Pain is often a top concern for patients dealing with knee osteoarthritis (OA), one of the most common joint disorders in the U.S. Consequently, many patients with knee OA eventually reach a point where a total knee replacement (TKA) is necessary.
Opioids are not the only option for managing pain that can result from these conditions. Fortunately, whether it’s to treat chronic knee OA pain, or to help improve postsurgical pain following TKA, the use of cold/freeze therapy has shown success in providing patients with an enhanced recovery experience. With the American Academy of Orthopaedic Surgeons (AAOS) reporting that approximately 790,000 knee replacements occur every year, optimizing the patient experience through the use of non-opioid options can have a profound impact on the TKA patient population which is expected to grow significantly in the next 10 years.
We spoke with Dr. Adam Rivadeneyra, a board-certified primary care sports medicine physician with Hoag Orthopedic Institute in Irvine, California, about a novel treatment he utilizes for his patients prior to TKA procedures and why it has been a gamechanger in his practice.
Can you tell us more about cold therapy and how it works?
The specific approach to cold therapy that I use is called cryoanalgesia. It utilizes the body’s natural response to cold to temporarily freeze nerves, which immediately reduces pain without the use of opioids. For up to 90 days, treated nerves are stopped from sending pain signals to the brain, after which nerves are fully restored. The hand-held device used to deliver the extreme cold temperature is highly localized and targeted, ensuring that only the necessary nerves are treated. This improved approach to cryotherapy has provided our field with a much less invasive and less complex method of using freeze therapy.
In my practice, I treat TKA patients with cryoanalgesia one to two weeks before their surgery to help them gain confidence in their overall pain management experience and provide long-lasting pain relief after the procedure. I perform the 10-15-minute treatment in the office and patients leave with immediate pain relief, often impressed by the quick and non-invasive nature of the procedure. I have also used cryoanalgesia to treat certain patients who may not be getting the pain relief they need for their chronic knee OA pain, in which case this method helps provide relief for 2-3 months.
How has cryoanalgesia improved your patients’ recovery experience?
I have been using this option since I was introduced to it nearly three years ago and have noticed a dramatic shift in the patient recovery experience. My patients are rebounding more quickly and have an overall faster return to range of motion compared to patients treated without this option. This is a critical benefit, as quicker return to range of motion leads to an improved rehabilitation experience overall, allowing patients to resume normal activity in a shortened period. In fact, I have had patients return for a second knee replacement due to their positive experience the first time around.
You mentioned that opioids are often overused in the surgical setting. How has this approach impacted opioid prescribing in your practice?
My practice has been able to significantly reduce opioid prescriptions, with quite a few patients taking zero opioids after surgery. This is extremely promising to see, given the ongoing opioid epidemic and the risks and side effects that come with taking these medications.
In fact, a 2018 survey noted that 8-12% of patients who had a soft tissue or orthopedic procedure reported that they had become addicted to or dependent on opioids following surgery. That same survey found that more than one-half of orthopedic surgery patients received opioids that are more potent than typically recommended by the Centers for Disease Control and Prevention (CDC) based on morphine milligram equivalency (MME). With this in mind, I remain dedicated to utilizing non-opioid pain management innovations in my practice to do my part to manage the opioid epidemic.
How can patients discuss non-opioid options with their own doctor?
Patients should have an active role in their pain management and feel empowered to raise concerns or questions regarding their procedure.
I encourage patients to educate themselves on non-opioid options available to them before surgery, especially when a TKA becomes a necessity. Patient education websites, such as www.planagainstpain.com, can serve as a helpful resource for patients to have pre-op conversations with their doctors. Patients can find discussion guides, including those designed for orthopedic surgery, as well as patient testimonials, survey reports, and other helpful information around the non-opioid pain management field, from pre- to post-operative care.
Given the availability of cryoanalgesia and other non-opioid options, how can physicians play a role in advocating for non-opioid options?
First, physicians should be aware of the different non-opioid options available to them – because our patients rely on us for this guidance. In fact, when patients were asked why they didn’t discuss non-opioids with their doctor prior to surgery, more than half (54%) said that they trust their doctor’s recommendations – which may include opioids for pain. It’s our responsibility to be the experts in our specialties, which includes not relying on outdated methods of pain control and patient care.
Taking a proactive multimodal approach to pain management by combining an array of non-opioid options helps lead to an enhanced patient experience, getting patients home quicker and in less pain. Pain is different for everyone, so ensuring that patients and doctors alike are open to discussing pain management, including the use of non-opioid options, will allow for the best experience possible.