Becker's ASC Review

50 Executive Briefing postoperative period after ACL reconstruction results in improved, short-term pain relief and a greater likelihood of independence from narcotic use compared with cryotherapy alone." The combined modalities can decrease the likelihood of narcotic use even more drastically than with cold therapy alone because they successfully alleviate pain and swelling, Dr. Mickelson explained. "There are studies that demonstrate decreased pain [and therefore decreased opioid] requirements with cryotherapy," he said. "Compression has been also shown to decrease swelling and inflammation, which we know improves early motion and rehab." Compelled by these and other findings, Dr. Mickelson uses cold therapy as part of his own multimodal pain management strategy. The compressive cryotherapy comes after prescriptions of Tylenol and nonsteroidal anti-inflammatory drugs, with limited narcotics prescribed for breakthrough pain. Both Dr. Mickelson and his patients are impressed by the results. "We have found that the majority of patients undergoing sports medicine cases involving the shoulder and knee benefit from cryotherapy by decreasing inflammation and pain," he said. "Athletes and trainers find it helps them rehab faster. For patients who are sensitive or tolerant to narcotic pain medications, this provides another means to decrease their dependence on them." Dr. Mickelson said he has had a number of patients "swear by their cold therapy systems" used to manage their pain after ACL or total knee replacement surgeries. As part of a multimodal pain management strategy, the cold therapy systems enable patients to reduce — if not eliminate — their reliance on narcotics. "They now recommend it to friends who have to undergo surgery as well," he said. "Many come in now for their preoperative visit and already have one setup." Opportunities on the horizon Patients will be seeking this kind of effective pain relief for orthopedic conditions after the COVID-19 crisis is contained and elective case restrictions are lifted — and practices will need to be prepared to help them despite pandemic-related financial hardship. Outpatient facilities in particular can expect cases to surge. Joint replacement volumes are expected to grow by 77 percent over the next decade, according to Sg2, and Bain & Co. projected in September 2019 that nearly 30 percent of knee replacements will be performed in ASCs by the mid-2020s. CMS has already taken steps to accelerate the migration of procedures to the outpatient setting, and specifically to ASCs. The agency added total knee arthroplasty to the ASC-payable list for 2020, indicating total hip arthroplasty could make the list in the near future. Outmigration will continue even after surgery centers are converted into COVID-19 relief centers and tapped to serve in new capacities, some industry leaders say. By stepping into these unfamiliar roles, ASCs are making their value known, which may help further the transition of surgical care to the outpatient setting after the pandemic. If analyst projections are correct, the rapid migration of total joints to outpatient settings is a given. Today, more than 300 ASCs offer total joint replacement in the U.S. Going forward, new outpatient total joint programs will be established, and physician experts will be put in charge of them. One of the most important assignments for these physician leaders will be developing appropriate pain management protocols. These clinical decisions can have a tremendous effect on the continuing opioid crisis — and motorized cold therapy, which has been shown to reduce the need for narcotics, will be a valuable tool to have on hand. "Our goal is to limit the amount of narcotics a patient needs while keeping their pain at a tolerable level," Dr. Mickelson said. "Since cold compression therapy has been shown to lower pain scores, reduce swelling, decrease the need for opioids, and improve early objective motion measurements, it would be a natural part of the program to get them recovered and rehabbed as fast as possible." n Breg makes orthopedic bracing and devices, but more than that, the company makes durable medical equipment programs easier for our customers every step of the way, from hurt to healthy. Breg is committed to supporting practitioners through comprehensive partnerships, supporting patients with high-quality products and services, and delivering seamless support to facilities navigating the complexities of modern healthcare. As the largest U.S. provider of cold therapy devices and second largest domestic provider of orthopedic bracing, Breg provides products to millions of patients annually. Founded in 1989, Breg is based in Carlsbad, Calif., and is a company of Water Street Healthcare Partners, a strategic investor focused exclusively on the health care industry. Visit www.breg.com.

• Cover