Physical therapists may hold vastly different opinions than anesthesiologists of the utility of peripheral nerve blocks after total knee and hip replacement surgeries.
“For a long time, we placed peripheral nerve catheters in every total knee replacement patient and every total hip replacement patient,” said Steven Porter, MD, assistant professor of anesthesiology at Mayo Clinic, in Jacksonville, Fla. “Over time, our practice has changed with regard to total joint replacement care pathways, and I noticed from working with physical therapists that it appeared that they thought the blocks made patients weak, increased the risk of falling and made physical therapy very difficult. So I thought maybe we could get this on paper and quantify or qualify it.”
Busting Through the Silos
To help clarify the issue, Dr. Porter and his colleagues anonymously queried all 20 full-time inpatient physical therapists at the institution, using a 24-question survey. “We came up with the questions ourselves, so it isn’t a validated questionnaire,” he explained. “We really couldn’t find anything published about this.”
As Dr. Porter reported at the 2016 annual meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 1281), the overwhelming majority of physical therapists (60%-95%) believe that peripheral nerve blocks impair patients’ ability to perform physical therapy and that nerve blocks make it more difficult for them to perform their professional responsibilities. “We also asked them about what they would prefer if they were undergoing these surgeries themselves, and the majority said they would not want a peripheral nerve block.”
Of interest, the researchers also found a negative association with respect to the number of years respondents have practiced and the likelihood of using nerve blocks to facilitate patient recovery after total joint replacement surgery. Similarly, the opinion that nerve blocks facilitate patient recovery was negatively associated with the frequency with which physical therapists treated total joint replacement surgical patients.
Therapists who believed that nerve blocks are an impediment to physical therapy also were likely to answer that periarticular infiltration is superior to nerve blocks for physical therapy after total knee replacement surgery. “We also asked them if they think that periarticular infiltration is superior to peripheral nerve blocks for hip replacement surgery, and 95% said yes,” Dr. Porter told Anesthesiology News.“Interestingly, we actually don’t use periarticular infusions in total hip replacement surgery. So we just assume that physical therapists think periarticular infiltration is a much better approach regardless of the surgery.”
Respondents’ opinions were not as pronounced with respect to shoulder surgery, although the majority still said they would prefer to not have a nerve block. “But it’s not like lower extremity surgery where they feel like the block really impeded their ability to do their job,” Dr. Porter explained.
Indeed, physical therapists’ perceptions about the potential for patient falls played an important role in their opinions about analgesic approaches to these patients. “We know from other research that it’s controversial whether lower extremity nerve blocks are associated with an increased risk of falls,” he added. “Certainly it’s a concern of the surgeons, anesthesiologists, physical therapists and the hospitals themselves. But with respect to falls, 100% of respondents believed that lower extremity nerve blocks increase the risk of falls.”
Medical Literature May Be Divergent
It’s these contrasting opinions that help demonstrate the need for various specialties to open lines of communication to ensure the best care possible. “We may have data in the anesthesia literature that suggests nerve blocks are safe and efficacious,” Dr. Porter said, but “maybe in the physical therapy literature it says that blocks impair therapy and greatly increase the risk of falls. And if we’re sitting in our silos patting ourselves on the back, it may be irrelevant to the patient if the physical therapists are saying otherwise. Because they impact patient care, too.”
Jacques E. Chelly, MD, PhD, professor of anesthesiology and orthopedics at the University of Pittsburgh School of Medicine, called the survey “very important,” and said it reflects the lack of sound randomized comparisons between low-concentration, low-volume continuous nerve block infusions and periarticular injections. “In a time where many health care systems are trying to contain costs any way they can, such opinions may lead to changes in practices, even if objective evidence is ultimately lacking,” Dr. Chelly said. “It is also important to remember that in a global reimbursement system, the party paying for continuous nerve blocks also represents a limitation to their use. Unfortunately, similar limitations will apply to the use of intra-articular injections, as in many cases, health care systems are proactively going back to intrathecal opioids.
“Yet through all of this,” Dr. Chelly added, “I am optimistic that the right approach will prevail.”