Dr. Andrea Cheville is an Assistant Professor and Director of Cancer Rehabilitation at the University of Pennsylvania Health System. After attending Harvard Medical School, Dr. Cheville completed a Physical Medicine and Rehabilitation residency program at the Kessler Institutes for Rehabilitation and the University of Medicine and Dentistry New Jersey. During this training, Dr. Cheville developed an interest in cancer rehabilitation and pain management. She pursued these with a two-year fellowship in pain, rehabilitation and palliative care at the Memorial Sloan-Kettering Cancer Center. At present she dedicates her time to pain control and function restoration in both cancer and non-cancer patient populations. Dr. Cheville has published extensively on the relationship between pain and functionality.

Robert M. Peroutka MD

Dr. Robert M. Peroutka is an orthopaedic surgeon in private practice with the Four East Madison Orthopaedic Associates in Baltimore. He is an assistant professor (part-time) of orthopaedic surgery at The Johns Hopkins University School of Medicine. Dr. Peroutka received his M.D. from the University of Maryland School of Medicine and completed his orthopaedic surgery residency at the Duke University Medical Center. He was then awarded the Maurice E. Mueller North American Fellowship in Adult Reconstructive Surgery.

Dr. Peroutka is the treasurer of the Southern Orthopaedic Association and the Councilor for Maryland in the Southern Medical Association. He is on the editorial boards of the Journal of the Southern Orthopaedic Association and the Southern Medical Journal. Dr. Peroutka has a special interest in surgical pain management and speaks regionally and nationally on this subject.

Colleen J. Dunwoody MS, RN

Colleen Dunwoody is the Clinical Nurse Specialist for Pain Management at the University of Pittsburgh Medical Center - Presbyterian in Pittsburgh, Pennsylvania. She received her nursing diploma from Presbyterian-University Hospital School of Nursing and her bachelor and master degrees from the University of Pittsburgh. She is a Past President of the American Society of Pain Management Nurses, and current member of the Board of Directors of the American Chronic Pain Association.

Colleen is a member of the Editorial Board of Pain Management Nursing, the journal of the American Society of Pain Management Nurses. She has published on orthopaedic nursing and pain management topics in Orthopaedic Nursing, RN, Nursing Clinics of North America, AORN Journal, Nursing, Dermatology Nursing and a number of book chapters. She has given presentations on a variety of orthopaedic and pain management topics regionally and nationally.

Pain.com: What pressures are rehabilitative services facing today with respect to post-surgical orthopaedic patient needs?

Dr Cheville: There are ever-increasing pressures from third party payers and hospital administrators to contain costs and reduce the utilization of health care resources. We are experiencing the effects of this pressure in both the in- and outpatient arenas of rehabilitation care. If patients fail to demonstrate steady functional progress and meet their rehabilitation goals, third party payers can deny coverage for hospital days. Some rehabilitation facilities have responded with mandates to select only those patients likely to make steady progress and to discharge patients rapidly. As a consequence, if patients are not "good" rehabilitation candidates or fail to achieve their functional goals in a timely manner, they may lose the opportunity to benefit from rehabilitative care. Uncontrolled pain has the capacity to undermine the rehabilitation process. Patients' ability to engage actively in their own functional recovery is impeded by anxiety, fear of injury, and increased pain associated with therapeutic activities. Effectively managed pain allows patients to benefit optimally from rehabilitation services.
Pain.com: What about your experiences with these concerns relative to your own clinical practice?

Dr Peroutka: Rehabilitative services must provide physical therapy and occupational therapy to patients with the potential for continued improvement. Once patients plateau in their improvement, they are discharged. The challenge occurs when patients are not meeting the requirements for continued progress on an expected timeline, but still would be better served as an inpatient. With better pain management, patients should be able to continue to progress with their rehab and reach their goals in an inpatient rehabilitation facility sooner than patients with poor pain control.
Pain.com: Can you comment on your experiences encountered with these services in your institution too?

Ms Dunwoody: Pressure to move the patient quickly through the acute care phase comes from the hospital and third party payers and managed care organizations. Whereas pain limiting the patient's ability to participate in rehabilitation activities may have postponed transfer to a rehabilitation facility a decade ago, our ability to treat and prevent pain with new medication formulations has eliminated this barrier. The use of specific anti-nociceptive or pre-emptive treatment, specifically regional anesthesia techniques, has also improved our ability to control post-operative pain, thus facilitating shortened acute care hospital stays.
Pain.com: What is the typical pain management procedure that you use in the rehabilitation process following TKA?

Dr Cheville: The provision of adequate pain control during the rehabilitation phase of recovery is deceptively challenging. One of the principle difficulties derives from the fact that pain is highly dynamic. Tissue healing occurs during this period and analgesic requirements can therefore be expected to diminish. However, functional demands are concurrently increasing, sometimes very dramatically. For patients who are discharged directly home from their acute hospitalizations and bypass inpatient rehabilitation, domestic and vocational demands may mandate an abrupt increase in patients' activity levels. This is generally associated with an increase in their pain. Patients' pain levels will be determined by the complex interplay between tissue healing and increasing functional requirements.

Patients are frequently provided with a limited amount of combined opioid and non-opioid analgesic preparations (e.g. Percocet®, Vicodin®, Darvocet®, Tylenol#3®). Some patients are provided solely with nonsteroidal anti-inflammatory drugs. While this may suffice for some patients, there are those for whom the associated pain relief is grossly inadequate. I strongly believe in early anti-nociceptive treatment to prevent the amplification of pain immediately entering the rehabilitation phase of care. Analgesics can always be reduced. Once inadequate analgesia allows a pernicious pain cycle to be established, restoring patient comfort and confidence can be extremely difficult. Patients' investment in the rehabilitation process is weakened, as is their belief in their chances of meaningful, symptom-free recovery. To avoid this unfortunate chain of events, I utilized controlled-release opioid preparations combined with liberal access to "as needed" immediate-release opioids for episodes of uncontrolled pain. At times, I incorporate adjuvant and non-opioid analgesics for patients who achieve inadequate pain relief with opioids alone.
Pain.com: How are orthopaedic patients typically educated and treated for their pain pre- and post- anesthesia care?

Dr Peroutka: In my practice, patients are educated about the types of pre-emptive, intra-operative, and post-operative pain management modalities utilized for total knee arthroplasty patients. I think it is imperative for the patient to know that his or her pain management will be addressed in a multimodal approached. I typically prescribe a COX-2 (non-steroidal cyclooxygenase-2) inhibitor to be started 2 to 3 days pre-op. Intra-operatively; all patients have the incision site injected with a local anesthetic (typically 0.5% plain bupivacaine) prior to the incision. Care is taken to handle the tissues gently, thereby keeping inflammation and swelling to a minimum. The incision is again injected with the local anesthetic once the incision is closed. Ice is used as an adjuvant to reduce swelling post-op. Patients who undergo the procedure with epidural anesthesia typically have an indwelling epidural catheter that is used to provide analgesia for the first 24 - 48 hours post-op. If general or spinal anesthesia is used, Patient-Controlled Analgesia (PCA) or IV/IM analgesia is utilized. Once parenteral analgesia is discontinued, the patient is typically given controlled-release Oxycodone q 12 hours, with immediate-release Oxycodone po q 4 hours as needed for breakthrough or incident pain. These oral opioids are continued when the patient is discharged. Physical therapy modalities are continued as an outpatient.
Pain.com: What are typical acute pain management nursing responsibilities for treating pain in this procedural process and are there any helpful hints that you can provide for ensuring quality patient care?

Ms Dunwoody: Frequent pain assessment begins in the Post Anesthesia Care Unit and continues throughout the patient's hospitalization. The single most reliable indicator of the existence and intensity of pain is the patient's self report (McCaffery and Pasero in PAIN: Clinical Manual, Mosby: 1999, p.40). Use of pain rating scales has become widespread and the JCAHO Pain Standards have brought needed attention to the assessment and management of pain. The attitudes and beliefs of patients and nurses have a profound influence on pain management. Both may believe that post-operative pain is an expected outcome, when, in fact, tolerable discomfort is an achievable goal. It may be useful to consider pain as a preventable complication, as we consider deep vein thrombosis, pneumonia, and infection. Changing our priority to preventing pain rather than treating pain PRN after it becomes intolerable, in other words, staying "ahead" of the pain is an important nursing responsibility.

Nursing responsibility includes completing a head-to-toe patient assessment at the beginning of every shift. This is often based on a systems review. An element of a systems review is the brief pain assessment that includes location, severity, quality, aggravating and alleviating factors. Discussing pain with the patient at the beginning of the shift affords the opportunity to set comfort goals, e.g. the degree of pain relief needed to facilitate participation in physical and occupational therapy sessions. Assuring a smooth transition from one pain management modality to another is also an important nursing responsibility. All too often, consideration is not given to the patient's opioid requirement when switching from intravenous Patient-Controlled Analgesia (PCA) to oral analgesics. It is important that physicians have easy access to medication administration records with accurate documentation so that equianalgesic doses can be prescribed. When switching from epidural analgesia or regional anesthesia infusions to oral analgesics, it is important to administer oral analgesics before the patient experiences pain.
Pain.com: Referring to your TKA study, can you provide us with a brief synopsis of your study and the conclusions drawn from the analysis? ("A Randomized Trial of Controlled-Release Oxycodone During Inpatient Rehabilitation Following Unilateral Total Knee Arthroplasty" Journal of Bone and Joint Surgery, April 2001; 83A (4) 572-76)

Dr Cheville: The study was intended to determine whether proactive and more intensive use of opioid analgesia could impact functional recovery following total knee arthroplasty. We chose to provide the "study" group with a controlled-release opioid preparation, believing that this would be the most reliable and effective way of delivering higher opioid doses. Fifty-nine total knee arthroplasty patients undergoing inpatient rehabilitation were randomized to receive controlled-release Oxycodone or placebo. Both groups had access to "as needed" immediate-release Oxycodone every four hours. The starting dose of the study medication (controlled-release Oxycodone) was 20 mg. in the morning and 10 mg. in the evening. Assuming that this arbitrarily chosen dose would not suffice for all patients we embarked on a blinded upward titration. The maximal dose of controlled-release Oxycodone in the study was 30 mg. twice per day. In additional to recording patients' visual analogue pain scores, numerous functional measures were collected. An identical panel of outcome measures was obtained on the first and the eighth day of physical therapy. Functional outcomes were of primary interest in this study. We wanted to determine whether patients who received more liberal doses of opioid would realize their functional goals at an accelerated rate. The results of the study were extremely straightforward. The patients who received controlled-release Oxycodone recovered passive and active knee range of motion, quadriceps strength, and ambulation velocity faster than patients who received placebo and PRN analgesics. Functional Independence Measure (FIM) scores demonstrated a trend towards improved function in the controlled-release Oxycodone group with respect to transfers (moving from laying down to sitting and sitting to standing) and ambulation. The intergroup difference did not reach statistical significance. However, FIM scores for stair climbing were dramatically different favoring the controlled-release Oxycodone group. Stair climbing is very important. If a patient has to mount stairs to enter their dwelling from the street, or if their only bathroom is on the second floor, they cannot be safely discharged home until they can negotiate stairs. The significant inter-group difference in stair climbing ability may explain why the average rehabilitation hospital length of stay for subjects who received controlled-release Oxycodone was 2.3 days shorter than for those subjects who received placebo.
Pain.com: What are your thoughts about the study and its conclusions?

Dr Peroutka: I think Dr. Cheville's study is an important paper that supports the use of fixed-interval dosing of opioids in the immediate post-op period. Dr. Cheville's study clearly documents that patients with fixed-interval dosing have more effective pain relief than patients with PRN dosing. The end result is improved rehabilitation as documented by superior range-of-motion of the knees and decreased inpatient rehabilitation hospitalization days.

Ms Dunwoody: I have been a member of the pain service team for 11 years and worked as a head nurse and clinical instructor in orthopaedics for 16 years previously. My years in orthopaedics taught me that PRN dosing schedules provided inadequate analgesia. The introduction of Patient-Controlled Analgesia (PCA) improved pain management but PRN schedules were adopted when PCA was discontinued so the problem persisted. As the science of pain management grew in the 80s, it became apparent that around-the-clock dosing schedules improved patient outcomes. However, it was necessary to awaken patients at night and nurses were often loathe to awaken a sleeping patient to give an analgesic, believing that a sleeping patient is a pain-free patient. The introduction of sustained-release formulations solved the problem but research was needed to prove efficacy. This study gave credence to our belief that maintaining relatively constant serum opioid levels throughout the 24- hour period benefited the patient in many ways. Not only could they participate in therapy sessions more successfully, they could sleep at night without interruption. The study also stresses the necessity for rapid titration; a concept accepted in cancer care but not widely accepted in orthopaedic and rehabilitation settings.
Pain.com: Please list and comment on some of the barriers encountered for using oral opioids to manage pain.

Dr Cheville: Many patients are misinformed regarding the risk of addiction associated with the use of these medicines and under-dose themselves despite the encouragement of their caretakers to utilize their analgesics in an anticipatory and proactive fashion. Conversely, many patients receive tacit and overt discouragement from their treating physicians from relying too heavily on their opioid analgesics. Whether the concern over opioid addiction comes from patients or clinicians, it can be a tremendous barrier to the delivery of appropriate analgesia.

There is also concern from rehabilitation physicians that untenable opioid side effects (e.g. nausea and somnolence) will interfere with the rehabilitation process. Interestingly, neither of these was noted in our study patients who received controlled release Oxycodone.
Pain.com: Are some of these barriers listed by Dr. Cheville commonly encountered by you and your peers, and are there any suggestions you can make to address them positively?

Dr Peroutka: I think the barriers to using oral opioids to manage pain can be separated into two general categories: objective adverse effects and subjective adverse effects.

The objective adverse effects encompass physical manifestations such as constipation, nausea, itching, and other common opioid side effects that need to be aggressively managed.

The subjective adverse effects are the patient's concern and fear about drug dependence or addiction, as well as the physician's similar concerns. The subjective barriers are easily addressed by education of the patient as well as the physician.
Pain.com: What do you do in your practice to overcome these and other barriers?

Ms Dunwoody: The importance of patient education cannot be overestimated. Patients and their loved ones are more concerned now than ever before about addiction. Teaching about the appropriateness of using opioids for post-operative pain control should begin with the first patient assessment. Assessment elements such as medication use, previous experience with pain control, current pain management strategies, patient expectations, and whether there is a history of substance abuse provide the opportunity to begin teaching early. At UPMC-Presbyterian, a Certified Registered Nurse Practitioner (CRNP) often completes the History and Physical during the preoperative testing phase of care. The CRNP discusses post-operative pain control with the patient and provides printed information about pain and its assessment, Patient-Controlled Analgesia (PCA), and epidural analgesia, giving the patient the opportunity to become familiar with the information before the day of surgery. Post-operative patient satisfaction surveys have revealed that our patients want to participate in decision-making about post-operative pain control so we are attempting to introduce patient education materials at a time when they can process the information, rather than immediately before surgery.

The term "narcotic" is value laden and frightening to patients. Using terms such as "pain reliever", "pain medication", "analgesic", or "opioid" are less likely to cause anxiety in patients who fear addiction.
Pain.com: What are the advantages and disadvantages of using immediate-release opioids compared to using controlled-release opioids during the rehabilitative stage?

Dr Cheville: Ideally, immediate- and controlled-release opioids should be utilized in concert. Immediate-release preparations have the advantage of abruptly increasing the serum opioid concentration. They offer the most effective means of alleviating pain that is spiraling out of control or engendering a crisis. Many patients feel confident knowing they have access to immediate-release opioid preparations should their pain escalate. Two drawbacks of immediate-release preparations include the transient establishment of supra-therapeutic opioid serum levels and their brief duration of action (roughly four hours for most commercially available formulations). Sole reliance on immediate-release opioids can lead to widely fluctuating serum levels with patients alternating between unnecessary side effects and inadequate pain relief. Additionally, there are frequently, delays in the provision of immediate-release opioids. Many patients wait until their pain has become moderate to severe before requesting an "as needed" immediate-release opioid. Once requested, significant time may elapse before the patient is provided with the medication. An additional 45 minutes is required for enteral absorption before therapeutic serum levels are achieved. Too often, by the time patients experience relief, their pain has increased to a level that interferes with function and engenders anxiety.

Immediate-release preparations are commonly used to control increased nociception during physical and occupational therapy. Unfortunately, scheduling inconsistencies and transport delays may prevent the coordinated delivery of therapy when opioid serum levels are optimal.

Controlled-release opioid preparations offer the tremendous advantage of establishing a relatively steady serum opioid level. They are dosed on a round-the-clock schedule that is far less vulnerable to patients' reluctance to request analgesics and staffing restrictions. With better ongoing pain relief, patients are encouraged to ambulate, perform functional transfers and range their limbs outside of formal therapy sessions. This contributes to accelerated recovery of independent mobility and self-care.
Pain.com: How have you used oral opioids for pain management in your practice?

Dr Peroutka: I use oral opioids for the management of moderate to severe pain in both the pre-op and post-op setting.
Pain.com: How should the pain management and rehabilitative teams (group/dept) interact with patients who are past opioid users (e.g., sickle cell) versus non-opioid users?

Ms Dunwoody: Recognition of opioid tolerance is crucial to successful post-operative pain management; regardless of which modality is employed. Every patient deserves pain relief, whether tolerance is due to prescribed medication or unauthorized use. Our Perioperative and Trauma Pain Service is frequently consulted for poorly managed post-operative pain in patients whose pre-operative opioid tolerance has not been considered. To prevent this, we have developed an algorithm that is printed on the back of the PCA order form to guide physicians in PCA prescribing when opioid tolerance is present. As pain decreases in the post-operative period, appropriate tapering schedules can be used to prevent abstinence syndrome. If chronic opioid therapy has been prescribed for a problem not corrected by the surgery, previous dosing schedules must be maintained with additional opioid available to manage post-operative pain. When substance abuse is present, consultation with an addictions specialist may be necessary.
Pain.com: Our medical health system is under extreme economic and productivity pressures to reduce or hold down health care expense; describe how the results of your study may address these pressures?

Dr Cheville: In rehabilitation medicine, over the past decade, we have experienced increasing pressure to limit hospital lengths of stay. This phenomenon is also affecting acute care facilities. Patients are arriving at rehabilitation hospitals much sooner after their surgeries. As a consequence, many have greater levels of pain, medical morbidity, and functional impairment. In the absence of effective pain management, the challenge of reaching necessary functional goals prior to discharge becomes formidable.

Our study demonstrated that the use of controlled-release Oxycodone both reduced pain intensity and enabled patients to achieve functional milestones more quickly following total knee arthroplasty. The patients who received controlled-release Oxycodone were discharged from the hospital an average of 2.3 days sooner than the patients who relied exclusively on "as needed," immediate-release Oxycodone. The study strongly suggests that controlled-release opioid preparations can serve the needs of both patients and third party payers. By enabling patients to recover their preoperative functional status more quickly, they can be safely discharged to home sooner. Rehabilitation services can be utilized more effectively and economically.
Pain.com: What other considerations should be evaluated to counteract the rising economic pressures in the orthopaedic setting?

Dr Peroutka: Consideration must be given to the most efficient and economic treatment of patients, but always with the patient's safety and efficacy of the patient's treatment kept in mind. We must remember not to be penny-wise and dollar-foolish. Oftentimes, the increased cost of good pain management and rehabilitation in the early post-operative period results in less spending in the long run on prolonged services.
Pain.com: Describe some of the physical and emotional problems that post surgical orthopaedic patients encounter during the rehabilitative phase of recovery?

Dr Cheville: During the rehabilitative phase of recovery, patients are struggling to regain or improve their preoperative functional status. Those patients for whom a structural problem has been surgically resolved (e.g., those undergoing a knee or hip replacement or a laminectomy for spinal stenosis) often hope that their functional status will improve significantly following surgery. The rehabilitative phase is a make or break window of time for realizing functional goals. If an arthroplasty patient's knee cannot be aggressively ranged during rehabilitation, they may never recover full range of motion. This will adversely impact their mobility indefinitely. Physical and occupational therapists endeavor to develop new, adaptive biomechanical patterns in their patients. These apply to ambulation, as well as the performance of self-care, vocational and avocational activities. Uncontrolled pain can render this effort impossible. Patients may forever reap the unfortunate consequences of incomplete functional recovery. An interesting study demonstrated the persistence of abnormal gait patterns six months following total knee arthroplasty in those patients with poorly controlled pain following surgery. This study suggests that inadequate pain control may severely undermine patients' recovery of adaptive, functional movement patterns.

The emotional status of orthopaedic surgical patients can be understandably labile. Pain plays a pivotal role in engendering anxiety and dysphoria during the rehabilitative phase of recovery. Often patients have negotiated high levels of pain preoperatively. Many, feeling ambivalent about surgery, wait until their symptoms become intolerable before agreeing to operative management. For this reason, a high percentage of patients have developed avoidant and antalgic movement patterns. Relinquishing these dysfunctional patterns in favor of more adaptive ones can be threatening if pain is inadequately controlled. If patients lack confidence that their pain can be reliably alleviated, they may withdraw emotionally into fear and mistrust.
Pain.com: : How does the surgeon provide positive support when patients experience moderate physical and emotional problems during their rehabilitation period in the hospital?

Dr Peroutka: It is the surgeon's duty to provide the long term perspective to each patient in terms of the amount and type of pain to be expected, the time course of improvement with therapy, and the time of expected return to normal or near-normal activities of daily living. Patients should be reminded frequently that it takes time to recover. A little reassurance to the patient can go a long way in making that patient feel more comfortable about his or her post-op course, and to be realistic in his or her expectations.
Pain.com: Can you provide an example of how the acute pain clinician can add to the positive support of this rehabilitation process?

Ms Dunwoody: Unrelieved pain often produces anxiety. When the patient is anxious and in pain, it may be difficult to determine which problem to treat. When two changes are made at the same time, e.g. increasing the pain medication and introducing an anxiolytic, and the patient improves, one can' determine what caused the problem. I have learned to treat pain first, usually by titrating intravenous opioid doses until pain levels decrease. Often, anxiety decreases as pain relief improves. If pain decreases and the patient continues to be anxious, introduction of an anxiolytic is necessary. It is also important to stress the value of reviewing the patient' past medication history to determine if anxiety is due to withdrawal, e.g. the patient who has been prescribed a benzodiazepine preoperatively without a post-operative order.

As a member of the Perioperative Pain Service team, I've often been the person that patients turn to for emotional support, telling me about much more than their pain. I've concluded that this is because we consistently ask patients to tell us how they feel, accept what they tell us, and act on it. At some unconscious level, they probably know that we'll always listen!
Pain.com: Describe why providing controlled-release analgesics prior to rehabilitation served as a successful technique in your study?

Dr Cheville: The early use of controlled-release analgesics is a useful pain management strategy that can be applied to many different patient populations. The relationship between pain management and functional outcomes has received surprisingly little attention. Common sense dictates that patients with adequate pain control should participate more fully and vigorously in physical therapy. Yet, rigorous scrutiny has not been paid to strategies for optimizing pain control during the rehabilitation phase of postoperative recovery. We did not collect data on patients' activity levels outside of formal physical and occupational therapy sessions, nor did we assess mood. Therefore, discussion regarding the precise mechanisms for the superior performance of the subjects who received controlled-release Oxycodone must remain speculative. I strongly suspect that the early use of an analgesic afforded by the controlled-release opioid preparation at the start of rehabilitation enabled patients to remain more consistently active. This would positively impact their confidence and willingness to stress their newly replaced knees. Reduced anxiety and greater comfort with the rehabilitation process likely also contributed to their accelerated recovery.
Pain.com: As a supporter of using specific anti-nociceptive treatment, how does this study's interventional strategy influence postoperative care for TKA in the future?

Dr Peroutka: Anytime we can prevent pain from occurring, or prevent severe pain from occurring, the patient benefits. Dr. Cheville's study supports the use of fixed-interval dosing of oral opioids to decrease patients' pain and increase rehabilitation potential in patients who undergo total knee arthroplasty.
Pain.com: Based upon your own experience having a similar surgical procedure, can you comment on this interventional strategy?

Ms Dunwoody: In 2000, I was the recipient of bilateral unicondylar knee arthroplasties, 9 weeks apart, with the typical 4-5 inch total knee replacement incision. My analgesic plan included spinal anesthesia, epidural analgesia for <24 hours, sustained-release Oxycodone with immediate-release Oxycodone for breakthrough pain, and ketorolac. With each surgery, I experienced pain at 8 on a 0 to 10 scale in the Post Anesthesia Recovery Unit that was quickly eliminated with local anesthetic in my epidural. My pain score remained 0-3 throughout both hospitalizations and I never needed a breakthrough dose of Oxycodone. On one occasion, I called the nurse for my sustained release Oxycodone when the dose was 45 minutes late and I was beginning to feel discomfort. I am convinced that appropriate anti-nociceptive treatment and having utmost confidence in my surgeon were the keys to my success. My surgeon would add that patient motivation was an important factor, too.
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