Knee replacement can be extremely painful. Previously, opioids or narcotics were administered for pain relief. But excessive addition of opioids is not exactly effective for controlling pain. 

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.

Multimodal denotes administering two or more than two types of medications that work with different mechanisms. The following are the techniques used:

Pre-operative Femoral Nerve Block: Prior to the surgery, a catheter is placed beside the femoral nerve for blocking it. This nerve is located in the upper thigh. Medication is delivered through the catheter for the nerve to be numbed for 24 hours. Thus, pain signals to the brain are blocked. This method reduces the use of narcotics and the consequent side effects.

Patient Controlled Analgesia (PCA): This method is also known as  Pain Pump . An intravenous pump is used to administer pain relief medications, such as oxymorphone or morphine, after the surgery. The control button of the machine could be pressed, by the patient for 6 to 10 times per hour. The machine is used for two post-operative days.

Oral Medications: The oral medications include Non-Steroidal Anti-Inflammatory drugs or NSAID; such as Celebrex which is similar to aspirin, structurally. Alternatively, acetaminophen, such as Tylenol or its equivalent composition, can also be used.

Acetaminophen: It acts on the Central Prostaglandin Synthesis and relieves the patient of pain through multiple mechanisms.

Epidural Analgesia: It produces lower pain scores and involves less time for achieving physical therapy goals. However, this is subject to side effects such as dizziness, urinary retention and itchiness.

Gabapentinoids: These medications include membrane stabilizers such as Gabapentin and Pregabalin.

The objective of multimodal treatments is to provide quick relief to the patient and immediately so. Earlier the rehabilitation, more successful will be the knee replacement surgery.

Multimodal Pain Relief After Total Knee Replacement

Knee pain is something that can affect anyone - irrespective of their age. While sometimes it may be of minor importance - and can easily be handled by self-care, often, lingering pain is a manifestation of some other serious underlying problem, such as arthritis. In this case, it is imperative that you consult a doctor and take appropriate measures to combat it.

Causes :

Arthritis: The chief cause of lingering knee pain, arthritis itself can be of a number of types:
 Osteoarthritis, which is a result of deterioration of cartilages due to wear and tear
 Rheumatoid Arthritis, an inflammatory chronic disorder
 Septic Arthritis, causing pain, swelling and redness.
 Gout caused due to the development of uric acid crystals in the joints
Fractures: These are caused by the breaking up of the kneecap due to falls or collisions.
ACL Injuries: Caused due to the tearing of the anterior cruciate ligament (that connects the femur and the shinbone). Especially common in sportspersons such as footballers or basketball players.
Meniscus tears: The meniscus or the rubber-like cartilage (that acts as a shock absorber) can be torn by sudden jerks or excess pressure.

Symptoms:The major symptoms of knee pain include weakness, redness, instability, stiffness or the inability to properly straighten or move the leg. Often, a deformity is also visible, such as a bone sticking out of the leg - in which case it is advisable to consult a doctor immediately.

Possible risks :Factors which include the odds of being inflicted by knee pain and cause serious complications include :
Being overweight: This exponentially increases the stress or pressure that is applied on the knee joints - even in doing mundane tasks like walking up and down stairs.
Excessive physical activity: Some activities, such as sports apply excess stress on the knees as compared to other tasks.
Loss of muscle flexibility: Tightness or weakness in muscles causes increasing number of problems in the knees.

All About Knee Pain

Why does PAIN occur? Understand the Mechanism of Pain

Pain is an unpleasant and distressing physical sensation caused by disease or injury, which induces hurt and anxiety in those suffering from it.
There are many different manifestations of pain, ranging from short term (acute pain) to long term (chronic pain). Other classifications include pain in the internal organs (visceral pain), injured tissue (inflammatory pain), nerves (neuropathic pain), etc.

The reason for the occurrence of pain depends on the cause and kind of pain being experienced. In most cases, pain acts as a warning sign that the body has been afflicted by a disorder of some sort, which may have arisen due to internal sickness or external wounding. Acute pains are generally cured on their own through rest or simple medication. Chronic pains, on the other hand, are more complicated in nature and the treatment requires more elaborate diagnosis.

The mechanism of pain

Pain is an extremely personal and subjective experience and affects each individual to varying degrees. The pain signals, which can arise in any part of the body, travel through the spinal cord to the brain along thousands of specialized nerves and nerve fibres. In the brain, it is processed in the centres associated with anxiety, emotions, memory, appetite, etc. Signals and pain inputs are then returned from the brain to the spinal cord, which may heighten or diminish pain.

In some cases, pain may also be induced by damage to the brain and spinal cord, which happens after a stroke.
A constant barrage of pain signals may cause the cells at the end of nerve fibres to become over-sensitized. This is known as 'wind-up' and is one of the most common causes of chronic pain that occurs even though the root of the problem has been identified and treated.

The causes and effects of pain differ from case to case depending on the signals received by the brain and its interpretation. It affects the individual's day to day activities and if persistent, can also have a harmful impact on mental health and psychosis. Pain is always handled, diagnosed and treated differently in all patients by drawing out the best possible solution to the problem.





Why does PAIN occur? Understand the Mechanism of Pain

Ayurveda is a very old system of medicine, which originated in India. Using herbs found in nature to cure various illnesses, knee pain can also be permanently cured with this method indigenous to India. It reduces knee pain caused by various illnesses including arthritis, inflammation of the cartilage and wearing of the patella among others. Here are some common Ayurvedic remedies, which help reduce knee pain:

1. Alfalfa: Alfalfa is medically known as Medicago Sativa. Alfalfa is excellent for making sure that your joint pain reduces, when taken in liquid form four times a day.

2. Ashwagandha: Ashwagandha is medically known as Withania Somnifera. In the West, Ashwagandha is popularly known as Winter Cherry. Also, it has a lot of therapeutic properties, which include reducing joint pains. 

3. Banyan: The Banyan tree's medical name is Ficus Benghalensis. It has a sap very similar to the form of rubber known as latex is derived from the Banyan tree. The Banyan tree's sap is externally applied over the joints and the pain usually disappears after a few regular applications. 

4. Bishop's weed: The medical name for Bishop's weed is Trachyspermum Ammi. The oil extracted from this herb is usually applied to the knees to reduce the intensity of such knee pains.

5. Celery: The medical name for celery is Apium Graveolens. Celery is not only an effective treatment for rheumatoid arthritis and associated pains in the knees, but it is also helpful in treating gout. It is usually agreed upon that this particular treatment is usually long lasting because of its alkaline nature.

6. Dandelion: Dandelion's biological name is Taraxacum Officinale. It is rich in magnesium and is crucial for the correct mineralization of the bones. This mineralization allows the bones to become stronger and also prevents knee pain.

7.  Garlic: The medical name for garlic is allium sativum. Five to six cloves eaten everyday has proved to reduce knee pains.

8. Ginger: Ginger is biologically called Zingiber Officinale. These can be easily included in your diet and go a long way in curbing knee pain.

Ayurveda and Knee Pain

Knee is a hinge joint where the lower leg bone tibia meets the thigh bone femur. During osteoarthritis, cartilage or ligament defects and degenerative arthritis, knee replacement surgery is recommended world-wide to get relief from extreme pain. Knee replacement surgery, also known as knee arthroscopy, is a surgical procedure, in which the affected knee joint is replaced with synthetic material. The most likely candidates for total knee replacement are the patients with severe destruction of the knee joint coupled with progressive pain and impaired function.

Modern technological advances have made computer assisted knee replacement surgery extremely popular around the globe. In this surgery, the surgeon is assisted by a computer to remove the optimum amount and angle of the bone, which otherwise is done by inspecting manually. This is an excellent example of surgery through small incision and it eliminates the chances of human error. A perfect alignment and balance is achieved and hence longevity is also increased to 20 - 30 years. Knee replacement surgery is also specific to gender as the anatomy of male and female patients is different.

There are many types of knee replacements, most common being the total knee replacement or Total Knee Arthroplasty. In addition, there is partial knee replacement, bilateral knee replacement, revision knee replacement and knee arthroscopy.

In knee replacement surgery, the worn out surfaces of joints of knee are replaced with artificial implant of plastic and metal. The lower end of the femur bone is removed and replaced with a metal shell. The upper end of the lower leg bone (tibia) is also removed and replaced with a channelled plastic implant with a metal stem. A plastic ball is also added under the kneecap depending on its condition. These artificial components are commonly referred as prosthesis. The design of these highly flexible implants replicate knee, with the rotating knee replacement implants assist in backward and forward swing of the legs.

Patients whose knee joints have been damaged by either trauma or progressive arthritis should consider total knee replacement surgery. Post-surgical hospital stay after knee joint replacement is usually three to five days. The surgery has a very high success rate and shows dramatic improvement after a month. This improvement is most notable one month or more after surgery. The pain caused by the damaged joint is reduced significantly when the new gliding surface is constructed during surgery. Initially, patient will walk with the help of a walking aid until the knee is able to support full body weight. After six weeks, patient can walk comfortably with minimal assistance. Patients with artificial joints are prescribed to take antibiotics during the course of any elective invasive procedures including dental work. Physiotherapy is an essential part of rehabilitation and it will increase the muscle strength and patient can enjoy most activities, except running and jumping.

Knee Replacement

Simple exercises for relief from knee pain

A lot of people suffer from knee pain, some hereditary, some due to injuries and some due to other reasons. Whatever be the reasons, the pain is very bothersome. 

Try the following exercises regularly to get relief from knee pain.

1. Leg lifts - sit straight on a chair with your feet firmly on the ground. Lift the leg for which the knee pains, until it is parallel to the ground. Hold for a couple of seconds and bring back to the initial position. Do 10 reps every day.

2. Knee bending - sit on a chair and keep a stool of same height as the chair in front of you. Place your knee on the stool, knee slightly bent. Slowly, straighten your leg and hold in the straight position for a couple of seconds before you release. Do 10 reps.

3. Leg straightening - stand straight and place the foot on a low platform. Bend down, place both your palms on the knee and slowly push it down until your leg is straight. Push only as far as it doesn't hurt too much. Hold for a few seconds and release.

4. Stretching - sit upright. Bring your leg towards your chest by bending the knee and keeping your hand above the ankle. Push your heel towards your buttocks. Release after a couple of seconds.

5. Chair pulling - stand straight near a door keeping your feet apart (shoulder-width), in front of a chair. Hold the knob of the door and slowly, sit back on the chair. Feel the pull in the muscles and go back to previous position after 2-3 seconds. Repeat.

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5 Only Exercises For Easy Relief From Knee Pain

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