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.

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.

_____________________________________________________________

Deepen Your Body of Knowledge

Hip or Knee Replacement?  Not So Fast

Knee replacement is not for everyone