How can patients get out of the hospital faster using less drugs?
It is no secret that the U.S. is facing an opioid epidemic at the moment. A common way that a person can become addicted to these drugs is to receive a strong prescription following surgery and develop a dependence on them. Although we are in the midst of a national crisis with the number of opioid related overdoses each year, we are also seeing the number of opioid prescriptions decrease slowly. This is likely due to increased awareness and progressive changes made throughout health care to make these drugs less of a necessity. This is seen in hospital protocols, especially when it comes to total knee replacements.
When to start physical therapy?
Total knee replacements leave patients in a good deal of pain due to the traumatic nature of the surgery. Pain should be the primary concern after surgery and physical therapists have the responsibility of combatting it while the patient is on minimal medication. The available research shows that the best way to do this is to get them up and weight-bearing ASAP. You do not want to wait until the next day to start working with the patient because the knee will be stiffer with more developed scar tissue. Therapy should start after the anesthesia has worn off, the pain doesn’t permit them from rehab, and the patient’s heart rate, blood pressure, and breathing are stable. It is important to continue with physical therapy the next morning as well, to not lose the progress that has already been made less than 24 hours before. If pain is too much for the patient in the morning session, that might be a sign to tone down the volume of exercises or reassess the exercises.
Why start physical therapy immediately?
The total knee replacement is one of the most common orthopedic surgeries in the U.S., and the need for the procedure is going to increase. This is due to reasons such as the aging baby boomer generation, obesity, and arthritis. The need for this surgery is not going away, so the only thing to do is adapt to the demand.
By starting physical therapy immediately after surgery, the length of time that the patient spends in the hospital is shortened. Patients are proven to be able to walk longer distances in a quicker amount of time after starting physical therapy the same day as their surgery compared to patients starting rehab the next morning. Being able to be get up and moving quickly not only makes the physical therapist and surgeon look good, but makes the patient more satisfied with the surgery.
Weight-bearing also has the important role of acting as an alternative to pain medication. Patients who ambulate immediately have a lesser need for opioids and show less pain than those who wait until the next morning. How amazing is it that by simply putting pressure on the new knee earlier, that the body responds with less pain overall?
Immediately diving into rehab with things such as knee range of motion, ambulation, and activities of daily living has the ability to give the patient a confidence boost by being back on their feet the same day.
Is it safe?
Yes, it is safe. Raphael et al.(2011) found that there was no significant difference in complications or 30-day readmission rates for patients who started therapy the day of surgery compared to patients starting the next day. That being said, it is the responsibility of the physical therapist to not overwork the patient and cause pain. They also need to keep in mind how to safely stretch the knee and perform exercises that do not stress the suture from surgery. Done correctly, the rehabilitation process should be able to decrease the patient’s length of stay and opioid consumption while not compromising their safety. Doing things such as constantly monitoring their pain and making sure they use and assisted walking device are good ideas.
In fact, a big part of the reason that patients are stood up so fast is to decrease the chance of a deep vein thrombosis. This is a blood clot that can form in the legs of patients who are sedentary for extended periods of time and can be life threatening. By weight-bearing the same day as surgery, the risk of this happening is made even smaller.
In conclusion, being able to safely make the rehabilitation process faster while decreasing the risk that opioids present is something that is very valuable and can have many positive outcomes for patients and practitioners alike.
Resources:
For more information regarding total knee replacements, opioids, and the opioid epidemic, check out the websites attached below. Additionally, the National Helpline for the Substance Abuse and Mental Health Services Administration is below if you or anyone you know is struggling with an addiction to opioids, or any other substance.
- 1-800-662-HELP (4357)
Patrick Bambrick is an undergraduate student in the Movement Science, Sport and Leisure Studies Department at Westfield State University, with a concentration in Sports Medicine. He is a member of ACSM and MAHPERD. Patrick can be reached at pbambrick4307@westfield.ma.edu.
References:
Centers for Disease Control and Prevention. (2019). Annual surveillance report of drug-related risks and outcomes.
Inacio, M., Paxton, E., Graves, S., Namba, R., & Nemes, S. (2017). Projected increase in total knee arthroplasty in the United States – an alternative projection model. Osteoarthritis and Cartilage, 25(11), 1797–1803.
Raphael, M., Jaeger, M., van Vlymen, J. (2011). Easily adoptable total joint arthroplasty program allows discharge home in two days. Canadian Journal of Anesthesia, 58, 902-910.
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