RESUMEN
BACKGROUND: U.S. practitioners have prescribed opioid analgesics increasingly in recent years, contributing to what has been declared an opioid epidemic by the U.S. Centers for Disease Control and Prevention (CDC). Opioids are used frequently in the preoperative and postoperative periods for patients undergoing total joint replacement in developed countries, but cross-cultural comparisons of this practice are limited. An international medical mission such as Operation Walk Boston, which provides total joint replacement to financially vulnerable patients in the Dominican Republic, offers a unique opportunity to compare postoperative pain management approaches in a developed nation and a developing nation. METHODS: We interviewed American and Dominican surgeons and nurses (n = 22) during Operation Walk Boston 2015. We used a moderator's guide with open-ended questions to inquire about postoperative pain management and factors influencing prescribing practices. Interviews were recorded and transcripts were analyzed using content analysis. RESULTS: Providers highlighted differences in the patient-provider relationship, pain medication prescribing variability, and access to medications. Dominican surgeons emphasized adherence to standardized pain protocols and employed a paternalistic model of care, and American surgeons reported prescribing variability and described shared decision-making with patients. Dominican providers described limited availability of potent opioid preparations in the Dominican Republic, in contrast to American providers, who discussed opioid accessibility in the United States. CONCLUSIONS: Our findings suggest that cross-cultural comparisons provide insight into how opioid prescribing practices, approaches to the patient-provider relationship, and medication access inform distinct pain management strategies in American and Dominican surgical settings. Integrating lessons from cross-cultural pain management studies may yield more effective pain management strategies for surgical procedures performed in the United States and abroad.
Asunto(s)
Analgésicos Opioides/uso terapéutico , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Relaciones Médico-Paciente , Pautas de la Práctica en Medicina , Toma de Decisiones Clínicas , Comparación Transcultural , República Dominicana , Humanos , Estados UnidosRESUMEN
BACKGROUND: Advanced osteoarthritis and total joint replacement (TJR) recovery are painful experiences and often prompt opioid use in developed countries. Physicians participating in the philanthropic medical mission Operation Walk Boston (OpWalk) to the Dominican Republic have observed that Dominican patients require substantially less opioid medication following TJR than US patients. We conducted a qualitative study to investigate approaches to pain management and expectations for postoperative recovery in patients with advanced arthritis undergoing TJR in the Dominican Republic. METHODS: We interviewed 20 patients before TJR about their pain coping mechanisms and expectations for postoperative pain management and recovery. Interviews were conducted in Spanish, translated, and analyzed in English using content analysis. RESULTS: Patients reported modest use of pain medications and limited knowledge of opioids, and many relied on non-pharmacologic therapies and family support to cope with pain. They held strong religious beliefs that offered them strength to cope with chronic arthritis pain and prepare for acute pain following surgery. Patients exhibited a great deal of trust in powerful others, expecting God and doctors to cure their pain through surgery. CONCLUSION: We note the importance of understanding a patient's individual pain coping mechanisms and identifying strategies to support these coping behaviors in pain management. Such an approach has the potential to reduce the burden of chronic arthritis pain while limiting reliance on opioids, particularly for patients who do not traditionally utilize powerful analgesics.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Crónico/terapia , Osteoartritis de la Cadera/complicaciones , Osteoartritis de la Rodilla/complicaciones , Manejo del Dolor/métodos , Dolor Postoperatorio/terapia , Adaptación Psicológica , Adulto , Anciano , Analgésicos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Artroplastia de Reemplazo de Cadera , República Dominicana , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/psicología , Osteoartritis de la Cadera/cirugía , Osteoartritis de la Rodilla/psicología , Osteoartritis de la Rodilla/cirugía , Periodo Posoperatorio , Investigación Cualitativa , Religión , Adulto JovenRESUMEN
OBJECTIVE: Musculoskeletal disorders are the second leading cause of years lived with disability globally. Total knee replacement (TKR) offers patients with advanced arthritis relief from pain and the opportunity to return to physical activity. We investigated the impact of TKR on physical activity for patients in a developing nation. METHODS: As part of the Operation Walk Boston surgical mission program, we interviewed 18 Dominican patients (78% women) who received TKR about their level of physical activity after surgery. Qualitative interviews were conducted in Spanish, and English transcripts were analyzed using content analysis. RESULTS: Most patients found that TKR increased their participation in physical activities in several life domains, such as occupational or social pursuits. Some patients limited their own physical activities due to uncertainty about medically appropriate levels of joint use and postoperative physical activity. Many patients noted positive effects of TKR on mood and mental health. For most patients in the study, religion offered a framework for understanding their receipt of and experience with TKR. CONCLUSION: Our findings underscore the potential of TKR to permit patients in the developing world to return to physical activities. This research also demonstrates the influence of patients' education, culture, and religion on patients' return to physical activity. As the global burden of musculoskeletal disease increases, it is important to characterize the impact of activity limitation on patients' lives in diverse settings and the potential for surgical intervention to ease the burden of chronic arthritis.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/tendencias , Actividad Motora/fisiología , Osteoartritis de la Rodilla/etnología , Osteoartritis de la Rodilla/cirugía , Cuidados Posoperatorios/métodos , Adulto , Anciano , Anciano de 80 o más Años , Boston/etnología , Estudios de Cohortes , República Dominicana/etnología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/diagnóstico , Cuidados Posoperatorios/psicología , Factores de Tiempo , Caminata/fisiología , Caminata/psicologíaRESUMEN
BACKGROUND: Evaluation of physical functioning is an important tool for planning rehabilitation. Instruments need to be culturally adapted for use in non-English speaking countries. The aim of this study was to culturally adapt, including translation and preliminary validation, the Toronto extremity salvage score (TESS) for Brazil, in a sample of adolescents and young adults treated for lower extremity osteosarcoma. PROCEDURE: The process included two independent forward translations of TESS questionnaire, consensus between translators on a forward translation, back-translation by two independent translators, and a review of the back-translations. Internal consistency of the TESS and known groups validity were also evaluated. RESULTS: Internal consistency for the 30 item TESS was high (coefficient alpha = 0.87). TESS score ranges from 0 to 100. Forty-eight patients completed the questionnaire and scores ranged from 56 to 100 (mean score: 89.6). Patients receiving no pain medications scored higher on the TESS than those who were receiving pain medication (P = 0.014), and patients using walking aids had slightly higher but not statistically different scores. Those who were treated with amputation had higher scores than those who were treated with limb salvage procedures (P = 0.003). CONCLUSION: Preliminary evidence suggests that Brazilian-Portuguese translation is acceptable, understandable, reliable, and valid for evaluating the function in adolescents and young adults with osteosarcoma in lower extremity in Brazil.