Managing chronic pain before during and after surgery leads to better outcomes

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Diagnosed with rheumatoid arthritis in her teens, Judy McGrath was desperate for relief from the pain and stiffness of her deteriorating joints by the time she was in her late 40s. After to replace her right elbow joint allowed her to comfortably use her arm again, she hoped to have similar surgery on her ailing knee.

“I was booked for the surgery, but the surgeon refused to operate when he learned of my condition,” recalls Judy. Disheartened by the refusal, she consulted Dr. Kevin Smith, an anesthesiologist practising pain medicine at Allevio Clinic and Rouge Valley Health System Ajax and Pickering Campus. She’d been seeing him for treatments for several years, since developing complex regional pain syndrome around her knee following an arthroscopy procedure.

“It’s not surprising the surgeon was hesitant to operate, given the extent and severity of Judy’s chronic pain,” says Dr. Smith. “When patients already have complex pain syndromes, surgery of any kind may not succeed. Even a mechanical success can be an overall failure if the patient ends up in worse pain or with less mobility than before the operation. This is not a risk most surgeons are willing to take.”

Dr. Smith and his colleagues at the Allevio Pain Management Clinic in Toronto, however, are part of a growing number of physicians striving to transform surgical outcomes for chronic pain patients.

“We’ve found that being hypervigilant in identifying and controlling people’s chronic pain before surgery, and aggressively managing their pain during and after, helps them withstand the operation and recover well,” Dr. Smith says. “In Judy’s case, her pain was under control and her motivation was strong, so I felt she was a good candidate for a knee replacement in spite of her chronic pain.” 

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Confident in his and Judy’s ability to effectively manage her pain, Dr. Smith took her plight to Rouge Valley orthopedic surgeon, Dr. Hamdi Benfayed.

“I was worried at first, because I have seen so many surgeries go poorly for patients with chronic pain,” Dr. Benfayed says. “But because Dr. Smith was so willing to manage Judy’s pain before, during and after the surgery, and she was so confident based on her experience with her elbow, I decided to go ahead in collaboration with Dr. Smith. He personally managed the anesthesia during the procedure to ensure Judy’s pain was controlled every step of the way.”

As it turned out, Judy’s recovery from the knee replacement surgery surpassed everyone’s expectations. “No one could believe I was ready to leave the hospital just a day and a half after the surgery,” she says. “The relief was astounding. I could feel the surgery pain, of course, but the underlying arthritis pain was gone. I was up and walking and attending a major festival within a few days, but without the surgery I don’t think I’d be walking at all.”

In addition to regular intravenous infusions of lidocaine and ketamine, which Dr. Smith administered to control her pain leading up to and following her surgery, Judy took part in Rouge Valley’s chronic pain management education course for patients. Run by registered practical nurse and patient educator, Sue Bradbury, this four-part course provides people with knowledge and skills to help them better manage and live with chronic pain.

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“It’s not just about taking your medications and going to your appointments,” insists Sue, who knows from personal experience what it’s like to live with chronic pain. “It’s about the choices you make, every day, to participate in your own wellbeing.”

In the course, Sue explains the nature of chronic pain and how to avoid triggering flare-ups by taking prescribed medications as scheduled (rather than as needed), choosing anti-inflammatory foods, exercising without overdoing it, sleeping well, and managing stress.

Patients, including Judy, have found the pain management course so helpful, Bradbury and Dr. Smith now recommend that some patients complete an educational course before seeking medical treatment for chronic pain. They also add it to the comprehensive services available at the Allevio Pain Management clinic—which range from OHIP-covered injections and infusions to physical and psychological therapies.

“Sue helped Judy develop a stronger sense of confidence in her ability to self-manage her pain, so she had less anxiety going into her surgery and therefore less pain,” says Dr. Smith. “Patients need more than medical support, they need social and psychological support as well.”

In fact, according to Dr. Smith, mental health problems can be exacerbated by surgery and play a role in intensifying patients’ post-operative pain. “Mental health issues need to be proactively managed just as much as chronic pain to ensure good surgical outcomes and prevent pre-existing problems from getting worse,” he says. “Surgeons need to pick up on red flags and refer patients to the appropriate pain management or psychological services before surgery, so their pre-operative care can be optimized for the best possible results.”

Dr. Smith, Dr. Benfayed, Sue Bradbury and their colleagues are pioneering just the sort of collaborative, multidisciplinary approach that’s required to ensure surgery delivers the desired result—a better quality of life for patients. As Judy McGrath says, “Chronic pain doesn’t have to be a life sentence… there is a better way, there is hope.”

 

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