Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on sleep in brain health

LIVE: Thursday 2nd May 2024, 18:00-19:30 (CEST)

Quality sleep is essential for health. But what happens to our brains when sleep patterns are disturbed? Join our experts to explore the interplay between sleep disruption and neurological diseases, and the questions that you need to be asking your patients to help you prevent the harmful effects of sleep deprivation.
ADVANCED SEARCH
Log in
Top
BMC Medicine
Published in: BMC Medicine 1/2022

Open Access 01-12-2022 | Knee-TEP | Research article

A digital application and augmented physician rounds reduce postoperative pain and opioid consumption after primary total knee replacement (TKR): a randomized clinical trial

Authors: Julia Stuhlreyer, Christian Roder, Florian Krug, Christian Zöllner, Herta Flor, Regine Klinger

Published in: BMC Medicine | Issue 1/2022

Login to get access

Abstract

Background

Severe postoperative pain not only is a considerable burden for patients but also leads to overprescription of opioids, resulting in considerable health concerns. The remarkable development of new technologies in the health care system provides novel treatment opportunities in this area and could exploit the additional placebo effect, provide added value for patients, and at the same time support hospital staff. We aimed to test the pain- and opioid intake-reducing effects of enhanced postoperative pain management by boosting pain medication by using a technical application and/or augmented physician rounds.

Methods

In a four-arm, randomized clinical trial, 96 patients (24 patients per group) scheduled for a total knee replacement (TKR) were randomized into four groups for four postoperative days: an “application” group (APP) with information via an iPad-based application; a “doctor” group (DOC) with augmented physician rounds; a combination group (APP+DOC), which received both interventions; and a “treatment as usual” group (TAU) as a baseline with no additional intervention besides the standard care which consists of standardized medication, regular physician rounds, and physiotherapy. Postoperative pain and opioid requirements pre- and postoperatively until hospital discharge were recorded.

Results

The difference between post- and preoperative pain was significantly different between the groups (P=.02, partial η2=.10). APP+DOC experienced greater postoperative pain relief than DOC (mean: 2.3 vs. 0.7, 95% CI: 0.08–3.09; P=.04) and TAU (mean 2.3 vs. 0.1; 95% CI: 0.69–3.71; P=.005), respectively, the difference compared to APP (mean 2.3 vs. 1.7; 95% CI −1.98–1.76) was not significant. Opioid consumption differed significantly between groups (P=.01, partial η2=.12). APP+DOC (72.9 mg) and DOC (75.4 mg) consumed less oxycodone than APP (83.3 mg) and TAU (87.9 mg; 95% CI: 2.9–22.1; P=.003). APP+DOC consumed significantly less oxycodone than DOC (d=0.2–0.4). There were no significant group differences in NSAID and Morphine sulfate consumption. Patients in APP+DOC were more satisfied with their treatment than patients in TAU (P=.03, partial η2=.09).

Conclusions

The combination of an innovative digital app, which implements open drug administration and augmented physician rounds that support the doctor–patient relationship can significantly improve postoperative pain management.

Trial registration

The protocol was approved by the local ethics committee of the ethical commission of the German Psychological Society (Deutsche Gesellschaft für Psychologie; DGPs). The study was registered at DRKS.de (identifier: DRKS00009554).
Appendix
Available only for authorised users
Literature
1.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569–76.PubMedCrossRef
2.
Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ. 2017;359:j4792.PubMedCrossRef
3.
Hirschfeld DJ. Trump Declares Opioid Crisis a ‘Health Emergency’ Requests no Funds The New York Times; 2017.
4.
Hollmann MW, Rathmell JP, Lirk P. Optimal postoperative pain management: redefining the role for opioids. Lancet. 2019;393(10180):1483–5.PubMedCrossRef
5.
Silva BM, Rodrigues JJ, de la Torre DI, Lopez-Coronado M, Saleem K. Mobile-health: A review of current state in 2015. J Biomed Inform. 2015;56:265–72.PubMedCrossRef
6.
7.
Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504.PubMedPubMedCentralCrossRef
8.
Hamnvik OR, Alford DP, Ryan CT, Hardesty IT, Drazen JM. NEJM Knowledge+ Pain Management and Opioids - A New Adaptive Learning Module. N Engl J Med. 2019;380(16):1576–7.PubMedCrossRef
9.
Babu KM, Brent J, Juurlink DN. Prevention of Opioid Overdose. N Engl J Med. 2019;380(23):2246–55.PubMedCrossRef
10.
11.
12.
Colloca L, Lopiano L, Lanotte M, Benedetti F. Overt versus covert treatment for pain, anxiety, and Parkinson's disease. Lancet Neurol. 2004;3(11):679–84.PubMedCrossRef
13.
Hack TF, Degner LF, Parker PA, Team SC. The communication goals and needs of cancer patients: a review. Psychooncology. 2005;14(10):831–47.PubMedCrossRef
14.
Del Re AC, Fluckiger C, Horvath AO, Symonds D, Wampold BE. Therapist effects in the therapeutic alliance-outcome relationship: a restricted-maximum likelihood meta-analysis. Clin Psychol Rev. 2012;32(7):642–9.PubMedCrossRef
15.
Epstein R, Street RL. Patient-centered communication in cancer care: promoting healing and reducing suffering: National Cancer Institute. Bethesda: US Department of Health and Human Services, National Institutes of Health; 2007.
16.
Baker PN, van der Meulen JH, Lewsey J, Gregg PJ. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007;89(7):893–900.PubMedCrossRef
17.
World Health O. ICD-10 : international statistical classification of diseases and related health problems : tenth revision. 2nd ed. Geneva: World Health Organization; 2004.
18.
Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, et al. Assessment of pain. Br J Anaesth. 2008;101(1):17–24.PubMedCrossRef
19.
Younger J, Gandhi V, Hubbard E, Mackey S. Development of the Stanford Expectations of Treatment Scale (SETS): a tool for measuring patient outcome expectancy in clinical trials. Clin Trials. 2012;9(6):767–76.PubMedCrossRef
20.
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41(4):1149–60.PubMedCrossRef
21.
Booth RG, Strudwick G, McBride S, O’Connor S, Solano López AL. How the nursing profession should adapt for a digital future. BMJ. 2021;373:n1190.PubMedCentralCrossRef
22.
Fairbrother P, Ure J, Hanley J, McCloughan L, Denvir M, Sheikh A, et al. Telemonitoring for chronic heart failure: the views of patients and healthcare professionals - a qualitative study. J Clin Nurs. 2014;23(1-2):132–44.PubMedCrossRef
23.
Barello S, Triberti S, Graffigna G, Libreri C, Serino S, Hibbard J, et al. eHealth for Patient Engagement: A Systematic Review. Front Psychol. 2015;6:2013.PubMed
24.
Eaton L, Walsh C, Magnuson T, Schweitzer M, Lidor A, Nguyen H, et al. On-line bariatric surgery information session as effective as in-person information session. Surg Obes Relat Dis. 2012;8(2):225–9.PubMedCrossRef
25.
Heikkinen K, Leino-Kilpi H, Vahlberg T, Salanterä S. Ambulatory orthopaedic surgery patients’ symptoms with two different patient education methods. Int J Orthop Trauma Nurs. 2012;16(1):13–20.CrossRef
26.
Matthew DA. The use of a computer website prior to scheduled surgery (a pilot study): impact on patient information, acquisition, anxiety level, and overall satisfaction with anesthesia care. AANA J. 2005;73(1):29.
27.
D'Haese PF, Pallavaram S, Li R, Remple MS, Kao C, Neimat JS, et al. CranialVault and its CRAVE tools: a clinical computer assistance system for deep brain stimulation (DBS) therapy. Med Image Anal. 2012;16(3):744–53.PubMedCrossRef
28.
de Visser H, Watson MO, Salvado O, Passenger JD. Progress in virtual reality simulators for surgical training and certification. Med J Aust. 2011;194(4):S38–40.PubMed
29.
Neuprez A, Neuprez AH, Kaux J-F, Kurth W, Daniel C, Thirion T, et al. Early Clinically Relevant Improvement in Quality of Life and Clinical Outcomes 1 Year Postsurgery in Patients with Knee and Hip Joint Arthroplasties. Cartilage. 2018;9(2):127–39.PubMedCrossRef
30.
Klimek M, Büchele G, Rehm M, Beyersmann J, Günther KP, Brenner H, et al. Long-term mortality of patients with osteoarthritis after joint replacement: Prognostic value of pre-and postoperative pain and function. Athritis Care Res. 2021;0(0):1–7. https://​doi.​org/​10.​1002/​acr.​24808.CrossRef
31.
32.
Amanzio M, Pollo A, Maggi G, Benedetti F. Response variability to analgesics: a role for non-specific activation of endogenous opioids. Pain. 2001;90(3):205–15.PubMedCrossRef
33.
34.
Kam-Hansen S, Jakubowski M, Kelley JM, Kirsch I, Hoaglin DC, Kaptchuk TJ, et al. Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med. 2014;6(218ra5).
35.
Levine JD, Gordon NC. Influence of the method of drug administration on analgesic response. Nature. 1984;312(5996):755–6.PubMedCrossRef
36.
Moore RA, Cai N, Skljarevski V, Tolle TR. Duloxetine use in chronic painful conditions--individual patient data responder analysis. Eur J Pain. 2014;18(1):67–75.PubMedCrossRef
37.
Rief W, Nestoriuc Y, Weiss S, Welzel E, Barsky AJ, Hofmann SG. Meta-analysis of the placebo response in antidepressant trials. J Affect Disord. 2009;118(1-3):1–8.PubMedCrossRef
38.
39.
Elsenbruch S, Kotsis V, Benson S, Rosenberger C, Reidick D, Schedlowski M, et al. Neural mechanisms mediating the effects of expectation in visceral placebo analgesia: an fMRI study in healthy placebo responders and nonresponders. Pain. 2012;153(2):382–90.PubMedCrossRef
40.
Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, Singer JP, et al. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One. 2010;5(12):e15591.PubMedPubMedCentralCrossRef
41.
Timmers T, Janssen L, Kool RB, Kremer JA. Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review. J Med Internet Res. 2020;22(4):e17342.PubMedPubMedCentralCrossRef
42.
Klinger R, Colloca L, Bingel U, Flor H. Placebo analgesia: clinical applications. Pain. 2014;155(6):1055–8.PubMedCrossRef
43.
Colloca L, Jonas WB, Killen J, Miller FG, Shurtleff D. Reevaluating the placebo effect in medical practice. Z Psychol. 2014;222(3):124–7.PubMedPubMedCentral
44.
Benedetti F. Placebo Effects. Understanding the mechanisms in health and disease. Oxford: Oxford University Press; 2014.CrossRef
45.
Colloca L, Miller FG. Harnessing the placebo effect: the need for translational research. Philos Trans R Soc Lond B Biol Sci. 2011;366(1572):1922–30.PubMedPubMedCentralCrossRef
46.
Enck P, Bingel U, Schedlowski M, Rief W. The placebo response in medicine: minimize, maximize or personalize? Nat Rev Drug Discov. 2013;12(3):191–204.PubMedCrossRef
47.
Miller FG, Colloca L. The legitimacy of placebo treatments in clinical practice: evidence and ethics. Am J Bioeth. 2009;9(12):39–47.PubMedCrossRef
48.
Schedlowski M, Enck P, Rief W, Bingel U. Neuro-Bio-Behavioral Mechanisms of Placebo and Nocebo Responses: Implications for Clinical Trials and Clinical Practice. Pharmacol Rev. 2015;67(3):697–730.PubMedCrossRef
49.
50.
Price DD, Finniss DG, Benedetti F. A comprehensive review of the placebo effect: recent advances and current thought. Annu Rev Psychol. 2008;59:565–90.PubMedCrossRef
51.
Finniss DG, Benedetti F. Mechanisms of the placebo response and their impact on clinical trials and clinical practice. Pain. 2005;114(1-2):3–6.PubMedCrossRef
52.
53.
54.
Ashton-James CE, Forouzanfar T, Costa D. The contribution of patients’ presurgery perceptions of surgeon attributes to the experience of trust and pain during third molar surgery. Pain Rep. 2019;4(3):e754.PubMedPubMedCentralCrossRef
55.
56.
Volkow ND, Collins FS. The Role of Science in Addressing the Opioid Crisis. N Engl J Med. 2017;377(4):391–4.PubMedCrossRef
57.
White AG, Birnbaum HG, Mareva MN, Daher M, Vallow S, Schein J, et al. Direct costs of opioid abuse in an insured population in the United States. J Manag Care Pharm. 2005;11(6):469–79.PubMedCrossRef
58.
Wolford ML, Palso K, Bercovitz A. Hospitalization for total hip replacement among inpatients aged 45 and over: United States, 2000-1010: US Department of Health and Human Services, Centers for Disease Control and …; 2015.
59.
Arthrose K-IR. Gesundheitsberichterstattung des Bundes. Berlin: RKI; 2013.
60.
Darley JM, Fazio RH. Expectancy confirmation processes arising in the social interaction sequence. Am Psychol. 1980;35(10):867–81.CrossRef
61.
Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain. 1992;50(2):133–49.CrossRef
62.
Klinger R, Krug F, Goßmann M, Damzog U, Dahme B, Bruch H-P. Das perioperative Schmerz- und Befindlichkeitsinventar: Ein Fragebogen zur Erfassung der perioperativen Lebensqualität. Der Schmerz. 1999;13:86.
63.
Flor H, Rudy TE, Birbaumer N, Streit B, Schugens MM. The applicability of the West Haven-Yale multidimensional pain inventory in German-speaking countries. Data on the reliability and validity of the MPI-D. Schmerz. 1990;4(2):82–7.PubMedCrossRef
64.
Lowe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al. A 4-item measure of depression and anxiety: validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1-2):86–95.PubMedCrossRef
65.
Lequesne MG. The algofunctional indices for hip and knee osteoarthritis. J Rheumatol. 1997;24(4):779–81.PubMed
66.
Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–91.PubMedCrossRef
67.
Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012;2(1):e000435.PubMedPubMedCentralCrossRef
68.
Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004;27(3):237–51.PubMedCrossRef
69.
70.
Bortz J, Schuster C. Statistik für Human-und Sozialwissenschaftler: Limitierte Sonderausgabe. Berlin: Springer-Verlag; 2011.
Metadata
Title
A digital application and augmented physician rounds reduce postoperative pain and opioid consumption after primary total knee replacement (TKR): a randomized clinical trial
Authors
Julia Stuhlreyer
Christian Roder
Florian Krug
Christian Zöllner
Herta Flor
Regine Klinger
Publication date
01-12-2022
Publisher
BioMed Central
Published in
BMC Medicine / Issue 1/2022
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-022-02638-0

Other articles of this Issue 1/2022

BMC Medicine 1/2022 Go to the issue

Research article

The impact and causal directions for the associations between diagnosis of ADHD, socioeconomic status, and intelligence by use of a bi-directional two-sample Mendelian randomization design

Research article

Impact of prenatal tobacco smoking on infant telomere length trajectory and ADHD symptoms at 18 months: a longitudinal cohort study

Research article

Ten years of tracking mental health in refugee primary health care settings: an updated analysis of data from UNHCR’s Health Information System (2009–2018)

Research article

External validation of models for predicting risk of colorectal cancer using the China Kadoorie Biobank

Research article

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000–2018

Research article

Exploring the causal role of intimate partner violence and abuse on depressive symptoms in young adults: a population-based cohort study