The Efficacy of Interventional Therapy and Collaborative Nursing in Postoperative Pain Management for Orthopedic Surgery Patients
Ming Zhang, Lining Xue*
Tongchuan People’s Hospital, Shaanxi Province 727000 China.
Author’s details
The First Author: Ming Zhang, Female, Bachelor’s degree, Nurse in Charge, 1966778783@qq.com
Corresponding author: Lining Xue, Female, Bachelor’s degree, Nurse in Charge, 343794741@qq.com
Abstract
Research motivation: Orthopedic surgery (OS) results in significant postoperative pain, which could recovery and quality of life (QoL). Effective pain management is crucial for optimal patient outcomes. This investigation seeks to determine whether combining interventional therapy with collaborative nursing (CN) can improve postoperative pain management compared to interventional therapy alone.
Introduction:OS is a medical field that diagnoses, treats, prevents, and rehabilitates musculoskeletal disorders and injuries, affecting mobility and functionality. It uses surgical and non-surgical techniques to address fractures, arthritis, sports injuries, congenital deformities, and spinal disorders. Through advanced technology and comprehensive care, it improves patients’ QoL.
Objective: The purpose of investigations to assess and compare the efficacy of individual physical therapy (PT) and PT combined with CN (PT+CN) for the management of postoperative pain in OS patients.
Methods: We investigated 169 OS patients. For conducting a randomized controlled trial nurses were divided into two teams including PT and PT+CN.The intervention involved introducing a pain management procedure and conducting training sessions for nurses. The PT Team received standard pain management, while the CN Team received additional CN support. Pre- and post-intervention, nurses’ knowledge, attitudes, and pain management practices were assessed using questionnaires. Patient-reported outcomes on pain intensity and interference with activities were collected through surveys.
Results and Conclusion: The obtained questionnaires were assessed using the SPSS analytical tool. Data analysis was performed using chi-square and t-tests to compare variations within and between Teams.The PT+CNTeam demonstrated superior outcomes compared to the PT team. Nurses in the PT+CNTeam showedconsiderably improved knowledge and attitudes about pain management. Additionally, patients in this Team reported lower pain intensity, less interference with activities, and better overall pain management.
Keywords: Orthopaedic Surgery (OS), Physical Therapy (PT), Collaborative Nursing (CN), Statistical Analysis, Pain Management
- introduction
Orthopedic procedures are widely known to cause significant discomfort for patients. According to various studies, trauma or orthopedic procedures affecting the extremities rank among the highest in terms of postoperative pain [1]. Effective pain management is critical in the postoperative treatment of these patients as severe pain can delay recovery, increase the risk of complications, and lead to longer hospital stays and higher re-admission rates. Consequently, the management of analgesic needs following OS involves a variety of pain control techniques [2]. Orthopedic physicians are noted for prescribing more opioids than any other medical specialty, while orthopedic nurses play a vital role in providing post-operative care and pain management. Despite the known efficacy of alternative therapies in reducing procedural or post-operative pain, their application specifically for orthopedic patients remains under-researched [3]. Figure 1 depicts various types of orthopedic aspects occurred.
Figure 1: overview of orthopedic occurred parts
Post-surgical pain can be complex and multifaceted, stemming from both neuropathic and nociceptive sources. Nociceptive pain arises from tissue damage, which activates nociceptive receptors present in terminal nerve fibers. Higher neuronal regions in the brain receive these impulses via ascending pathways, which affect pain perception [4]. An individual’s experience of pain is influenced by several elements, such as feelings, sex, personality, and cultural origin. Conversely, neuropathic pain is caused by actual harm to the neurological system and is characterized by the activation of bigger nerve fibers [5]. When tissue is injured, chemicals like bradykinin, prostaglandins, and serotonin are released, which increases neural activation and causes pain [6]. Central sensitization, a condition that makes pain management more difficult, can be brought on by persistent simulation.Medication and non-pharmacological techniques are employed to effectively control pain after surgery in patients with OS. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs,) opioids, nerve blocks, and local anesthetic infiltration are a few of the often used medicinal methods [7]. Orthopedic nurses are crucial when it comes to administering these medications and providing care. In addition, it employs complementary therapies such as guided imagery, music therapy, media diversion, and relaxation training to address pain and anxiety [8]. In a number of medical situations, supplemental treatments have demonstrated potential in lowering pain.
Opioids have been the go-to medication for treating postoperative pain for a long time. In addition to having a high risk of addiction, its usage is restricted by adverse effects such as ileus, pruritus, nausea and vomiting, respiratory depression, and urine retention [9-11]. Drugs such as these are mostly used as life-saving drugs when other methods of pain management are ineffective when combined with effective no-opioid usage. Table 1 presents the maximum frequently prescribed treatments in OSs.
Table 1: Types of opioid analgesics and their classification
| Types of Drug | Dosage | Duration of Analgesia (hours) | process of metabolism | Remarks |
| Immediate-release opioid medication administered orally | ||||
| Codeine | 15to 60 mg | 4to 6 | CYP2D6 | Protect in young children as it raises intracranial pressure |
| Hydrocodone | 2.5to 10 mg | 4to 6 | CYP3A4 and CYP2D6 | Steer clear of adolescents.An increase in brain pressure. |
| Oxycodone | 5to 10 mg | 3to 6 | CYP2D6 and CYP3A | Avoid CYP3A4 inhibitors.This leads to a rise in cerebral pressure |
| Tramadol | 50to 100 mg | 3to 6 | CYP2D6 and CYP3A4 | Avoid CYP3A4 inhibitors. |
| Oxymorphone | 5to 10 mg | 3to 6 | Glucuronidation | – |
| Intrauterine Opioids | ||||
| Hydromorphone | 0.5 to 1 mg | 2 to 4 | Glucuronidation, Renal clearance | Useful for people with reduced kidney functionAvoid individuals with hypovolemic shock. Genitourinary obstructions should not be treated with this medication. |
| Meperidine | 50to 150 mg | 2to 3 | CYP3A4 and CYP3A5 | Seizures can be brought on by normeperidine, an active metabolite.Not recommended when using monoamine oxidase inhibitorsThe elimination rate is slower in the elderly. |
| Fentanyl | 1to 2 mcg | 30 min–1 | CYP3A4 andCYP3A5 | A hundred times as potent than morphineSuitable for people with compromised kidney function.Suitable for individuals with bronchospasm or hemodynamic instability |
| Morphine | 2to 4 mg | 3to 4 | Glucuronidation, Renal clearance. | Histamine release can cause Bradycardia, hypotension, and vagally mediated vasodilation. |
Research objective: This study evaluates and compares the effectiveness of individual PT and PT+CN in managing postoperative pain in OS patients.
Contribution of the study
- Examining the effects of postoperative pain management on quality of life and rehabilitation in OS.
- Investigate the effectiveness of PT and PT+CN through therapy for Performance of pain management.
- A two-team randomized managed experiment: PT and PT + CN, introducing a pain management procedure and conducting training sessions.
The following sections include the remaining research: Part 2 presents the literature review; Part 3 classifies the approaches; Part 4 displays the results and discussion; and Part 5 provides the conclusion.
- LITERATURE REVIEW
The present literature review provides a thorough synopsis of OS pain management and rehabilitation techniques, emphasizing the value of multimodal approaches, collaborative care models, and patient-centered treatments in maximizing results and promoting recuperation.
Pain Management and Rehabilitation in Orthopedic Surgery (OS): An overview of pain rehabilitation for senior knee replacement patients is given in [12] editorial, with a focus on the value of a multimodal approach to recovery from surgery.Investigates the association between nurses’ attitudes and pain-related knowledge and patients’ postoperative pain outcomes [13]. To assess the effectiveness of the one-year follow-up and surgical care of senior individuals with fractures of the intertrochanteric area by the multidisciplinary team (MDT) [14].
Pain Management Strategies and Interventions: Study [15] examined 116 senior individuals who underwent knee replacement surgery at a hospital. Patients were divided into observation and management Teams, receiving CN and automatic care. A pain management team was formed, and functional, ADL, and VAS scores were tracked. To investigate the efficacy of an integrated multidisciplinary therapy (MDT)[16] intervention strategy in the perioperative care of patients suffering from infectious non-union to ascertain how guided imagery [17] enhanced patients’ postoperative pain management following lower limb surgery.
Multi-disciplinary Approaches and Collaborative Care: The purpose of research [18] is to assess how a person-centered postoperative pain management intervention program affected the patients’ satisfaction with postoperative pain management, shared decision-making and postoperative discomfort during lumbar spine surgery.From January to September 2020, [19] was conducted at a public hospital’s medical centers, surgical clinics, and surgical units. It addressed the following fields: urology clinics, orthopedics, otorhinolaryngology, general surgery, and neurosurgery; moreover, it covered postoperative care, surgical critical care, day surgery, and small intervention units [20]. The action of a team of specialists employing a methodology started by the pharmacist provided pain treatment to the team, with primary outcome measures including postoperative pain scores, breakthrough pains, and hospital stay length.To examine a multidisciplinary cooperation structure integrating medical services was applied during the perioperative phase of femur neck fractures [21].Various analgesic techniques were used in orthopedic therapy to treat postoperative pain [22]. It examines the pharmacological landscape of analgesics like acetaminophen, opioids, and adjuvant treatments, their modes of action, effectiveness profiles, and side effects. The study emphasizes the growing importance of multimodal analgesia, which blends multiple medicines to minimize side effects and achieve synergistic pain management.
Assessment and Evaluation of Pain Management: To investigate variations in postoperative pain assessments made by patients and nurses [23], variations in the self-assessments mentioned about the characteristics of both respondent Teams and the relationship between the Numerical rating scale (NRS) and the Verbal rating score (VRS) scale [24].To clarify the impact of family care in perioperative CN children with an inguinal hernia and the role of multidisciplinary CN for enhanced recovery after surgery (ERAS) [25-26] on the prognosis. To assess the utilization of non-pharmacological post-operative pain treatment by nurses in public referral hospitals in Ethiopia’s Amhara regional state.
- MATERIALS AND METHODS
In a study involving 169 OS patients, two Teams were formed: one receiving PT and the other Team PT+CN. The intervention focused on implementing a pain management protocol and providing training sessions. The intervention included a structured pain management protocol and comprehensive training sessions for nurses. The findings demonstrated notable enhancements in pain management and overall patient care, underscoring the advantages of integrating nursing and therapy strategies in orthopaedic care environments.
- Data collection
The study compared two OS teams involving Team A and B. Team A consisted of 86 participants, while Team B included 83. The study reveals differences in CN care and pain management strategies between surgical teams. Overall, the study highlighted distinct practices in CN care and pain management strategies between the two surgical teams.
Inclusion Criteria: Patients having OS operations, including fracture fixation, arthrodesis, joint replacement, and associated surgeries, who were at least 18 years old, were eligible to participate in our study.
Exclusion criteria: Patients who were under the age of eighteen, those for who PT or CN treatments were prohibited those undergoing emergency operations or procedures unconnected to orthopedics, patients with cognitive disorders that might affect their capacity to give informed permission or engage in study evaluations, and all of the above were included in this. Individuals with noteworthy medical illnesses or comorbidities that might potentially distort the research’s results or have a substantial impact on its conclusions were also eliminated.
- Surgical Procedure
For OS patients, we used two different surgical methods in our study: (Team A) PT and (Team B) PT + CN.
Team A- Physical Therapy (PT):The initial stage of orthopaedic physical therapy involves a thorough evaluation of the patient’s condition, including their functional abilities, muscular strength, and flexibility.The results of this evaluation inform the creation of a personalized treatment plan that aims to increase function overall, lessen discomfort, and improve mobility. Resistance bands, therapy balls, and balance boards are used as equipment in physical therapy sessions to target certain muscle teams and enhance stability. Additionally, the therapist can use physical methods like massage and joint manipulation to reduce stiffness and accelerate the healing process. To aid in healing and enhance mobility, physical therapy practitioners employ a range of treatments (see Figure 2) including heat therapy, ultrasound therapy, stretching exercises, joint manipulation, and joint mobilization.
Figure 2:Types of Pts and their Definitions
Team B-Physical Therapy with Collaborative Nursing (PT+CN):For orthopedic patients, including CN into PT improves the integration of therapy. CN specialists in conjunction with physical therapists to support the objectives of PT. Monitoring vital signs, managing wounds following surgery, giving prescriptions, providing expert nursing care and teaching patient’s self-care skills are all part of this partnership. Knives for dressing changes, sterile equipment for proper drug administration, and wound dressings are examples of surgical instruments used during CN procedures.
- Statistical analysis
The software SPSS was used to evaluate the collected inquiries. Significant disparities in gender distribution and anesthetic type were found when the study compared the demographic and procedural features of Team A and Team B using statistical analysis. The assessment of patient pain and the delivery of analgesics were done using chi-square testing. Patient satisfaction, complication rates, and pain progression throughout rehabilitation were all examined using descriptive statistics. This investigation shed light on the variations and patterns between Teams A and B.
- Results and Discussion
Two teams, Team A with 86 individuals and Team B with 83, are shown in Table 2 along with their demographic and procedural details. The data includes anaesthesia type, age distribution, gender distribution, and surgical procedures performed. Statistical analysis using t-tests and p-values shows significant differences in gender distribution and type of anaesthesia between both teams, but not in terms of surgical procedures. The data provides anequivalent percentage for comparisons among teams.
Table 2: Patient characteristics
| Characteristics | Team A (N=86) | Team B (n =83) | t | P Value | |
| Gender | Male (%) | 22 (25.58%) | 62 (74.69%) | 2.666 | 0.009 |
| Female (%) | 64 (74.41%) | 21(25.30%) | |||
| Anaesthesia | General anaesthesia | 49 | 74 | 3.622 | < 0.001 |
| Regional anesthesia | 55 | 44 | 0.751 | 0.460 | |
| Surgical procedures | Fracture Fixation | 28 (33%) | 23 (28%) | 1.203 | 0.235 |
| Arthrodesis | 25 (29%) | 37 (44%) | 0.874 | 0.387 | |
| Joint replacement | 21 (24%) | 15 (18%) | 1.567 | 0.123 | |
| Other | 12 (14%) | 8 (10%) | 0.402 | 0.689 | |
- Pain Management
Team 3 demonstrates a comparison between team A and Team B in terms of analgesic administration and patient pain assessments. It includes data on the administration of opioids, non-opioids, and a combination of both, as well as the percentage of patients whose pain was assessed using multi type of tools. In analgesic administration, teamsa and b show similar proportions of using opioids and non-opioids with no significant difference in p values. However, there is a notable difference in the administration of both non-opioids and opioids, with Team B administering this combination significantly more than Team A.
In terms of patient pain assessment, the majority of patients in both teams had their pain assessed, with no significant difference in the proportions of patients assessed using different tools as shown in table 3.
Table 3: Analgesic Administration and Patient Pain Assessment Comparison between Team A and Team B
| Category | Team A (N=86) | Team B (n =83) | Pvalue | |
| Administrationof analgesics | Opioids | 20(16.4) | 17 (14.3) | 0.884 |
| Non-opioids | 24(23.9) | 19 (19.5) | 0.626 | |
| Bothnon-opioidsand opioids | 37(38.8) | 56(66.2) | <0.001 | |
| patient pain assessment report using tools | ≤ 50%patients | 3 (6.3) | 4 (6.7) | -0.668 |
| 50%-99%patients | 7 (25.0) | 6 (20.0) | ||
| 100%patients | 21 (68.8) | 24(73.3) | ||
- Analysis of Pain Sensation
Analyzing pain perception is a difficult procedure that includes perceptual, psychological, and physiological elements. When noxious stimuli activate the nociceptor, the central nervous system receives signals. The brain interprets these impulses, influencing the intensity, kind, location, and affective response to pain. Psychological factors that impact perception include pain thresholds, expectations, and individual attention. It is important to have a comprehensive comprehension of pain perception, including its subjective and physiologic components. The pain levels for Teams A and B during their respective recovery periods are shown in Table 4. In this context, Team B consistently shows better outcomes in terms of pain relief compared to Team A across10 days of rehabilitation, a higher percentage of individuals in Team B reported lower levels of pain or no pain at all. For instance, by day 6, 44% of Team B experienced no pain compared to 40% of Team A, and this trend continues throughout the rehabilitation period. Notably, Team B reaches higher percentages of “No pain” and “Mild pain” more quickly and consistently, indicating more effective pain management and recovery than Team A. This data suggests that the interventions or treatments applied to Team B are more successful in reducing pain levels during rehabilitation. figure 3 demonstrates the analysis of the outcomes of pain management between Team A (a) and TeamB (b).
Table 4: Rehabilitation Pain Progression Comparison between both Teams
| Rehabilitation | Team A | Team B | ||||||
| No pain | Mild | Moderate | Excruciating pain | No pain | Mild | Moderate | Excruciating pain | |
| 1 | 16 | 40 | 92 | 100 | 18 | 43 | 95 | 100 |
| 2 | 17 | 30 | 92 | 100 | 20 | 35 | 94 | 100 |
| 3 | 21 | 32 | 94 | 100 | 25 | 38 | 96 | 100 |
| 4 | 28 | 36 | 95 | 100 | 32 | 44 | 98 | 100 |
| 5 | 40 | 50 | 98 | 100 | 44 | 52 | 97 | 100 |
| 6 | 41 | 55 | 97 | 100 | 48 | 64 | 98 | 100 |
| 7 | 43 | 60 | 97 | 100 | 49 | 62 | – | 100 |
| 8 | 49 | 70 | 98 | 100 | 54 | 76 | – | 100 |
| 9 | 58 | 62 | 97 | 100 | 60 | 70 | – | 100 |
| 10 | 60 | 71 | 99 | 100 | 62 | 75 | – | 100 |
Figure 3: Analysis of pain management between Team A (a) and Team B (b)
- Patient Satisfaction
A patient’s optimal recovery after OS depends on their PT satisfaction and the coordinated nursing care they get after surgery to manage their pain. Patients are more satisfied and motivated to recover when they have a good experience with PT, have tailored care plans, and receive clear information regarding outcomes and progress. Improved pain control, functional outcomes, trust, engagement, and satisfaction with the healthcare experience are facilitated by CN interventions, like routine pain assessments and medication management. These measures also improve postoperative recovery.Table 5and Figure 4 presentedsignificant differences were found between Team B (N=83) and Team A (N=86) in a comparison study on patient satisfaction across a number of variables. With a p-value < 0.0001, Team B’s (95%) communication satisfaction was greater than Team A’s (30%), as shown by the Chi-Square (χ²) value of 68.05. Team B’s satisfaction with wait time was 87%, whereas Team A’s was 50% (χ² = 20.33, p < 0.0001). Team B’s satisfaction with the quality of treatment was 98%, while Team A’s was 40% (χ² = 49.56, p < 0.0001). Team B’s staff friendliness score was 90%, whereas Team A’s was 50% (χ² = 21.55, p < 0.0001). Team B’s satisfaction with cleanliness was 94%, whereas Team A’s was 60% (χ² = 23.86, p = 0.0002). Ultimately, Team B’s treatment results were 95%, whereas Team A’s were 45% (χ² = 48.51, p < 0.0001). All p-values indicated statistical significance, highlighting Team B’s superior performance.
Table 5: Comparison of Patient Satisfaction in both teams
| Patient satisfaction (%) | Team A (N=86) | Team B (N=83) | Chi-Square (χ²) | p-value |
| Communication | 30 % | 95 % | 68.05 | <0.0001 |
| Wait Time | 50% | 87% | 20.33 | <0.0001 |
| Quality of Care | 40% | 98% | 49.56 | <0.0001 |
| Staff Friendliness | 50% | 90% | 21.55 | <0.0001 |
| Cleanliness | 60% | 94% | 23.86 | 0.0002 |
| Treatment Outcome | 45% | 95% | 48.51 | <0.0001 |
Figure 4: outcomes of patient satisfaction
- Complication rate
In OS, the complication rate describes the proportion of patients who have unfavorable occurrences or consequences, which can range from mild to serious. It is essential for assessing the safety and quality of surgical care, and providing direction for advancements in methods, patient care, and postoperative care guidelines. Clinical research and hospital performance measures usually report it. A comparison of Team A and Team B’s complication rates is shown in Table 6 and figure 5. 86 individuals on Team A had mild problems, including allergic reactions (3.44%), bleeding (5.81%), and infections (11.63%). By comparison, Team B, including 83 patients, demonstrated a reduced infection rate of 2.44%, no documented occurrences of bleeding, and a rate of 2.41% for allergic reactions. In terms of severe problems, Team B reporteddeep vein thrombosis(DVT) in 1.32% of patients and delayed healing in 2.21% of cases, while Team A reported delayed healing in 6.49% of cases and DVT in 2.25% of instances.There was a noticeable disparity between Team A’s total complication rate of 29.62% and Team B’s 8.38%.
Table 6: Outcomes of complication rate between Team A and Team B
| Complication rate (%) | Team A (N=86) | Team B (N=83) | |
| Minor Complications | Infection | 11.63% | 2.44% |
| Bleeding | 5.81% | – | |
| Allergic Reaction | 3.44% | 2.41% | |
| Major Complications: | Delayed Healing | 6.49% | 2.21% |
| Deep Vein Thrombosis (DVT) | 2.25% | 1.32% | |
| Total Complications | 29.62 | 8.38 | |
Figure 5: Outcomes of complication rate
- Psychological assessments
An emotional evaluation is a thorough examination of an individual’s thoughts, feelings, and behaviors related to their emotional well-being. These assessments often employ a range of techniques, such as surveys, in-person observations, and interviews, to gather data on a subject’s coping mechanisms, emotional state, and overall mental health. The objective is to comprehend the person’s emotional strengths, limitations, and patterns of response to different situations. This will assist mental health practitioner’s psychologists, therapists, and counselors, for example in developing treatments and plans of care that are individually customized to meet the requirements of each client (figure 6).
Figure 6: Outcomes of Psychological Assessments
- Conclusion
Combining CN with interventional treatment significantly reduces postoperative pain for OS patients. With the use of targeted interventions such as nerve blocks, epidural analgesia, and patient-controlled analgesia combined with a comprehensive nursing care model that prioritizes patient education, support, and individualized pain management plans, this integrated approach has shown promising outcomes in terms of enhancing pain relief, reducing the use of opioids, improving patient satisfaction, and accelerating quicker recovery times.Additionally, the combined efforts of nurses and interventional therapists have enabled a comprehensive and patient-centered pain management strategy that addresses the intricate aspects of postoperative pain, enhancing overall patient outcomes and care quality. The study’s small sample size can limit how broadly the results can be applied to OS patients, necessitating caution when making such assumptions. By learning more about the long-term impacts of combined nursing and interventional therapy on postoperative pain management, treatment approaches can be improved.
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