Dr. Gerber on Pain Management and Preparing for Knee Surgery

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Toree: Hi, I’m Toree McGee, and this is the Rapid Recovery Report, sponsored by ROMTech, the modern technology of rehabilitation. I will be doing this series 4:00pm Pacific, 7:00pm Eastern Thursdays, where we talk to different guests. Sometimes, it’s surgeons, sometimes patients, sometimes insiders here at ROMTech. We talk about all things wellness, health, and we will actually touch on ROMTech’s PortableConnect.

Now, if you are new to ROMTech or the PortableConnect, you can see this little cutie right here is exactly what we’ve been talking about, our PortableConnect. It is a high-tech recovery device, and it’s basically just geared to get people moving and recovering from surgeries faster, and just get back on their feet. If you want to learn a little bit more about it, you can always visit us at www.romtech.com. Also, please subscribe to our channels, and just check us out. We’d love to hang out with you.

Expert Orthopedic Surgeon, Dr. Sam Gerber

Introduction: It’s hard to describe success in just a few words. It means so many different things to so many different people. In the world of orthopedics, there is a doctor who is the quintessential definition of success and also an example of how to build your practice, innovating along the way, for 35 years and still going strong. Dr. Samuel Gerber is that definition of success.

Dr. Gerber has set the excellence bar very high 35 years ago. Guess what, it’s even higher now, if that’s even possible. Dr. Samuel Gerber, we salute you.

Toree: We’ve got a great guest today. Dr. Gerber is a graduate of Yale University and Harvard Medical School. He’s among the first in the nation to be awarded subspecialty certification in orthopedics sports medicine. He founded the Orthopedic Surgical Associates of Lowell. He is a past president of Massachusetts Orthopedic Association and prior chief of orthopedic surgery at Lowell General Hospital. Dr. Gerber is also an adjunct professor at the University of Massachusetts Lowell. He serves on the board of councilors for the American Academy of Orthopedic Surgeons. That’s just a few of the awesome things that you’re doing. Welcome, Dr. Gerber. We’re so happy to have you.

Dr. Gerber: My pleasure, Toree. Nice to see you again.

Pain Management in the Past

Toree: Yeah, you too. You’re very impressive. That resume, my goodness. I didn’t even hit everything. Now, when you started your career, what was the normal practice for pain management then? Was it different for sports medicine versus a more general patient population?

Dr. Gerber: Things have changed a lot over time, as you know. When we first started doing orthopedic surgery, people were in the hospital a lot longer. There was lot more IV pain medicine, more narcotics being used, and less mobilization of patients. The things that really have changed is we’ve gone to a more ambulatory model, where people get up and around, they’re moving quicker, and less narcotics. There’s less addiction as a result. There’s less chance for blood clots. People seem to do better in terms of rehabilitation, getting up and around, in being more familiar environment as well.

Toree: Yeah. Now, as medicine has had to rethink pain management after opioid addiction and all of those issues occurred, can you tell me how well other methods have been working so far? In particular, the multi-model approach, and what exactly is that for those watching and don’t know?

Dr. Gerber: Sure. We went through a transition where people were getting injectables and by-mouth medicines for pain, largely narcotics. Then they went to a PCA model, in which people are administering their own pain medicine with narcotics as a pump. Then we went to long-lasting narcotics with the idea that we didn’t want people to have any pain at all. All that led to is addiction. Didn’t really help with pain control.

Now, what we’ve done between increased mobilization and using the chemical methods, using things like anti-inflammatory drugs in conjunction with Tylenol, nerve medicines that suppress nerve pain, and a small amount of narcotics in the beginning, people rehabilitate much quicker, better, have less complications from the surgery, and have less pain. Actually, motion itself will help people have less pain, and that’s really. As we stress things, we have to educate patients. That was very important.

A lot of them will say, “Well, I can’t move it because it hurts.” I said, “No, if you don’t move it, it’s going to hurt. You need to start moving it, and it will pump some of the fluid out of the tissues, and make them more flyable, and make it more flexible, and you’ll be able to get moving.

Toree: Yeah. I know, growing up, I used to tell my mom, “Mom, it hurts when I do this,” and she’d say, “Well, don’t do that then.” Most of us are kind of—

Dr. Gerber: I think we all have the same mother.

Toree: Yeah, we’re all conditioned to that, so it’s hurting to do that makes us not want to do that. Of course, movement, body in motion stays in motion. Movement helps.

Dr. Gerber: Absolutely.

Toree: You had said something interesting in an earlier conversation that we had that was patients used to spend 10 days in the hospital for knee replacements, as part of the normal procedure. Now, we have surgery day centers. Do you believe that all procedures could be migrated to a surgery day center presently?

Dr. Gerber: Probably not all. It really depends a lot on the patient’s other comorbidities, their other medical conditions, their age, their family support situation, and what the psychosocial situation is for the patient. Do they have people at home? Do they have a lot of stairs at home? How well are they moving ahead of time? What other medical conditions do they have? How functioning they are mentally? Some people just can’t process all the information, particularly elderly people. They need a lot of cues. Sometimes, a day or two in the hospital is necessary.

I would say probably it’s going to be majority of people, at least with total knees, that will able to do as day surgery at some point in time.

Toree: Yeah. My grandma just had to have a plate put in, because she had fractured a bone in her leg, and she could not wait to get out of the hospital. She’s a very busy body and bossy lady. I’m sure all of those folks with that same kind of personality are very excited that it’s a quick in-and-out outpatient procedure.

Dr. Gerber: For a lot of people, they feel much more comfortable in their home environment anyway. If they have a good support system, it’s just a better place to be. Plus, you’re not around other people who can bring you infections of all sorts. These days, we worry about that obviously. If you’re home, you can be more mobile, less likely to get blood clots and other complications in the surgery.

Preparing for Surgery

Toree: That makes sense. Now, I wanted to ask you about proper prepping before procedure. You really stressed this practice beforehand. Can you explain what prepping is?

Dr. Gerber: We think of prepping is just prepping the skin, but no, it’s prepping the patient for being able to have a major procedure. They have to be educated, first of all. They have to understand what’s going to happen, what can I expect, how is this going to affect my life, when will I be on crutches, when will I be using a cane, how quickly will I be moving, when will I be able to take care of my dogs and take them for a walk, all those sorts of things. A lot of it is education.

I like to have patients see a physical therapist ahead of time, and hopefully the same therapist they’re going to see later on, so they understand what they’re going to have to do, get on to the various devices they’re going to use, the modalities they’re going to use, so they understand. Also, walk up and downstairs ahead of time to figure out how they’re going to do that with a cane or a crutch, and how they’re going to manage at home. That’s always very useful.

I have a wonderful physician assistant who works with me, who really helps with that education as well, who sees the patient a week before, and spends time with them going through all the things they’re going to get. When do you need to call for your pain medicine? When do you need to get off your pain medicine? When do you need to start moving and starting therapy? In terms of the ROMTech and the PortableConnect, when are you going to get that? What are you going to start on that? How are you going to manage that? Those are all important things.

It doesn’t become overwhelming when you have a procedure. Having a major surgery is still a major surgery. If you’re prepared, you’re much more likely to be successful and have good results. If you’re not prepared, it all comes as a big stress to people. You don’t need to add stress on top of the surgery.

Toree: Yeah, no kidding. The process for prepping is going to be a little bit different, depending on patient’s age, right?

Dr. Gerber: Patient’s age, sometimes language issues are – we have communication issues with people. Sometimes these people have a whole psychological overlay that’s different for everybody. Some people are used to dealing with stress and managing a stressful situations. Other people need a little more emotional support. You get to know that as you get to know the patients. It’s important to understand the patient and know them. By understanding that, you can get them through it, and make them have a successful result.

Toree: Okay, that’s great. I love that you spend so much time to learn about each individual patient and what would be best suited for them, even something as simple as explaining to them the process of before and after. A surgeon that cares.

Dr. Gerber: Well, you have to listen to the patient. That’s the only way you can know what they’re thinking and talk to them.

Toree: Absolutely.

Dr. Gerber: You got to spend a little more time listening than talking. We all have things we want to say, and we kind of feel pressured to get them in a short period of time. Sometimes, you learn a lot more by just being quiet, and just listening, and let the other person talk.

Non-Opioid Pain Management Techniques

Toree: I think so, too. Tell us a little bit more about some of the non-opioid pain management techniques that you’re using like Iovera. I know you’d mentioned that one before.

Dr. Gerber: For sure. Iovera has been a great benefit for people like the insurance will allow it. My PA does this. It’s a way of freezing the sensory nerves ahead of time, so that there’s less pain after the surgery. Obviously, if they have less pain, it’s easier for them to move, and they require less medicine.

Toree: How long does the freezing essentially last?

Dr. Gerber: I think it lasts a few weeks.

Toree: Okay, great. That’s awesome. Now, do you ever worry about patients overdoing it, because the Iovera has frozen—

Dr. Gerber: Really don’t, because it doesn’t relieve all the pain. It just gets rid of sensory pain that you have. You still have a feeling of what’s called proprioception, a feeling where your joint is in space. When you’re walking to a dark room, you can’t feel where your feet are. When you’re walking, you have to see your feet in order to know where they are. That’s proprioception. You still have that available to you. You have a good sense of where your body is. You just don’t have as much pain in moving.

Toree: Okay. Not like Novocaine, huh?

Dr. Gerber: No. It’s not like being completely numbed. That’s correct.

Dr. Gerber’s Patients on the PortableConnect

Toree: Okay. I want to ask you about the results that you discovered when you started using the ROMTech PortableConnect with your patients.

Dr. Gerber: We’ve had great results with that, Toree. I’m sorry. I didn’t mean to interrupt you. We actually had one patient who we had a little video from ROMTech about, who I had done the first knee without ROMTech and the second knee with ROMTech. She said it was like two different experiences. Her second experience where she had very little pain, she was moving. She was three months ahead of where she was with the other knee at one point. She was really delighted with how that worked out.

I’ve had that experience largely. Most people have come back, and done very well with their motion. They feel like they’re participatory in their rehab. It’s not somebody doing something to me, but rather I’m part of the whole process. I’m using this device. The device interacts with me. Some of it is passive. Some of it is active. It’s interactional. The therapist can get data off of it. It’s awesome. It’s very useful.

Toree: Yeah. That’s a pretty dramatic comparison, three months ahead of where she was with her first knee. It’s huge.

Dr. Gerber: Yeah, she was delighted.

Toree: Yeah, I bet. I bet I would be, too. It’s interesting that the willingness that patients have to do more with their recovery when they have a PortableConnect device, versus just doing exercises that a physical therapist asks them to do. I don’t know if it’s the feeling of having something high-tech in their home and them really wanting to go for it, or them being able to actually see in a chart their progress. Something is motivating them a little bit more than when physical therapist says, “Okay, do this three times a day when you’re at home, these exercises.”

Dr. Gerber: Well, nothing is more motivating than having results that you can see you’re progressing. When you can see I’m improving, it gives you more incentive to work harder to improve even more. That’s true. You see that all the time, people and their study habits. People who are good students, they get positive reinforcement being good students, they study harder. People who are told, “Oh, no, you’re doing terribly,” then they kind of give up on it. Well, I’m not good at math, or I’m not good at this, or whatever. They just stop trying. A lot of times, it’s just gaining their confidence back, and they can then feel like they’re part of the process, and that they’re making progress.

I think the ROMTech PortableConnect has been really good in terms of that. It gives people instant feedback. They can see how they’re doing better than they did last time. They feel like they’re part of the whole process, and that’s just how people react and respond. We all like positive reinforcement. It makes us feel better. Somebody gives you a compliment, makes you feel good about how you’re doing in your day.

That’s part of the nice things about seeing patients. They come back, and they tell me how it feels so much better with my surgery. It’s like a positive reinforcement for me too to be doing what I’m doing.

Toree: Yeah, absolutely. That’s why surgeons stay up on what’s modern, because things getting a little bit better.

Dr. Gerber: Absolutely.

Toree: You had mentioned that you’re enjoying overall maturing of your practice. You said that it matured along with you.

Dr. Gerber: It’s true.

Toree: Yeah, a move to a more total knee procedure.

Dr. Gerber: Part of that is we talked. I’ve done a fellowship in sports medicine and arthroscopy. A lot of patients who 20, 30 years later end up with arthritis, they need to still be taken care of. I’ve always done knee replacements, but the percentage of my knee replacement practice probably has increased a little bit as my patients have aged along with me. That’s because that’s what they need. You don’t do things because you want to do them. You do them because that’s what your patients need. My patients have progressed along with me, and so as my practice. It is kind of funny how everything develops and matures in a certain manner.

Toree: Yeah. Here’s the thing. If you did an ACL procedure on me before, and did such a great job, and if eventually I need that knee replaced, who am I going to go back to, right?

Dr. Gerber: It’s very comforting to see people do that, and come back to see me at times.

Toree: I bet.

Dr. Gerber: I also have multigenerational families that are coming to me as well.

Toree: That’s great. I love that. We have that in primary care physician. My grandma and mom go to the same that I go to. Find somebody you like.

Dr. Gerber: Absolutely.

Toree: In your overall medical experience, do you feel that there’s still room for improvement for overall patient care?

Dr. Gerber: Of course. That is what the practice of medicine is. That’s why we call it a practice of medicine. We’re always learning new things and new ways to help people. That’s what’s fun about it. It really is. It’s funny, I’d pull something out of this bag that is an old technique that works for certain rare situations. It’s something that I came up recently like that. It’s always interesting to have all these new things, then you say, “Well, sometimes, oh, it might be worthwhile.” For this particular patient, we might pull this one out, and try that.

Toree: That’s fair. Now, if you sat down with a young surgeon, what would be your first piece of advice to him or her as they venture into the world of orthopedics?

Dr. Gerber: Listen to the patient.

Finding Information on Knee Replacements

Toree: Yeah, okay. Go back and rewind, and listen to that again, you guys. Listen to the patient. Now, do you have any advice for someone who is seeking information about a knee replacement?

Dr. Gerber: Well, there’s lots of places they can look and get information. The American Academy of Orthopedic Surgery has an excellent website, and has lot of good references and videos and brochures and that sort of thing. That’s an excellent reference for patients to go to, and a good starting point.

Toree: Is there anything that they should avoid, as far as like misinformation, or things to be careful on?

Dr. Gerber: Be careful on the internet. It’s like the Wild West in the sense. It’s not regulated. There are some excellent things on the internet. There’s some total bonk. You got to see some crazy stuff that people put on the internet as though it was the gospel. It’s just crazy. It requires a discerning eye. A lot of times, just go back, and talk to your doctor about it.

I had somebody today who was asking me about a new technique that’s being done for anterior cruciate ligament reconstructions. I said, “Yeah, what you run on the internet is a really good thing, but it’s experimental, and it’s not yet well accepted.” For the various reasons, I said, “You’re not a candidate for that at this time, so you wouldn’t be appropriate for that.” It was an excellent question, and it was good information that she had. It just wasn’t appropriate for her at that time, but it’s hard to put things in context. So, a lot of times, it’s just going back to your own surgeon and talking to them, I think they’ll be able to put things in context, and make them make sense for you individually. A lot of this is individualized. You can’t cookie-cutter people. They’re not meant to be cookie-cuttered.

Toree: Yeah, well, that’s fair. I imagine it’s interesting to see what people come up with that they have found on the internet with their Google medical university degree.

Dr. Gerber: It’s all okay. It’s just information that’s out there. It’s good to talk about it. It’s bad to be defensive or afraid to discuss things with patient. They have a question, they ought to answer it.

Toree: Yeah, absolutely. I’m going to come to you if I need a knee replacement.

Dr. Gerber: It’s a long way from California.

Toree: That’s okay. I’m willing to travel for a good surgeon. Do you think that there will ever be a future where all knee and ortho procedures will be done in a non-hospital setting?

Dr. Gerber: I think a majority may be. I think hospitals are redefining their roles right now. I think it’s not clear. Clearly, the emergency room is a necessary part of a hospital. Intensive care unit is a necessary part of the hospital. Certain number of hospital beds are needed for a medical care. Multiple-trauma probably needs a hospital. There’s a lot of things we used to do in the hospital that have evolved over time. It’s not just in orthopedics. In general surgery, hernias are done as a day surgery procedure. That didn’t use to be the case. People are in the hospital five to seven days after a hernia. It’s not just orthopedics.

Medicine has evolved and changed. It’s not just cost consideration. It’s just health for the patients. It’s the right thing to do. Patients don’t want to be in a hospital if they don’t have to.

Toree: Right. I’d much rather be in a surgery center instead of the hospital. That makes sense. Thank you so much. I don’t want to take up too much of your time, Dr. Gerber. This has been awesome. I have loved every minute of doing this interview with you.

Dr. Gerber: You’re very sweet. Thank you, Toree.

Toree: It’s been a lot of fun. Folks, if you want to visit Dr. Gerber, and talk to him, and you need to have a procedure done, and talk to somebody who’s carrying and very informed, please visit him. His website and Twitter and email are all below. They’re going to be in the description below as well. If you can’t find it, you can always reach out to us at Romtech.com. Ask us any question that you’ve got, and follow us for more information and videos like this.

Finally, if you’d like to be a guest on our show, please email [email protected], and we’d be happy to chat with you a little bit.

Thanks again, Dr. Gerber. I’ve had a blast with you. I hope that you had as much fun as I did.

Dr. Gerber: I did. Thank you very much. Pleasure talking to you today.

Toree: Absolutely. Bye-bye.

Dr. Gerber: Bye now.

Disclaimer: The content discussed on this program is often medical in nature, and is used for informational purposes only. No content discussed should be taken as medical advice. Please consult your healthcare professional for any medical questions. Privacy is also of the utmost importance to us. All people, places, and scenarios mentioned have been changed to protect patient confidentiality, unless given explicit written permission to share. This podcast should not be used in any legal capacity whatsoever, including but not limited to establishing a “standard of care” in a legal sense, or as a basis for expert witness testimony.

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