A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery

Abstract

Objectives: To examine the effect of a multicomponent intervention on pain and function after orthopedic surgery.

Design: Controlled prospective propensity score-matched clinical trial.

Setting: New York City acute rehabilitation hospital.

Participants: Two hundred forty-nine patients admitted to rehabilitation after hip fracture repair (n=51) or hip (n=64) or knee (n=134) arthroplasty.

Intervention: Pain assessment at rest and with physical therapy (PT) by staff using numeric rating scales (1 to 5). Physician protocols for standing analgesia and preemptive analgesia before PT were implemented on the intervention unit. Control unit patients received usual care.

Measurements: Pain, analgesic prescribing, gait speed, transfer time, and percentage of PT sessions completed during admission. Pain and difficulty walking at 6, 12, 18, and 24 weeks after discharge.

Results: In multivariable analyses intervention patients were significantly more likely than controls to report no or mild pain at rest (66% vs 49%, P=.004) and with PT (52% vs 38%, P=.02) on average for the first 7 days of rehabilitation, had faster 8-foot-walk times on Days 4 (9.3 seconds vs 13.2 seconds, P=.02) and 7 (6.9 vs 9.2 seconds, P=.02), received more analgesia (23.6 vs 15.6 mg of morphine sulfate equivalents per day, P<.001), were more likely to receive standing orders for analgesia (98% vs 48%, P<.001), and had significantly shorter lengths of stay (10.1 vs 11.3 days, P=.005). At 6 months, intervention patients were less likely than controls to report moderate to severe pain with walking (4% vs 15%, P=.02) and that pain did not interfere with walking (7% vs 18%, P=.004) and were less likely to be taking analgesics (35% vs 51%, P=.03).

Conclusion: The intervention improved postoperative pain, reduced chronic pain, and improved function.

Figure 1

Details of Subject Enrollment

Figure 2

Pain at rest (Figure 2A) and pain with PT (Figure 2B) for intervention and control patients for intervention and control patients from rehabilitation day 1 to rehabilitation day 7. Overall adjusted mean pain at rest scores from admission through day 7 were 2.2 (95% CI 2.14 to 2.30) for intervention patients and 2.6 (2.46 to 2.63) for control patients (parameter estimate = -.33; 95% CI -.52 to -14; P<.001). Overall adjusted mean pain scores during PT for rehabilitation days 1-7 were 2.6 (2.48 to 2.65) for intervention patients and 2.8 (2.72 to 2.91) for control patients (parameter estimate = -.20; -.34 to -01; P=.04). All values reflect propensity score matched normalized weighted data.

Figure 3

Percent of patients reporting moderate to very severe pain with ambulation (Figure 3A) and percent of patients reporting pain interfered with ambulation (Figure 3B) for intervention and control patients for the 24 weeks following hospital discharge. Overall adjusted mean pain with ambulation scores over the 24 weeks were 1.50 (95% CI 1.47 to 1.53) for intervention patients and 1.77 (1.73 to 1.81) for control patients (parameter estimate = -.27; 95 CI -.46, -.05; P=.01). Overall adjusted mean interference scores over the 24 weeks were 1.18 (1.16 to 1.20) for intervention patients and 1.48 (1.45 to 1.51) for control patients (parameter estimate =-.25; 95 CI -.41, -.10; P=.001). All values reflect propensity score matched normalized weighted data.

Appendix 1

Analgesic Prescribing Protocol for Intervention Unit

Appendix 1

Analgesic Prescribing Protocol for Intervention Unit

Appendix 2

Protocols for Management of Opioid Related Side Effects