Patient diagnosed with acute on chronic left knee pain.
Acute: post-surgical
Chronic: Inflammatory degenerative joint disease
Question: Which of the following describe physical therapy treatments found to effectively manage chronic inflammatory knee pain?
Ambulation
Range of Motion
Strength training
Benefit of Early Mobilization
- Improves the recovery of range of motion
- Improves muscle tone
- Decreases post operative pain
- Increases patient independence, which decreases the length of hospital stay
- Decreases risk of Deep Vein Thrombosis (DVT)
- Decrease incidence of respiratory infections
Physical Therapy Goals and Discharge Criteria for a Patient Following Total Knee Arthroplasty
- Demonstrate safe and independent transfers
- Demonstrate safe ambulation with appropriate assistive device.
- Fair to good static and dynamic balance with appropriate assistive device.
- Attain full extension (0°) and 90° flexion of the involved knee.
- Demonstrate home exercise program (HEP) accurately.
Post-Operative Day 1-2
Patient with acceptable left knee pain management at rest (4/10) but complains of severe pain (8-10/10) pain with early mobilization.
Pain with movement limits ability to participate with physical therapy or fulfilling criteria for physical therapy (PT) goals of discharge - despite taking as needed (PRN) oral opioid analgesics.
Non-Opioid Analgesic Modalities Shown to Reduce Pain with Mobility
Although post-surgical pain at rest may be managed with opioid analgesics, there are non-opioid analgesic modalities shown to reduce pain with mobility.
- Multimodal analgesia (acetaminophen, gabapentinoids, NSAIDs)
- Neuraxial Analgesia (Epidural)
- Regional Analgesia (local anesthetic peripheral nerve block / continuous local anesthetic infusion via perineural catheter)
Non-Opioid Analgesic Strategies to Improve the Patient’s Pain Management with Movement and Fulfill the Goals of Successful Mobilization
- NSAIDs
Now all NSAIDs have Black Boxed Warning, the strongest caution issued by the FDA:
“NSAIDs may cause an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, which can be fatal. This risk may be increased in patients with cardiovascular disease or risk factors for cardiovascular disease. Ibuprofen is contraindicated for the treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery. NSAIDs can also cause an increased risk of serious gastrointestinal adverse events especially in the elderly, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal.”
Discharge Planning
Through the inclusion of a non-opioid multimodal analgesic strategy (acetaminophen, gabapentin, NSAIDs) plus non-pharmacologic modalities (cooling, relaxation techniques), patient now reports reduced L knee pain score of 2/10 at rest and 4/10 ambulating with a reduced opioid requirements (PCA morphine discontinued, reduced extended release morphine).
Medications
- Acetaminophen (shown to reduce acute post-operative opioid requirements)
- Gabapentin (shown to reduce acute post-operative opioid requirements)
- NSAID* (COX-II inhibitor) (shown to reduce acute post-operative opioid requirements)
- Morphine sulfate sustained release 15 mg po q 12hr (reduced)
Successful management of patients suffering from complex painful conditions often require coordinated interdisciplinary care from:
- Physician / Provider
- Pharmacist
- Nurse
- Physical Therapist
- Psychologist
