrition promotes strength and may reduce pro-inflammatory state, nausea and other hindrances to mobility. Distraction, caring presence can help with mobility and task perseverance.
Example: Reiki, either before bed or early in the morning, can help with reduce anxiety or fear before a painful activity or promote comfort after MEP and sleep if used at night.
Social and spiritual modalities: Activities that facilitate interpersonal and intrapersonal adaptive coping, task persistence, and existential fulfillment.	Prayer Meditation Support Groups Stress, Coping & Resiliency Training Guided imagery	Provides strength, comfort, motivation and meaning for the individual.	Spirituality may be equated with religiosity and be distressing if the person feels they are being punished for mistakes; or angry to have bad things happen when they did all the “right” things.	Align with beliefs, values, routines and rituals. Find meaningful connections as a motivator for movement.
Example: Set a long-term goal of resuming realistic routines and rituals, with a daily activity goal despite MEP to work towards that goal. Use social or spiritual resources to aid in coping with the distress or grief over losses to maintain and strengthen meaningful connections. This may include inviting a chaplain or spiritual guide to visit patient or encouraging a prayer or meditation prior to any activity that will stimulate pain.

Table 2.

Pharmacologic Pain Management Strategies that Facilitate Movement

Category	Common Examples	Benefits	Risks	Effect on Mobility
Topical analgesics: Cream, gel, drop, spray, liquid, or patch applied to intact skin over painful areas.	NSAIDs (e.g., diclofenac gel, ibuprofen gel) Local Anesthetics (Xylocaine jelly, LMX4) Topical rubefacients (e.g. Trolamine salicylate, menthol, isopropryl, camphor) Capsaicin (Capzaicin-HP)	Lower rates of side effects or toxicity than systemic (e.g., IV, PO) routes. Local anesthetics best for neuropathic/procedural pain. NSAID’s good for skin and superficial musculoskeletal pain. Rubefacients may be effective for mild muscle and joint pain. Redness at application site is expected given its counterirritation, cooling or heating action. Capsaicin (from chili peppers) cuts production/release of pain signaling neuropeptide. Low dose available over the counter. High dose (for neuropathic pain) administered by professionals in a clinical setting.	Skin irritation/dryness common. Local anesthetics develop tachyphylaxis, avoid sustained use. Mild (rash) or serious allergies may occur. NSAIDs could cause uncommon GI upset or renal impairments with preexisting problems in those systems. Rubefacients risk salicylate toxicity with repeated applications over large areas. Capsaicin can burn sensitive mucus membranes (e.g., eyes), wash hands immediately after use.	Generally positive effect on mobility linked to its effectiveness.
Non-opioid analgesics: Medications that are not opioids or listed as controlled substances.	Acetaminophen (e.g., Tylenol, Panadol, Ofirmev injection) NSAIDs (e.g., ibuprofen, naproxen, ketorolac, meloxicam, diclofenac, indomethacin, celecoxib)	Acetaminophen blocks neuro-inflammation and pain signals in the central nervous system. Effective for mild to moderate pain and slightly enhances the effect of other analgesic. NSAIDs both prescription and non-prescription reduce pain-producing inflammation.	Acetaminophen may cause liver and kidney damage with high dose/long duration exposure, especially with age extremes, dehydration and/or alcohol use. Know acetaminophen-containing medications (Excedrin, NyQuil, Vicodin, Advil Dual Action) NSAIDs of high dose/long duration exposure linked to GI ulceration or bleeding; kidney and heart disease; neurotoxicity with some drugs.	Pain reduction facilitates movement. NSAID-induced drowsiness possible.
Adjuvant medications: Drugs that have analgesic properties to which pain relief is not their typical primary indication.	Antidepressants (e.g., nortriptyline, imipramine, duloxetine, venlafaxine) Anticonvulsants (e.g., gabapentin, pregabalin, carbamazepine) Muscle relaxants or antispasmodics (e.g., benzodiazepine, orphenadrine, baclofen, tizanidine) Corticosteroid (e.g., hydrocortisone, methylprednisolone, cortisone, prednisone)	Exert analgesic effect by targeting cause or altering the transmission, modulation, and/or perception of pain. May improve sleep. Best for neuropathic or widespread pain. May be opioid-sparing.	Side effects may outweigh benefits initially. Watch for confusion, drug interactions, edema, fall risk and oversedation. Consider co-morbidities (e.g., cardiovascular, renal, psychiatric). May produce physical dependence over time requiring a taper period before stopping.	Sedation, edema, fluid-electrolyte imbalance, altered vital signs or other side effects may impede mobility and increase risk of falls.
Opioid analgesics: Controlled substances that provide powerful pain relief.	Mu agonists (e.g., morphine, fentanyl, oxycodone, hydromorphone) Atypical opioids (e.g., tramadol, tapentadol, buprenorphine)	Pain reduction often improves physical functioning and sleep. Synthetic opioids (fentanyl, methadone, and atypical opioids) may have less gastrointestinal, skin and histamine-related side effects.	High side effect burden, especially initially. Oversedation, sleep apnea, and respiratory depression a major concern, especially if other sedating medicines are used. Aberrant drug use behaviors or addiction may result from exposure. May produce physical dependence over time requiring a taper period before stopping.	Sedation, dizziness, visual disturbance, confusion, edema, fluid-electrolyte imbalance, altered vital signs or other side effects may impede mobility and increase risk of falls.
Example: Nearing the peak action of pharmacological medications, lead the patient in 10-minute guided imagery scenario, while incorporating other environmental relaxants like aromatherapy and soft music or soundscapes. This enhances the analgesic effect and distraction from pain.
Interventional approaches: Procedural techniques or devices applied to relieve pain; can be invasive or non-invasive.	Nerve Blocks: Local anesthetics (or combination of medications) administered to block pain transmission of specific nerves (e.g. Brachial Plexus, Femoral, Interscalene, Paravertebral, Sciatic, Supraclavicular, Transversus Abdominis Plane) Neuromodulators (e.g. Percutaneous Peripheral Nerve Stimulators)	Nerve Blocks & Epidurals block the transmission, amplification and prolonged maintenance of pain signals. Prevents multisystem complications associated with severe pain. May prevent pain Opioid-sparing. Liposome bupivacaine may extend effects. Experimental neuromodulation techniques are emerging that uses cold temperatures or electrical stimulation to suppress pain signals from selected nerves. These appear to have safety and efficacy advantages over currently used medications.	Local Anesthetics used in Nerve Blocks and epidurals have serious toxic reactions if administered into the blood stream. May diminish awareness of actual/potential tissue damage and increase risk of falls by altering sensorimotor, proprioception and autonomic functioning. Hypotension may also increase risk of falls (especially if dehydrated). Risk of bleeding (including epidural hematoma), especially with anticoagulation. Bupivacaine damage muscles. Special equipment and trained professionals needed. Wrong route errors (vascular, intrathecal) may occur.	Removes pain as a barrier to movement. Uses little, if any opioid which improves alertness. Precautions needed to prevent falls. May have motor limitations in area affected by nerve block.

An opioid-sparing individualized treatment plan can be built on previously helpful coping skills while avoiding past failures. Nurses should advocate for the expansion of treatment types, including the use of non-pharmacological pain control interventions and expanding the treatment team to include more modality types. Current best practices in treating high intensity and/or prolonged pain supports extending this multimodal approach beyond medications (Table 1) to include interventional, rehabilitative, behavioral, and complementary/integrative approaches (Table 2) as appropriate into patient-centered care (U.S. Department of Health and Human Services, 2019). For example, after surgery, a combination of medications, nerve blocks, physical therapy, education and counseling combined with complementary comfort measures is likely to produce the best outcomes (See Figure 1 for a patient exemplar). The intensity of pain along with the impact on patient functioning will determine the appropriate types and invasiveness of therapies. For example, three or more CNS-active drugs (e.g., opioids, anticonvulsants, anxiolytic-hypnotic drugs, antidepressants, etc.) are riskier in older adults, and avoided as related oversedation may diminish functioning while increasing the risk of injury or adverse effects (Beers-AGS, 2019). Patient-centered interprofessional teamwork may be needed to balance concerns for pain reduction, therapeutic movement and avoidance of adverse effects in complex cases.

Figure 1.

Case Scenario

Promoting Wellness and Quality of Life through Movement

Although seemingly counterintuitive after surgery, it’s time to replace the outdated notion that “rest is best,” with the widely accepted “motion is potion” perspective. Both pain and movement are required for life, but like too much pain, too little movement creates a catabolic, proinflammatory, immunosuppressed state increasing the risk of life-threatening complications or illnesses. Balancing the need to enhance movement while controlling pain counter these effects and promote healing. The benefits of consistent movement and exercise include improved pain, range of motion, strength, tissue repair, and analgesic endorphin release (Wun et al., 2021). Teaching and practicing self-regulatory strategies is important and may differ based on pain types. For example, diaphragmatic breathing can be used during severe procedural or MEP, whereas distraction or sleep hygiene may be best for less intense pain. Combining physical and mental strategies (e.g. mindfulness-based cognitive interventions and isometric exercises) can work synergistically to improve pain and functioning after surgery (Reynolds et al., (2022). Other wellness approaches promote movement and engagement with valued people, places and things (e.g. going to a comfortable place to socialize) can be considered. Many settings offer chaplaincy, reiki, pet, music, art or aroma therapies to promote comfort and wellness. These not only promote comfort and mobility, but can also reduce the risk of persistent postsurgical pain (PPP) and related disability. Farzad and colleagues (2021) found that MEP scores after post-immobilization of radius fracture predicted both wrist pain and disability 6-months after injury, unlike pain at rest which only predicted pain. Thus, the need for multimodal analgesia to treat MEP and prevent PPP and long-term functional disability.

Interventional techniques that suppress pain transmission can also facilitate movement. Peripheral nerve blocks or regional (e.g., epidural) analgesia often provide excellent partial, temporary relief; but may pose additional risks when mobilizing the patient. Quelled sensory-motor nerves may produce weakness, bypass the protective nature of pain, and when combined with diminished proprioceptive and autonomic activity can elevate the risk of falls/injuries. Percutaneous devices sending electrical impulses to a peripheral, regional or central nerve disrupt pain-signals are being tested to yield similar benefits without the risks of local anesthetics.

During the acute postoperative period, exercise, as well as any activity restrictions, should be ordered. Therapeutic movement (guided by physiotherapists in some cases) prevents diminished functional capacity, increases range of motion, strength and stamina that is lost with immobility. Tailored, therapeutic movement reduces pain and stiffness and can increase the production and release of innate hormones/chemicals that naturally alleviate pain and promote healing. One option is to introduce a modified style of Tai Chi, which encourages mindful movements and stretching. Exercise routines that build muscle strength, range of motion, balance, and endurance are balanced against the risks of overexertion, increased pain, inadequate circulation and mechanical strain or bleeding at the surgical site. Functional goals may include increasing strength, stamina, and mobility to a level required for safe discharge or transfer. Adaptive equipment (orthotics, walkers, compression sleeves, etc.) may be needed for optimal comfort and functional independence. An activity plan approved by the surgeon, often developed by a Physical/Occupational Therapist, is recommended to safely mobilize patients and prevent the undesired effects of immobility that mount with each passing day. Nurses have an important role in implementing the plan, reporting undesired responses and preventing avoidable harm (e.g., falls, skin breakdown) related to the activity or equipment used. These approaches emphasize movements needed to maintain and restore optimum functionality.

In the postoperative period, teaching activity pacing helps patients overcome fear-avoidance patterns, setting a schedule of when to start or stop activities. Pacing activities can prevent pain exacerbation by avoiding pain induced by overexertion and spasms secondary to muscle/ROM loss due to inactivity. For patients too afraid to move, graded-exposure approaches (identify and overcomes fear – starting with the least feared step) and graded activity (from motor imagery to progressively more difficult movements) may enhance adherence by reducing catastrophizing, fear, and avoidance of movement (Corey et al., 2021). Complementary and wellness approaches (e.g., diaphragmatic breathing, humor, nutrition, sleep hygiene, music, acupuncture, aromatherapy, etc.) can reduce pain and facilitate activity by making pain more tolerable. An emerging wellness concept is pain hygiene, which stresses that management be a routine process that incorporates basic and individualized techniques to address the biopsychosocial-behavioral aspects of pain (Saravanan, Reagan, Bai, Booker, & Starkweather, 2022).

Recovery Bundles

A growing body of evidence supports Enhanced Recovery After Surgery (ERAS) approaches as best perioperative practices for a variety of surgery types. Protocols typically start with preoperative prehabilitation (exercise), nutritional, education and counseling using motivational interviewing techniques to improve preoperative physical and mental preparation (Wainwright, et al, 2022). Perioperative preemptive multimodal analgesia, with early postoperative mobilization, sleep hygeine and oral intake has better outcomes than traditional restrictive approaches (Dorey, et al., 2022). Early mobilization is considered one of the most important components of ERAS protocols (Johnson, 2020) although movement-evoked pain assessments are not considered standard because of differences in setting-specific resources and procedure-specific factors.

Although these current best practices are being adopted internationally, they are inconsistently applied across procedures and settings. Nurses are in a key position to help refine ERAS protocols for their setting given their knowledge of perioperative pathways, surgery, procedures and resources in their setting. Nursing engagement is key to actualizing these opportunities for improvement through interprofessional team collaboration to develop standardized approaches to preoperative preparation, optimizing analgesia, nutrition, hydration and early mobilization (Wainwright, et al., 2022). Adopting MEP as a standard part of pain assessment and reassessment as a basis for daily treatments is an important component of recovery. Alternate approaches for those not achieving pain control and functional benchmarks at defined intervals should also be discussed by the team to facilitate refinement in treatment plans if first line therapies fail (McEvoy, et al., 2017).

Research Trends in MEP Management

Internationally, MEP is increasingly being recognized as an important patient outcome to measure before and after surgery. Research on MEP and its management has been conducted primarily in Canada, United States, Netherlands, Denmark, Israel, and Australia. In Europe, pain management recommendations promote regional anesthesia, fewer opioids, and more non-pharmacological interventions, such as music, virtual reality, relaxation, and physiotherapy. Recent research has investigated the effect of several therapies in people experiencing MEP: exercise, transcutaneous electrical nerve stimulation (TENS), kinesiotaping, continuous and pulsed ultrasound, manual therapy and medications (Leemans et al., 2022; Treister, Suzan, Lawal, & Katz, 2019). A systematic review concluded that there was moderate evidence for exercise therapy and low evidence for TENS in providing a beneficial treatment effect for MEP (Leemans et al., 2022). While multimodal pain treatment is a recommended best practice, it is not consistently applied and could benefit from implementation science investigations and consensus-developed nursing order sets for MEP management.

EVALUATION OF INTERVENTIONS, PROGRESS TOWARDS GOALS, AND REFINEMENT OF THE TREATMENT PLAN

Evaluation and refinement of the goals, intervention and treatment plan contributes to positive patient outcomes (Toney-Butler & Thayer, 2021). Regular reassessment or evaluation of timely attainment of benchmark pain control and functional outcomes inform you whether recovery is on track or the plan of care needs refinement based on responses to therapy.

When evaluating, it is important to assess multiple dimensions of pain rather than focusing only on its intensity. For example, after ankle surgery a patient reporting a severe pain rated as “8” on a 0–10 scale would be evaluated and treated differently if it was a sharp ankle pain compared to a crushing chest pain. Consistently documenting multiple dimensions of pain promotes continuity of care by “telling the story” of what is helping or possibly harming the patient. Promoting consistency in how pain is assessed, documented and communicated can aid in refining an ineffective treatment plan or reveal concerning complications that impede healing and recovery. Pain assessed at rest is less revealing, as it fails to identify patients who refuse to deep breathe or engage in prescribed activities because the pain is too severe with movement. Therefore, assessments should be completed both at rest and with movement.

Reassessments of pain are done periodically per organizational routines in general; and in particular before and after an analgesic is provided to determine if the intervention is working or if the patient is experiencing undesired effects. Understanding the onset, peak and duration of analgesics administered is important, so that reassessments can be done at a time that approximates its peak effect. This information can also be useful when engaging patients in painful activities. For some patients, engaging them in activities soon after the onset of an analgesic helps them move despite the presence of pain; knowing that when the activity is completed the medication will be working at its best. When safety concerns exist such as ambulating patients with a nerve block or epidural, making sure that they can stand with the strength to lock their knee; and delaying supplemental analgesics that may weaken them or contribute to orthostatic hypotension is advised.

The effect of the interventions on pain, functioning and adverse events, should be evaluated near its peak effect and documented within 4 hours per organizational policy. In outpatient settings where the desired and undesired effects of pain-relieving interventions are not yet fully known, that fact should be documented along with the education provided to the patient and caregiver about anticipated and reportable undesired effects. Nurses in these settings should consider follow-up phone calls with patients and caregivers to determine level of pain control. When evaluating the effects on pain, use the same pain intensity measure post-intervention as was used at baseline. Document progress (if any) made towards comfort/function goals as found in the care plan, and any undesired effects. Adjust the comfort/function goals if needed, to be more realistic.

SUMMARY

Postoperative nurses are faced daily with balancing mobility concerns to safely achieve pain reduction and functional improvement goals. To do this, nurses need to quantify and qualify the impact of pain during movements associated with functional goals and manage MEP using evidence-based techniques tailored to the individual’s responses.