Abstract
Background
Poorly controlled post-operative pain may adversely affect total joint replacement (TJR) patients’ outcomes and associated healthcare cost. Understanding effective pain management after surgery is important to patients, surgeons, and hospitals. We evaluated patient-reported receipt of pre-operative pain management information in a national prospective cohort evaluating post-operative pain and function following elective TJR.
Methods
Preoperative, 2-week and 6-month postoperative survey data of 1609 TJR patients collected between 6/2013 and 12/2014 were analyzed. Data included demographics, medical and musculoskeletal comorbidity, operative joint pain, physical function and mental health. At 2-weeks post-operative, patients were asked if they had received pain management information prior to surgery, the content of that education, and pain management strategies. Descriptive statistics were performed.
Results
At 2 weeks post TJR, one third of patients reported not receiving information about pain management; an additional 11% did not find the information helpful. There were no differences pre-operatively in demographics or clinical profiles between those who received pain information and those who did not. Patients who received pain information reported less pain 2-weeks post-operatively; greater use of non-narcotic pain care strategies; and, better physical function scores at 6-months post-operatively. No differences in operative joint pain were identified at 6-months between education and non-education groups.
Conclusion
Forty-four percent of patients reported that they did not receive/received unhelpful information regarding post-operative pain management, highlighting a need for improved patient education. In this sample, the lack of pain management information was associated with poorer 6-month post-operative function.
Keywords: pain management education, patient reported outcomes, elective surgery, Non-medicine pain management
Introduction
Patients undergoing total joint replacement (TJR) experience significant arthritic pain prior to electing surgery [1,2] and are often managing pain with the use of prescription and non-prescription pain medication. Additionally, the majority experience new surgical pain in the early post-operative period. [3] Effective pain management continues to be a challenge for orthopedic surgeons and their patients. [4,5] Poorly controlled post-operative pain may have adverse effects on patients’ post-operative course, including an increased length of hospital stay, greater risk for adverse events such as readmission and deep vein thrombosis, as well as delayed physical recovery and return to activities of daily living. Associated increased overall healthcare costs will impact bundled payments, which the Centers for Medicare and Medicaid is now linking to 30 day all-cause readmission and complications. [6] Finally, as TJR patients are increasingly discharged directly to home, it is important that patients understand how to self-manage post-surgical pain. Thus, understanding effective pain management after TJR is important to patients, surgeons, and hospitals.
Several studies have focused on TJR pain management during hospitalization [7–12] with less attention paid to addressing the management of pain after discharge. Currently, prescription pain medications such as opioids are the most common approach to managing pain postoperatively. Although current standard of care for elective surgical patients includes a pre-operative education class, in their review of the literature, Louw et al. (2013) concluded that patient education classes that use the “biomedical model” have little impact on post-operative pain after TJR. [13] A 2014 Cochrane review also found no difference in patient reported outcomes of pain and function between participants receiving a pre-operative patient education intervention and those receiving usual care.[14]
Although these studies have examined the impact of pre-operative patient education on patient outcomes after surgery, little is known about the patients’ perception of the information received pre-operatively regarding managing their pain at home post-operatively. In this study, we evaluated patient reported receipt of pre-operative pain treatment options information for managing pain post-operatively in a national prospective multi-center cohort of TJR patients. The dataset includes post-operative pain and function. [15] Additionally, we explored the use of non-medical methods of pain management by patients to help decrease or alleviate their postoperative pain.
Methods
Participants and setting
Data were obtained from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) study, a national cohort of more than 132 orthopedic surgeons in academic and private centers from 22 states across the country.[15] A randomized sample of surgeons were invited to participate, and were stratified by region of the US and surgical volume. Overall, 75% of participating surgeons are community-based orthopedists.
Design
Patients were prospectively enrolled into the cohort beginning in 2011, at a preoperative visit within three months of undergoing their primary, elective, unilateral total joint replacement surgery. Follow-up data were collected at 6 months post-operatively and annually thereafter. The response rate for the FORCE study was 80 to 85%.[16] For the current study, a subset of patients, between June 2013 and December 2014, were invited to complete an additional survey at 2 weeks post-operatively, which collected data regarding pain intensity and pain treatment information. Data were accessed in July 2015.
Instruments
FORCE-TJR collects demographic data, clinical comorbidity, and patient reported outcomes (PRO) through a self-administered questionnaire. Demographic data included age, gender, race, ethnicity, income, insurance status, educational level. Patient-reported outcome measures include the Mental Component Summary (MCS) score and Physical Component Summary (PCS) score of the Short Form-36 (SF-36) [17,18] and the Knee or Hip Disability and Osteoarthritis Outcome Score (KOOS/HOOS) [19, 20]. Medical comorbidities were measured using the modified Charlson Comorbidity Index (CCI) [21]. Musculoskeletal disease burden was assessed using the KOOS/HOOS pain subscale in non-operative joints and one item from the Oswestry Disability Index was used to measure back pain [22,23]. Body mass index (BMI) information was also collected. Patients completed the same PRO measures six-months postoperatively.
At 2 weeks post-operatively, a subset of patients from the FORCE-TJR registry completed a pain survey that included questions regarding whether or not they had received information prior to surgery about pain management options and if so, how helpful the information was (on a Likert scale of 0 to 10, with higher scores indicating greater helpfulness). Additionally, patients were asked about the use of and number of non-medication methods employed to relieve operative joint pain, about their current pain level, maximum pain level in the past 24 hours (higher scores indicating greater pain), and pain relief from all pain treatments combined (higher scores indicating greater relief). Patients were also asked about how much pain interfered with activities of daily living, including physical therapy (higher scores indicating greater interference).
Analyses
Descriptive statistics were calculated for continuous variables. Frequencies were determined for categorical variables including race, ethnicity, income, insurance status, educational level. Some variables with more than two categories were dichotomized; for example, race was considered as either white or nonwhite. Additionally, some continuous variables were collapsed into categorical variables. For example, HOOS and KOOS pain scores were collapsed into None/Mild (HOOS/KOOS score of 70 to100) and Moderate/Severe (HOOS/KOOS score of 0 to less than 70). Independent sample t-tests and two-sample Wilcoxon rank-sum tests were used to compare means of continuous variables as indicated. Chi-square tests were used to compare frequencies of categorical values. Statistical significance level was set at p<0.05.
IRB Approval
Study protocols and consent procedures were approved by the institution Committee for the Protection of Human Subjects in Research.
Results
Complete preoperative, 2 week and 6 month postoperative data were obtained from 1609 primary unilateral TJR patients. One third of patients (33% or 526/1609) reported not receiving information about pain management options prior to their surgery, and an additional 10.6% (n=171), who did receive information, reported that they did not find the information helpful (rated helpfulness of information as a 4 or less on a 0 to 10 scale).
Patients who had received information that was not helpful were similar to those who had received helpful information in demographic and clinical factors, thus we compared patients who reported not receiving information about pain management options post-operatively (n=526) with those who did (n=1083).
Preoperative Data
There were no statistically significant differences in demographics, including age, gender, race, ethnicity, education level or household income pre-operatively between those participants who received pain management information and those who did not (Table 1).
Table 1.
Patient demographics and pre-operative medical characteristics
| Received Information regarding pain treatment options | ||||
|---|---|---|---|---|
| Yes 1083 (%) |
No 526 (%) |
Total 1609 |
P | |
| Demographics | ||||
| Age | ||||
| Mean [SD] | 66.56 [9.06] | 66.99 [9.40] | 66.70 [9.17] | 0.510 |
| Range | 30–97 | 30–99 | 30–99 | |
| Gender | ||||
| Female | 652 (60.2) | 333 (63.3) | 985 | 0.231 |
| Male | 431 (39.8) | 193 (36.7) | 624 | |
| Race | ||||
| White | 1004 (94.6) | 484 (94.7) | 1488 | 0.942 |
| Non-White | 57 (5.4) | 27 (5.3) | 84 | |
| Ethnicity | ||||
| Hispanic | 12 (1.3) | 8 (1.8) | 20 | 0.444 |
| Non-Hispanic | 937 (98.7) | 440 (98.2) | 1377 | |
| Education Level | ||||
| High School Graduate or less | 272 (27.2) | 150 (30.6) | 422 | 0.301 |
| Post High School | 730 (72.8) | 341 (69.4) | 1071 | |
| Household Income | ||||
| Less than or equal to $45,000 | 275 (32.2) | 137 (33.6) | 412 | 0.821 |
| Greater than $45,000 | 579 (67.8) | 271 (66.4) | 850 | |
| Pre-operative Medical Characteristics | ||||
| BMI | ||||
| Mean [SD] | 30.30 (5.89) | 30.41 (5.84) | 30.34 (5.87) | 0.764 |
| Range | 15.04–54.92 | 18.04–54.92 | 15.04–54.92 | |
| Surgery Type | ||||
| Total Knee Replacement | 672 (62%) | 315 (60%) | 987 (61.3%) | 0.435 |
| Total Hip Replacement | 411 (38%) | 211 (40%) | 622 (38.7%) | |
| KOOS/HOOS pain in operative joint | ||||
| None/mild | 108 (10.4) | 48 (9.6) | 156 | 0.708 |
| Moderate/severe | 933 (89.6) | 451 (90.4) | 1384 | |
| PCS | ||||
| Mean [SD] | 33.07 [8.17] | 32.46 [8.62] | 32.87 [8.32] | 0.208 |
| Range | 10.44–59.60 | 12.19–54.66 | 10.44–59.60 | |
| < 40 | 820 (79.8) | 381 (80.0) | 1201 | 0.48 |
| 40 or greater | 208 (20.2) | 95 (20.0) | 303 | |
| MCS | ||||
| Mean [SD] | 53.07 [11.60] | 52.22 [12.26] | 52.80 [11.82] | 0.213 |
| Range | 18.67–76.06 | 10.54–75.34 | 10.54–76.06 | |
| Medical Comorbidity | ||||
| 0 | 696 (66.2) | 335 (65.2) | 1031 | 0.141 |
| 1 | 198 (18.9) | 82 (15.9) | 280 | |
| 2–5 | 87 (8.3) | 58 (11.3) | 145 | |
| ≥6 | 70 (6.6) | 39 (7.6) | 109 | |
| Pain in other knee/hip joints | ||||
| 0 | 776 (73.8) | 355 (71.0) | 1131 | 0.121 |
| 1–3 | 276 (26.2) | 145 (29.0) | 421 | |
| Lower back pain | ||||
| None/mild | 793 (80.6) | 382 (80.6) | 1175 | 1.0 |
| Moderate/severe | 191 (19.4) | 92 (19.4) | 283 | |
| Surgical Practice | ||||
| Low volume (< 100 patients) | 417 (38.8) | 191 (36.9) | 608 | 0.098 |
| Moderate Volume (100 to < 200 patients) | 366 (34.1) | 160 (30.9) | 526 | |
| High volume (≥ 200 patients) | 291(27.1) | 167 (32.2) | 458 | |
Additionally, there were no statistically significant differences in the type of joint surgery, the number of patient reported comorbid conditions, operative joint pain severity measured by the HOOS/KOOS pain scale, musculoskeletal disease burden which included pain in other joints and lower back pain, or pre-operative SF36 PCS and MCS between those who reported receiving pain management information and those who did not.
When the patient volume of the surgical practice where patients were recruited was examined, there were no statistical differences between low volume sites (less than 100 patients with data), moderate volume sites (100 to less than 200 patients) and high volume sites (more than 200 patients) for patients reporting no pain education.
2 weeks post-operative data
Patients who received information about pain management options reported lower current pain in the last 24 hours (2.96 versus 3.31; p < 0.01) and lower maximum pain in the last 24 hours (mean 4.80 versus 5.17) p < 0.01) (Figure 1) in their operative joint as well as higher levels of pain relief in the last 24 hours (mean 7.46 versus 7.04; p < 0.01). Figure 1 demonstrates the differences in distribution between patients who received information about pain management options and those who did not as it relates to maximum pain in the last 24 hours.
Figure 1.
Distribution of Maximum Pain level in the last 24 hours at 2 weeks post-operatively by receipt of pre-operative pain management demonstrating a higher proportion of those receiving pain education reporting less pain (lower scores).
Patients who received information about pain management options were more likely to report the use of at least one non-medication method to relieve operative joint pain after TJR (90% versus 79%, p < 0.01). Among the strategies reported, patients who received information about pain management were more likely to report: using a cold pack (85% versus 73%, p < 0.01); using distraction such as watching TV and reading (50% versus 42%, p = 0.01); using relaxation (21% versus 16%, p = 0.04); listening to music (14% versus 8%, p < 0.01); walking (30% versus 24%, p = 0.01) and; imagery (3% versus 1%, p = 0.04) than patients who did not receive information about pain management. There were no significant differences between those who received information and those who did not in the use of prayer, massage, deep breathing, heat, and meditation.
When asked about pain interfering with activities of daily living, patients who received information about pain management options reported statistically significantly less interference doing activities in bed (e.g., turning, sitting up and repositioning) (mean 3.47 versus 3.86; p=0.01), doing activities out of bed, (e.g., walking, sitting and standing) (mean 3.05 versus 3.37; p = 0.01), participating in physical therapy (mean 2.76 versus 3.34; p < 0.01), and falling asleep (mean 3.31 versus 3.75; p = 0.01). There were no differences between the two groups regarding staying asleep.
6 months post-operative data
At 6 months post-operatively, patients who reported receiving information about pain management pre-operatively had statistically higher mean physical function scores than those not receiving information (44.20 versus 45.74; p = 0.012). Additionally, when PCS was examined dichotomously (PCS less than one standard deviation below normal, or less than 40 versus 40 or greater and PCS less than two standard deviations below normal, or less than 30 versus 30 or greater) patients who reported receiving information about pain management pre-operatively were less likely to be in the lower PCS groups (p = 0.03 and p = 0.001, respective) (Table 2 and Figure 2). Figure 2 demonstrates the differences in distribution of the 6 month post-operative function scores between patients who received information about pain management options and those who did not. There were no differences in self-report of pain in the surgical joint or the MCS score at 6 months post-operatively. Finally, PCS scores were also examined by joint replaced (hip versus knee). Due to the smaller sample size by joint, most of the analyses were not statistically significant, however there was a consistent pattern of higher mean physical function scores for patients who reported receiving information about pain management pre-operatively than those not receiving information. For patients with hip replacements, this difference was significant when examined dichotomously (PCS less than 40 versus 40 or greater and PCS less than 30 versus 30 or greater) (p = 0.008 and 0.002 respectively).
Table 2.
Six month Post-operative patient reported outcomes
| Received Information regarding pain treatment options | ||||
|---|---|---|---|---|
| Yes 1083 (%) |
No 526 (%) |
Total 1609 |
P | |
| KOOS/HOOS pain in operative joint | ||||
| None/mild | 862 (86.8) | 413 (84.6) | 1275 | 0.290 |
| Moderate/severe | 131 (13.2) | 75 (15.4) | 206 | |
| PCS | ||||
| Mean [SD] | 45.74 [9.21] | 44.20 [10.07] | 45.24 [9.52] | 0.012 |
| Range | 14.09–64.51 | 14.56–61.25 | 14.09–64.51 | |
| < 40 | 256 (25.5) | 149 (31.0) | 405 | 0.028 |
| 40 or greater | 746 (74.5) | 332 (69.0) | 1078 | |
| < 30 | 63 (6.3) | 54 (11.2) | 117 | 0.001 |
| 30 or greater | 939 (93.7) | 427 (88.8) | 1366 | |
| MCS | ||||
| Mean [SD] | 55.48 [8.93] | 55.70 [9.11] | 55.55 [8.99] | 0.418 |
| Range | 4.72–70.47 | 16.32–70.79 | 4.72–70.79 | |
Figure 2.
Distribution of Physical Function Score (PCS score) at 6 months post-operatively by receipt of pre-operative pain management information demonstrating a higher proportion of those receiving pain education reporting better function (higher scores).
After adjusting for age, gender, BMI as well as pre-operative PCS, MCS and musculoskeletal disease burden, receiving information about pain management pre-operatively remained statistically significant for higher 6 month post-operative physical function (p = 0.017).
Discussion
Although patients in this study had elective TJR surgery, which should allow time for planning/educating patients, 33% reported that they did not receive pain management information prior to their planned surgery. This finding is similar to a study by Apfelbaum et al. (2003) that found 37% of post-operative patients reported that they did not receive information from a health care professional regarding pain management prior to surgery.[3] The current study could not determine when patients received pain management information and who provided this information, but qualitative data from semi-structured interviews with a selected sample of participating patients from all surgeon offices indicated that information about pain management after discharge was not included in the pre-operative education class [24]. As two recent literature reviews found that pre-operative education classes have little impact on postoperative pain [13, 14] and function [14] after TJR, it may be that the content of the information provided or lack thereof in pre-operative education classes is not sufficient to meet the postoperative pain management needs of the patient.
This study highlights the overall lack of knowledge in both groups regarding the use of non-medication strategies for managing pain post-operatively, with the sole exception of using cold therapy on operative joints. With trends toward shorter hospital stays, optimal home-based pain management is a priority. Additionally, with growing recognition and attention to what the Centers for Disease Control and Prevention (CDC) has classified as a prescription drug abuse epidemic [25], and with proposed solutions focusing on prescribing habits [25,26], use of narcotic medications as the primary method to control outpatient post-operative pain will most likely change. Narcotics may be required in the early post-operative period, but it will be important to minimize and shorten the time for which they are prescribed. Increasing the diversity of tools that patients can utilize to decrease narcotic use, increase self-efficacy and self-management may not only improve participation in physical therapy, home exercise, and rehabilitation, but could also provide skills for managing future osteoarthritis pain in other joints.
Enhanced educational goals for pain management post-operatively should focus on the appropriate timing of education. [27] It may be appropriate to provide additional pain management education at multiple time points after surgery using a multi-pronged approach. Possible methods could include: using media such as web-based education or CDs that patients could access as needed; using visiting nurses or in-home physical therapist in the first weeks after surgery and/or; case management from the surgeon’s office. Increasing patient knowledge of non-medication methods of pain management would be an important place to start. Materials should also be tailored to specific patient sub-groups, such as tailored material by literacy, language, and culture. The American Pain Society, in their recently published “Guidelines on the Management of Postoperative Pain” (2016), recommended many of these approaches, including patient centered education pre-operatively and in the transition to outpatient care as well as the use of multimodal therapies. [28] Despite these recommendations, Gordon et al. (2016) recognized evidence gaps in the current literature, specifically, the need for research to better understand the educational needs of all post-surgical patients in managing their post-operative pain [28]. Next steps will include interviewing participating patients to better understand the challenges they faced managing their pain postoperatively and identify their educational needs.
Two weeks after surgery, patients who reported receiving pain management information pre-operatively had lower levels of current and maximum pain in their operative joint compared to those who did not. It is important to recognize this difference. Having a better understanding of how to manage pain may help to increase activity post-operatively, thus making full participation in rehabilitation more successful for patients. It is also important to note that patients that did not receive pain management education reported greater interference with the activities of daily living, including physical therapy. Adequate pain management appears to be essential for encouraging appropriate engagement with post TJR exercise and activities.
Perhaps of greatest importance is that patients who reported receiving pain management information had a small, but statistically significant, increase in functional outcome at 6 months post-operatively than those who did not receive information. As mentioned previously, the ultimate goals of elective joint replacement surgery are to maximize function and reduce pain. As insurers, including CMS, increase focus on patient reported pain and functional outcomes after elective TJR [6], developing more effective ways of educating patients about managing their post-operative pain after discharge from the hospital should be a priority.
While this study reports pain management education data from a large national study, it has a few limitations. It is possible that patient recall bias regarding receipt of pain management information before surgery influenced the results as the question was asked 2 weeks after surgery. However, recall limitations will not influence the importance of the findings of this study. If pre-TJR pain management education was provided, but the patient does not remember the pain management options when they are needed after TJR, this is an important educational gap. We also did not measure literacy levels to determine the differences among groups, however there were no differences regarding education and income pre-operatively. We did not collect information about pre-operative methods that patients used to manage pain, including narcotics and non-medication management. However, there were no differences pre-operatively in operative joint pain, pain in other joints and lower back pain all of which are possible indicators for pre-operative narcotic use (see Table 1). Additionally, there were no differences in SF MCS Score, a measure of anxiety and depression, which can be associated with chronic pain requiring narcotic use. Although we did not collect information regarding the content of the pre-operative education class, patient report of absent of pain education did not vary by surgeon volume. Finally, it is possible that prior narcotic use may influence medication and non-medication methods of pain management after TJR. The relationships among pre-surgical use of medical and non-medical pain management strategies require additional research.
Although the findings from this study regarding the differences in pain at 2 weeks and function at 6 months post-operatively between patients reporting receipt of pain management education and those who did not are statistically significant, they may not be clinically significant, as the differences were not large. However, the consistent trends of more pain, more pain interference, and poorer physical function at 6 months consistently support a relationship between early post-TJR pain and functional gain. Additionally, when PCS was examined dichotomously (PCS less than one standard deviation below normal, or less than 40 and PCS less than two standard deviations below normal, or less than 30) patients who reported not receiving information about pain management pre-operatively were more likely to be in the lower PCS groups (31% versus 26% for less than 40 and 11% versus 6% for less than 30). This difference is illustrated in Figure 2 in the distribution of function scores between the two groups for those who did not receive post-operative pain self-management options. Although not statistically significant, the trend of poorer physical function remained consistent when examined by joint type. Next steps will include examining the subset of patients with little or no improvement in function 6 months post-TJR to help identify who may be at greater risk for poorer outcomes post-operatively.
Conclusion
Forty-four percent of TJR patients in this study reported that they did not receive or received unhelpful information regarding post-operative pain self-management options for surgical knee or hip pain. This gap highlights a need for improved patient education with innovative strategies to reinforce pain management education after TJR. Furthermore, in this cohort, the lack of pain management information was associated with poorer 6 month post-operative function. Thus, peri-operative education about the optimal use of prescription and non-medical methods to manage joint pain are urgently required to assure maximum functional gain following successful primary total joint replacement surgery. A better understanding of the factors that influence consistent and effective pre-operative pain self-management options after TJR surgery could inform interventions and potentially reduce pain, reduce post-surgical narcotic use and improve functional outcomes. It is also important to note that although this study only included patients electing to have TJR surgery, the findings indicating the need for improved pain management education prior to elective surgery could have implications for other surgical interventions.
Supplementary Material
Acknowledgments
Funding: This project was supported by grants from the Agency for Healthcare Research and Quality (AHRQ) P50HS018910 and 1U19HS021110-03
The authors would like to thank Dr. Sylvie Puig for her editorial assistance with this manuscript.
Footnotes
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Contributor Information
Celeste A. Lemay, Research Instructor and Senior Project Director, Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655.
Courtland G. Lewis, Hartford Hospital, 80 Seymour St, Hartford, CT 06102.
Jasvinder Singh, Professor of Medicine, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294.
Patricia D. Franklin, Professor and Director, Clinical and Outcomes Research, Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655.
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