Factors Affecting the Speed of Recovery After ACL Reconstruction
| Status: | Completed |
|---|---|
| Conditions: | Hospital, Orthopedic, Orthopedic |
| Therapuetic Areas: | Orthopedics / Podiatry, Other |
| Healthy: | No |
| Age Range: | 18 - 75 |
| Updated: | 12/12/2018 |
| Start Date: | March 24, 2017 |
| End Date: | June 11, 2018 |
Factors Affecting the Speed of Recovery After Anterior Cruciate Ligament Reconstruction
The purpose of this study is to find out how postoperative pain affects recovery after
anterior cruciate ligament (ACL) repair. Complete recovery after ACL repair involves healing
of tissues at the surgical site, but also recovery of strength of the muscles that control
movements at the knee. Some pain is normally experienced after ACL repair; the severity is
variable from one individual to another. Pain is usually controlled by intravenous and oral
(by mouth) pain medicines. It is also frequently controlled by numbing nerves that supply
sensation to the knee joint and surrounding tissues. This procedure is called a nerve block.
The investigators want to determine if standard methods of pain control after surgery affect
future pain control, and the ability to exercise and recover muscle strength after surgery.
The investigators are also interested in determining what other factors, such as age, gender,
anxiety, or coping skills might be predictive of pain severity and speed of recovery. As part
of the study, the investigators will record subject's ratings of pain severity, use of
painkiller medicines, and muscle bulk measured by standardized tests, at various time
intervals in the first 6 months after surgery. The investigators will also ask them to
complete two questionnaires,one that enquires about subject's responses to pain in the past
(catastrophizing test), and one that measures anxiety they might have about surgery or pain
on the day of surgery. The investigators will be studying approximately 180 people who are
having ACL repair at University of Washington. Subjects may be involved who are having
multiple ligaments repaired including the anterior cruciate ligament
anterior cruciate ligament (ACL) repair. Complete recovery after ACL repair involves healing
of tissues at the surgical site, but also recovery of strength of the muscles that control
movements at the knee. Some pain is normally experienced after ACL repair; the severity is
variable from one individual to another. Pain is usually controlled by intravenous and oral
(by mouth) pain medicines. It is also frequently controlled by numbing nerves that supply
sensation to the knee joint and surrounding tissues. This procedure is called a nerve block.
The investigators want to determine if standard methods of pain control after surgery affect
future pain control, and the ability to exercise and recover muscle strength after surgery.
The investigators are also interested in determining what other factors, such as age, gender,
anxiety, or coping skills might be predictive of pain severity and speed of recovery. As part
of the study, the investigators will record subject's ratings of pain severity, use of
painkiller medicines, and muscle bulk measured by standardized tests, at various time
intervals in the first 6 months after surgery. The investigators will also ask them to
complete two questionnaires,one that enquires about subject's responses to pain in the past
(catastrophizing test), and one that measures anxiety they might have about surgery or pain
on the day of surgery. The investigators will be studying approximately 180 people who are
having ACL repair at University of Washington. Subjects may be involved who are having
multiple ligaments repaired including the anterior cruciate ligament
Anterior cruciate ligament (ACL) tears of the knee are frequently repaired by surgically
implanting a tendon graft in place of the torn original cruciate ligament. The graft may be
taken from the patient having the repair (an autologous graft) or from a cadaver (an
allograft). Complete recovery from surgical repair of an anterior cruciate ligament
reconstruction requires that the graft becomes firmly engrafted at the site, surrounding
tissues are healed and strength is restored in muscles that control movements at the knee.
The recovery process typically requires from six months to one year. Pain in the early phase
of recovery is typically moderate to severe and may be a major factor determining patient
return to normal activity. It may also be a major factor limiting the patient's ability to
cooperate with rehabilitation maneuvers.
Traditional methods of treatment for pain include use of opioid pain killers (such as
morphine) and/or femoral nerve block at the groin. The potential hazards of opioid pain
killers include opioid side effects (nausea, vomiting, constipation, drowsiness, respiratory
depression and the potential for developing opioid dependency=addiction). Pain in the early
phase of recovery, if severe, can lead to changes in the spinal cord that predispose to
amplifying pain sensations, thus intensifying the need for pain killer medicines, a process
referred to as "windup" or neuroplasticity. Similarly, the use of opioid pain killers may
activate pain amplification systems potentially contributing to persistence of pain and
favoring development of chronic pain. For these reasons, there is a belief that early
aggressive efforts to treat postoperative pain, and minimize the use of opioid pain killers,
can have significant benefits to patients both by improving their comfort level after
surgery; facilitating rehabilitation efforts and return to normal activity.
Anesthesiologists at the University of Washington may use pain medicines alone and/or perform
a nerve block to help patients undergoing ACL repair with their pain control. Patients are
given a choice as to their desired methods of pain control. These options are normally
discussed by the regional block team with the patient prior to surgery and the merits of each
discussed. Approximately 60-70% of patients typically request the use of nerve blocks in the
recovery unit to help control their pain. For those patients who choose a nerve block, the
anesthesiologist will choose to perform the nerve block at the level of the groin or the mid
thigh. This decision varies by provider and is typically random in nature. Both locations for
the nerve block appear to work most of the time and each may have small differences: the
speed of onset is typically faster when performed at groin level, while quadriceps muscle
function may be less affected when performed at mid thigh. Neither method is known to be
superior for this type of surgery. Because patients are non-weight bearing for at least the
first 24 hours after surgery and must use crutches for mobilization, the weakening of the
quadriceps muscles may be relatively unimportant during that time.
The investigators hypothesize that pain treatment after ACL reconstruction which includes a
nerve block in combination with other pain medications will be associated with better pain
control immediately after surgery and will minimize the need for patients to use opioid pain
killers and experience common opioid- related side effects. A secondary hypothesis is that
the effectiveness of pain control, whether by pain medicines, and/or in combination with
nerve blocks will determine the patient's ability to perform routine activities of daily
living in the acute phase (0-7 days), and subsequently may affect their ability to perform
physical therapy maneuvers that are prescribed for their routine care.
STUDY PURPOSE
Aim 1: Determine whether pain reported by patients after surgery is related to the type of
pain control utilized - (1) either intravenous and oral pain medication alone, (2) combined
with nerve block at the groin, or (3) combined with nerve block at the mid thigh.
Aim 2: Examine whether pain severity affects the ability of patients to perform activities of
daily living in the acute phase (recovery index measured at 7 days), and physical therapy
maneuvers in the ensuing 6 months after surgery possibly retarding restoration of muscle
function in the affected leg.
Aim 3: Determine whether preoperative psychologic tests designed to assess patients' coping
skills (Pain Catastrophizing score) and anxiety (Stait anxiety index) predict postoperative
pain reported by patients, acute phase recovery scores (recovery index), and rehabilitation
endpoints
implanting a tendon graft in place of the torn original cruciate ligament. The graft may be
taken from the patient having the repair (an autologous graft) or from a cadaver (an
allograft). Complete recovery from surgical repair of an anterior cruciate ligament
reconstruction requires that the graft becomes firmly engrafted at the site, surrounding
tissues are healed and strength is restored in muscles that control movements at the knee.
The recovery process typically requires from six months to one year. Pain in the early phase
of recovery is typically moderate to severe and may be a major factor determining patient
return to normal activity. It may also be a major factor limiting the patient's ability to
cooperate with rehabilitation maneuvers.
Traditional methods of treatment for pain include use of opioid pain killers (such as
morphine) and/or femoral nerve block at the groin. The potential hazards of opioid pain
killers include opioid side effects (nausea, vomiting, constipation, drowsiness, respiratory
depression and the potential for developing opioid dependency=addiction). Pain in the early
phase of recovery, if severe, can lead to changes in the spinal cord that predispose to
amplifying pain sensations, thus intensifying the need for pain killer medicines, a process
referred to as "windup" or neuroplasticity. Similarly, the use of opioid pain killers may
activate pain amplification systems potentially contributing to persistence of pain and
favoring development of chronic pain. For these reasons, there is a belief that early
aggressive efforts to treat postoperative pain, and minimize the use of opioid pain killers,
can have significant benefits to patients both by improving their comfort level after
surgery; facilitating rehabilitation efforts and return to normal activity.
Anesthesiologists at the University of Washington may use pain medicines alone and/or perform
a nerve block to help patients undergoing ACL repair with their pain control. Patients are
given a choice as to their desired methods of pain control. These options are normally
discussed by the regional block team with the patient prior to surgery and the merits of each
discussed. Approximately 60-70% of patients typically request the use of nerve blocks in the
recovery unit to help control their pain. For those patients who choose a nerve block, the
anesthesiologist will choose to perform the nerve block at the level of the groin or the mid
thigh. This decision varies by provider and is typically random in nature. Both locations for
the nerve block appear to work most of the time and each may have small differences: the
speed of onset is typically faster when performed at groin level, while quadriceps muscle
function may be less affected when performed at mid thigh. Neither method is known to be
superior for this type of surgery. Because patients are non-weight bearing for at least the
first 24 hours after surgery and must use crutches for mobilization, the weakening of the
quadriceps muscles may be relatively unimportant during that time.
The investigators hypothesize that pain treatment after ACL reconstruction which includes a
nerve block in combination with other pain medications will be associated with better pain
control immediately after surgery and will minimize the need for patients to use opioid pain
killers and experience common opioid- related side effects. A secondary hypothesis is that
the effectiveness of pain control, whether by pain medicines, and/or in combination with
nerve blocks will determine the patient's ability to perform routine activities of daily
living in the acute phase (0-7 days), and subsequently may affect their ability to perform
physical therapy maneuvers that are prescribed for their routine care.
STUDY PURPOSE
Aim 1: Determine whether pain reported by patients after surgery is related to the type of
pain control utilized - (1) either intravenous and oral pain medication alone, (2) combined
with nerve block at the groin, or (3) combined with nerve block at the mid thigh.
Aim 2: Examine whether pain severity affects the ability of patients to perform activities of
daily living in the acute phase (recovery index measured at 7 days), and physical therapy
maneuvers in the ensuing 6 months after surgery possibly retarding restoration of muscle
function in the affected leg.
Aim 3: Determine whether preoperative psychologic tests designed to assess patients' coping
skills (Pain Catastrophizing score) and anxiety (Stait anxiety index) predict postoperative
pain reported by patients, acute phase recovery scores (recovery index), and rehabilitation
endpoints
INCLUSION Criteria:
- Subjects must be age 18-65,
- Subjects must be undergoing ACL repair at UWMC
- Subjects must be between an anesthesia risk category of 1-3
- Subjects must be candidates to have a nerve block if they should choose so.
- Subjects must be free of neurologic disease or coagulation defects
- Subjects must have no allergies to typical medications used during nerve blocks.
- Subjects must be fluent in English, able to read, and understand English readily in
person or and/over the phone.
EXCLUSION Criteria:
- Any patients under 18 or over 75
- Patients with a BMI in excess of 40
- Non-English speaking patients
- Patients with allergies to nerve block medications
- Patients with neurological disease or coagulation defects
- Patients not undergoing ACL repair at UWMC
- Patients who are opioid tolerant
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