Guest Post: Chronic Knee Pain after Knee Joint Replacement

There’s a great blog - healthskills.wordpress.com — that helps peo­ple with chron­ic pain help them­selves. It’s writ­ten insight­ful­ly and with lov­ing atten­tion by an occu­pa­tion­al ther­a­pist and psy­chol­o­gist in New Zealand — Bron­wyn Thomp­son.

Knee

She’s been kind enough to let me repub­lish one of her posts. It’s about the per­sis­tence of pain in some patients after they’ve had knee replace­ment surgery. What I appre­ci­ate about this arti­cle is that it illus­trates the nuanced, mul­ti­di­men­sion­al nature of pain and the individual’s response to health chal­lenges.

Here’s the article on persistent pain during total knee replacement rehabilitation:

I share an office with an Emer­i­tus Pro­fes­sor of Orthopaedic Surgery. He snort­ed at me one day, and showed me the stats from our nation­al joint reg­is­ter data­base where I saw that while the main rea­son giv­en for revi­sion of a total hip joint was dis­lo­ca­tion, and pain was the sixth most com­mon rea­son giv­en; in the case of revi­sion of knee joint replace­ments, per­sis­tent pain was the most com­mon rea­son giv­en.

Some stud­ies have shown between 6 – 30% of peo­ple receiv­ing total knee joint replace­ments have ongo­ing pain months after their imme­di­ate post-sur­gi­cal recov­ery. With knee joint replace­ment such a com­mon surgery for osteoarthrit­ic knees, and some reports of up to 33% of the adult pop­u­la­tion hav­ing OA of the knee, that’s a lot of peo­ple who con­tin­ue to have pain!

It’s not clear why some peo­ple go on to devel­op chron­ic pain after surgery, but some vul­ner­a­bil­i­ties include hav­ing had per­sis­tent pain in the past, hav­ing psy­choso­cial fac­tors present such as unhelp­ful beliefs (hurt = harm) or depres­sion, anx­i­ety or oth­er psy­chopathol­o­gy, and hav­ing oth­er unhelp­ful health habits such as smok­ing. It’s cer­tain­ly an aspect of post-sur­gi­cal pain that I’m inter­est­ed in because of the large num­ber of surg­eries that are per­formed – and the rel­a­tive­ly high rate of dis­sat­is­fac­tion with the out­come (one study esti­mat­ed 1 in five peo­ple were not hap­py with the out­come, and sat­is­fac­tion with pain relief var­ied from 72–86% and with func­tion from 70–84% for spe­cif­ic activ­i­ties of dai­ly liv­ing, Bourne, Chesworth, Davis, Mahomed & Char­ron, 2010).

How well peo­ple accept, adapt to, or cope with per­sis­tent pain after a total knee replace­ment varies. In a study by Jef­fery, Wylde, Blom, and Hor­wood (2011) qual­i­ta­tive method­ol­o­gy was used to begin to under­stand how peo­ple live with pain when the ‘fix’ they were hop­ing for doesn’t work out as well as they want­ed.

These par­tic­i­pants were recruit­ed 12 months after TKJR, a pro­ce­dure they’d had in the UK’s Nation­al Health Ser­vice. They all report­ed mod­er­ate to severe pain (as part of anoth­er research study), and had not had revi­sion surgery. Because of the method­ol­o­gy employed, quite a small group of par­tic­i­pants were inter­viewed (a total of 28 were inter­viewed until ‘data sat­u­ra­tion’). Data sat­u­ra­tion, in this case, occurred when inter­view tran­scripts had been cod­ed using the­mat­ic analy­sis, and no new codes emerged. (The­mat­ic analy­sis has some sim­i­lar­i­ties with ground­ed the­o­ry, btw, but dif­fers in that isn’t a com­plete method­ol­o­gy)

Cut­ting to the chase, sev­er­al themes emerged from this analy­sis:

  • The degree of accep­tance or adjust­ment to ongo­ing pain wasn’t relat­ed to the degree of pain expe­ri­enced
  • Adjust­ment or accep­tance depend­ed on var­i­ous fac­tors includ­ing whether they were bet­ter, or worse off since surgery, as well as the input pre- and post-surgery by the sur­geon
  • Par­tic­i­pants report­ed they felt aban­doned by sur­geons – and dis­cussed the kinds of sup­port they would have liked

It’s impor­tant not to over-inter­pret the find­ings from this study, but I did think it inter­est­ing that about half of the respon­dents didn’t appear over­ly con­cerned about their pain – the authors of the study thought this indi­cat­ed accep­tance. These par­tic­i­pants said things like

…it’s just a case of you’ve got­ta face up to it and you’ve got­ta get on with life and you’ve got­ta accept it” (John, age 74 years).

…Once again, it’s part of my life, you know, I just don’t, I don’t think about it much…” (Phyl­lis, age 81 years).

The oth­er half of the par­tic­i­pants were not as accept­ing, and said things like

Depressed, total­ly depressed, sad, mis­er­able, charred off, all the things that go with that that you can think of” (Den­nis, age 59 years).

… I just don’t know what to do with it.… I was in so much pain I said to my hus­band, and it’s only him I’d tell, I wouldn’t tell the fam­i­ly, I said if I don’t do some­thing I shall, well I shall jump off the bridge” (Sal­ly, age 75 years).

The impor­tant point was made by the authors: the degree to which peo­ple accept­ed their pain was almost always relat­ed to “…indi­vid­u­als’ per­cep­tions of improve­ment or dete­ri­o­ra­tion in cir­cum­stances since their TKR. Those per­ceiv­ing an improve­ment in pain or func­tion­ing expressed lit­tle dis­tress and a more accept­ing atti­tude.”

One of the oth­er stud­ies I looked at while research­ing this post was a paper by Rid­dle, Wade, Jiranek and Kong (2010) which iden­ti­fied that pre-sur­gi­cal pain cat­a­strophis­ing pre­dict­ed post-sur­gi­cal pain out­comes.

I wasn’t sur­prised at this – it makes sense that some­one who cat­a­strophis­es is like­ly to (a) be pre­dis­posed to hav­ing an over-active amyg­dala which will influ­ence the way in which the whole sen­si­tive ner­vous sys­tem responds to a planned insult to the body and (b) also inter­pret post-oper­a­tive pain in an equal­ly alarmed way. This doesn’t bode well for post-sur­gi­cal recov­ery involv­ing mobil­is­ing on a painful and pos­si­bly swollen knee, and espe­cial­ly in any hos­pi­tal sys­tem that wants peo­ple dis­charged as soon as pos­si­ble so the bed can be avail­able for some­one else.

We need to be cau­tious, though, about the way the Rid­dle, et al., study is inter­pret­ed – con­clu­sions we can draw from many stud­ies such as the Bourne, et al., (2010), Jef­fery, et al., (2010), and many non-joint-replace­ment stud­ies on back pain and dis­abil­i­ty show that it’s the dis­tress, or how well the per­son adjusts to hav­ing ongo­ing pain, and the impact that this has on func­tion, treat­ment seek­ing and well-being in gen­er­al, not the pain inten­si­ty that seems to mat­ter.

Return­ing to the Jef­frey, et al. (2011) study, presur­gi­cal prepa­ra­tion by the sur­geon seemed to play an impor­tant role in how well peo­ple accept­ed ongo­ing pain. Those that had been advised that pain is like­ly seemed to view pain as nor­mal, and were there­fore more able view the pain as able to be tol­er­at­ed.

Where am I going with this? The main points I want to make are these:

  • post-TKJR pain is com­mon, with up to 30% of peo­ple con­tin­u­ing to have pain for 12 months after surgery
  • per­sis­tent pain is the most com­mon rea­son for revi­sion of TKJR
  • the degree of pain is not direct­ly relat­ed to dis­tress or func­tion
  • there are sev­er­al vul­ner­a­bil­i­ty fac­tors that can be iden­ti­fied before surgery that are cor­re­lat­ed with post-sur­gi­cal pain
  • at least some of these fac­tors can be addressed before surgery, while how we respond imme­di­ate­ly after surgery can also have an impact

Maybe one of the best ways we can help peo­ple cope is to inform peo­ple pri­or to surgery that per­sis­tent pain after­wards is com­mon, there­fore not an indi­ca­tor of some­thing awful — then after surgery, give peo­ple with risk fac­tors such as cat­a­strophis­ing, health anx­i­ety, dis­tress, low mood and lim­it­ed social resources ade­quate and appro­pri­ate chron­ic pain self man­age­ment soon­er rather than lat­er.

And per­haps sur­geons could remem­ber that surgery is not a quick fix for up to one third of their knee joint replace­ment patients.

Bourne, R. B., Chesworth, B. M., Davis, A. M., Mahomed, N. N., & Char­ron, K. D. (2010). Patient sat­is­fac­tion after total knee arthro­plas­ty: who is sat­is­fied and who is not? Clin­i­cal Orthopaedics & Relat­ed Research, 468(1), 57–63.

Jef­fery, A., Wylde, V., Blom, A., & Hor­wood, J. (2011). “It’s there and I’m stuck with it”: Patients’ expe­ri­ences of chron­ic pain fol­low­ing total knee replace­ment surgery Arthri­tis Care & Research, 63 (2), 286–292 DOI: 10.1002/acr.20360

Rid­dle, D. L., Wade, J. B., Jiranek, W. A., & Kong, X. (2010). Pre­op­er­a­tive pain cat­a­stro­phiz­ing pre­dicts pain out­come after knee arthro­plas­ty. Clin­i­cal Orthopaedics & Relat­ed Research, 468(3), 798–806.

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About Ronald Lavine, D.C.

Dr. Lavine has more than thirty years' experience helping patients alleviate pain and restore health using diverse, scientifically-based manual therapy and therapeutic exercise and alignment methods.

His website, askdrlavine.com, provides more information about his approach.

Please contact him at drlavine@yourbodyofknowledge.com or at 212-400-9663.

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