After performing total knee replacement surgeries for more than 25 years, Ira Kirschenbaum, MD, found himself under the knife for a knee operation of his own. And his understanding of the process a patient endures, from pre-surgery to pain to rehabilitation, certainly shifted.
"We, as surgeons, don't get to see every second of every day of a patient's progress," says Dr. Kirschenbaum, chairman of New York City-based Bronx Lebanon Hospital's orthopedic surgery department. "It changed my perspective, because now I had information second-by-second in real time, from every aspect of the surgery."
Dr. Kirschenbaum followed the path of a patient to the tee, even taking the pre-operation course provided by his surgeon to grasp the full extent of the surgery. Even though the pre-op education included sections he had written, Dr. Kirschenbaum says the process hit home just how valuable the pre-op preparation is for a patient.
"Understanding the surgery and understanding that pre-op preparation is so important decreases the fear and any anxiety," he adds.
Undergoing his operation also emphasized the intensity of pain. Throughout his career, Dr. Kirschenbaum has heard innumerable patients describe the same pain differently.
He underwent an aggressive, but safe pain management protocol. Based on his experience, Dr. Kirschenbaum re-evaluated the pain management protocol he offers to his patients, emphasizing pre-op education and post-op connectivity with staff.
"I now have a pretty unique perspective: what I've learned as my experience as a surgeon, from the literature and as a patient," Dr. Kirschenbaum says. "I have the triad here."
Multimodal pain management
As a method of focusing on strategies to fight opioid abuse, Dr. Kirschenbaum suggests physicians focus on combating pain in new ways.
"The opioid prescribing culture is something that all of us doctors have been guilty of," he says. "I'm a product of how I trained. And I, myself, am changing my opioid prescribing. I am an older dog who's learning a new trick — this is not a trick that's hard to learn."
Following his operation, Dr. Kirschenbaum only took three 10 mg doses of opioids over four weeks. The alternative pain method involves a multimodal approach, attacking the pain through a variety of avenues.
"Think of pain as giving them a package, rather than throwing darts at it as needed," Dr. Kirschenbaum explains.
His surgeon placed him on a classic multimodal pain plan:
- Perioperative injections
- Cold therapy
- Tylenol around the clock immediately after surgery
- Anti-inflammatory medications
- Small amount of opioids as last resort
"Pain is like a bark behind a closed door. You get scared because you think it's a big dog and then you open the door and it's a little Yorkie barking like crazy," he says.
A multimodal approach, like the one Dr. Kirschenbaum received, has many proven benefits, supported by the fact that pain arrives at a person's brain via multiple pathways. By utilizing a multimodal approach, providers hit every possible pain pathway.
Some studies suggest cutting out certain modalities, but Dr. Kirschenbaum disagrees.
"Multimodal pain medicine is a package that is going to be hard to decide which individual piece may impact each individual patient," he cautions. In an era of patient satisfaction, providers should be wary of cutting out certain modalities, like icing, if the patient experiences relief, even if there are no proven benefits associated with the modality.
Altering the pain management protocol
Equipped with a deeper understanding of the total knee replacement patient, Dr. Kirschenbaum is now prepared to answer several questions about patient pain:
- What does my pain management process include?
- Can you give me a detailed pain management program overview, from the day before surgery to four weeks post-surgery?
- How should I look at my pain?
- Can you outline my rehabilitation? When will I reach certain milestones?
- How much will I rely on a caregiver following surgery?
- What are some common complications patients have described post-surgery?
Dr. Kirschenbaum stresses the importance of joint camp, and believes many facilities' programs could be enhanced to anticipate the majority of patient questions. Additionally, preoperative physical therapy education will prove beneficial, as patients will learn how to use all of the equipment when they are healthy.
"Surgeons are developing guides and they can't be white bread and mayonnaise — practices need to develop custom surgeon guides for patients," urges Dr. Kirschenbaum.