Dr. Nicholas Frisch, an orthopedic surgeon who focuses on knee and hip replacement surgery at Ascension Crittendon Hospital in Rochester Michigan joined me on a podcast to talk about pre-hab (what patients need to know and do before they go in for elective surgery) and rehab (what they should do to get better quickly after the surgery).
Here’s what we talked about (transcription has been condensed and edited for readability):
Why pre-hab?
Pat: Nick, please explain the need for pre-hab.
Nick: Surgeons consider the day of surgery as Day Zero. Anything prior to that we consider a part of the pre-op or pre-hab period. People used to think you could just show up for surgery without any preparation but we now realize that a lot can be done on the front end to optimize the results of the surgery. That’s where a pre-hab program comes into play.
Pat: You use a platform called PeerWell to supplement the kind of preparatory advice and take-home materials that you give in your office. Can you tell us about the PeerWell platform, how you use it in and what its different components are?
Nick: Absolutely. In the past, a patient would come in for a pre-op medical clearance and then we would have a discussion about what’s going to happen during the surgery. That would take anywhere from ten to thirty minutes depending on what type of surgery you were having and what type of information was needed. We also gave out booklets with information and frequently asked questions to help you understand what to expect during surgery and what to do after surgery. Now, I recommend that patients use the PeerWell platform as part of their preparation for surgery as well. It is an app-based technology that’s easy to use and seamlessly integrates with my workflow. It provides patients with a variety of meaningful content at set intervals prior to surgery.
Pat: Please give us some examples of the content. Does it provide information about exercises to do before surgery or should I just leave that joint alone and wait for you to fix it?
Nick: The first thing I tell everybody is just because you’re having surgery, it shouldn’t change what you do on a daily basis. You want to be as active as you can within whatever amount of pain you’re in. We don’t want people to sign up for surgery and then lay in bed until they have the operation. The PeerWell app includes a series of exercises that don’t overstress the joints. It provides instructional videos to help you do those exercises safely. It’s mobile so you can do them anywhere. I encourage people to try them if they’re comfortable doing them. It’s a powerful pre-surgery tool to help patients stay in good condition and improve their ability to bounce back.
Pre-op nutrition
Pat: Does the app include any recommendations about what to eat in the pre-hab period so I can make sure my body is in as good of shape as possible before I undergo surgery?
Nick: There are certain fundamentals related to diet that are important for recovery from surgery including wound healing, soft tissue healing, overall wellness, and maintaining an appropriate energy level in the post-operative period. PeerWell includes some great modules about building a meal plan and avoiding certain foods like sodas and other things that aren’t healthy. It provides information in a basic enough way that most of my patients tell me that they learned something from the module.
Pat: One of the great things about digital health is that it can expand the care that you’re providing for patients. People often criticise doctors for not knowing much about nutrition but if they’re able to provide patients with a resource like PeerWell it far better than thinking everything has to happen at the doctor’s office or somehow be directly related to the doctor communication.
We know that it takes a team for people to get well and part of the team now is digital health. We also know that you can’t give people all this information at one time because no one can absorb it. Apps, like PeerWell, allow people to get information in smaller doses over time.
Mindfulness
Nick: The platform has lifestyle modules that address tobacco use and alcohol consumption. Another important component is the module on mindfulness. It includes things like dealing with anxiety, breathing, managing pain through mindful thought. I’ll be totally honest with you, when I first encountered those modules, I thought they were nice and well done. There was music, video, and some nice people who had very soothing voices, but I didn’t pay much attention to it. I just didn’t see that as something that I would personally use. But I have to tell you a story about one of my patients, an older lady who lived alone. She came to see me because she needed a hip replaced. After the operation, I checked in on her and found her lying in her hospital bed. She reached up and she grabbed my hand and she said “Oh my gosh, I am so at ease right now from these mindfulness exercises,” I had to step back and think about it because it was so long ago that I actually did the exercises and I had never paid much attention to them, but she loved them.
Surgeons usually don’t get to follow patients over time and often don’t get to develop great personal relationships with them. So some of the things that people value and benefit from might not be recognized without programs like this particularly ones that develop a comprehensive program. I don’t think everybody is going to get something out of each of these modules but I do think that everybody will get something out of the program and that’s where it brings such value.
Pat: We know that patients do better if they’re truly engaged in their own care and yet a lot of times they don’t really know how to do it. A program like this that could teach mindfulness, safe exercise, and other topics providing patients with tools to take control of their self-care. The fact that you prescribed it makes the app an important part of the total package of your relationship with the patient.
Home safety
Pat: PeerWell also has a new app to help make sure the home environment is safe when patients come home from the hospital. Can you talk about that?
Nick: This is critical. Yesterday I got a call from my assistant telling me one of my patients had fallen at home. I was supposed to do her knee replacement in three weeks but she fell at home and broke her shoulder after tripping on a rug. We now have to postpone her knee replacement until after her shoulder surgery. This illustrates how hazards in and around the home exist but we often desensitized to them. How many times had she walked over that rug without giving it a second thought?
After surgery you’re going to be taking medications, you’re going to be coming out of the hospital using different devices such as a cane or walker. Many the things around the house that might otherwise have gone unnoticed can pose a threat your health after surgery.
This where PeerWell has gone above and beyond and I think it is what’s going be a 
differentiating factor. They have created an augmented reality home hazard detection app. You open app guides you through your home as it uses your smartphone camera to look for hazards. Afterward, it creates a risk assessment report that describes things you need to do, such as “these cords need to be removed” or “this rug should be rolled out until after year you’re recovered from surgery.” That is not something I can physically do in the office but it is something that can affect care. Imagine if my patient had gone home and tripped on the rug after a knee replacement surgery. She could have broken her implant and that would have been devastating. I’m very excited about the potential of this app.
Pain
Pat: The last thing I want to ask you about is post-op pain control. What is PeerWell doing to help patients with pain?
Nick: Many surgeons, including myself, have been using a “multi-modal program” that uses a lot of different non-opioid medications to target the pain pathways proactively before patients actually get pain. PeerWell’s approach to pain fits nicely into this concept – it gives patients another way of preparing for pain before they have it. It involves mindfulness, understanding that you’re going to have pain, coming to terms with it and with the anxiety that’s associated with pain once you have it.
The app also provides information about different approaches to pain, for example, what is a nerve block? Or why is Tylenol (acetaminophen) being recommended? The latter is important because people hear the word Tylenol and think “oh, that’s what you give kids when they have a cold, right?” But Tylenol is actually a very powerful medication even though it is available over-the-counter. We use it as part of our multi-modal pain protocol. Educating people ahead of time about the various treatments fits nicely into our approach.
Pat: I fractured my shoulder a couple of years ago and turned down an opioid in favor of getting IV acetaminophen which took my pain down from about an eight to a one. I think part of the reason it worked so well for me was that I believed it could reduce severe pain because I had seen it work for my husband when he had severe back pain.
Nick: It is not about setting new expectations but redefining expectations. It sends a powerful message and resonates with patients throughout the whole spectrum of the process of having and recovering from surgery.
Post-op rehabilitation
Nick: PeerWell also provides help through the post-op rehabilitation stage as well. It builds a consistent message and I have found that my patients like that consistency. The more consistent the message, the more they respond to what you’re giving them in terms of content. That is very effective.
Pat: Does PeerWell take you through whatever rehab exercise home program that you may prescribe for them?
Nick: Yes, the program it doesn’t shut off once you have surgery. Instead, it changes to the rehabilitation component to help you get back to your normal activities. The exercises change right because there is a different process involved in gaining motion and strength and maintaining stability after surgery. This part of the PeerWell program is geared toward “OK, now you’ve had your surgery, your environment is safe, how are you going to maximize your outcome?”
Who pays for it?
Pat: I thought we would close our conversation by talking about some financial aspects, one of which is who pays for this, are patients having to pay for this, do you pay for it, how does the money flow when it comes to making sure that people can have access to this program.
Nick: I’m fortunate because I had started using the program very early on when the company was doing a lot of the development work. But to answer your question more generally, I think some physician offices may pay for the program themselves if that’s something that they’re capable of doing. We are taking more of a systems approach, engaging with Ascension, and saying this is the direction I’m going. We are developing a pre-op optimization clinic right now that will include a process for looking at the medical criteria for surgery and making sure that patients are optimized medically before surgery. I feel that this kind of technology fits very well into that process. Right now about half of the people on the committee to develop that clinic are going through the PeerWell program themselves to see exactly what that brings to the table.
Full disclosure
Pat: A final question, in the interest of full disclosure, is what your relationship with the company, are you a paid adviser or are you just an enthusiastic user?
Nick: I’m not a consultant, I don’t get paid, and I didn’t get any shares for free. I got introduced to the CEO and some of the management team of PeerWell when I was a resident at Henry Ford Hospital in Detroit. I started working with them as they were developing it. I was very involved in patient engagement and one of my interests in research has been looking at how to maximize the experience through the whole process of joint replacement surgery and look at it more from the patients perspective. I ended up investing in the company because I believe in the product. I’m just really amazed where they keep going with it.
Pat: Full disclosure on my part, I have no financial interest in the company but got a pitch from them about this story. I was very intrigued about the potential of the home hazards app to being able to identify hazards and wanted to be sure that people knew about the platform so they could ask their doctor about it if they’re not already offered it. Hopefully, it can help them have a better pre- and post-surgery experience as a result.
Thank you very much for joining us and sharing your experience with PeerWell.
Nick: Thank you so much Pat, it was a pleasure.