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

The knee is the largest joint in the human body and is a complex structure formed of bone, muscle and cartilage. Development of pain in the knees can be caused by numerous factors such as aging, injuries, diseases, dietary deficiencies, etc.

Arthritis is the most common cause of knee pain and usually affects the elderly and aged. It occurs due to an inflammation of the joint and causes pain, swelling, redness and inflexibility of the knees.

What are the factors that determine treatment method?

Diagnosis for knee pain varies from patient to patient as each case is different and must be approached differently. Some of the factors that determine the treatment method are as follows:

- Cause of the problem
- Nature and intensity of pain
- Age of the patient
- Medical history of the patient
- Diet and lifestyle of the patient

There are a number of different types of arthritis which can affect the knees in different ways and, consequently, require different types of treatment methods.

What are the various treatment methods for knee pain?

1. Conventional Remedies - These are used in case of conditions that are not too severe or chronic. It includes keeping on bed rest, using an ice pack, taking a painkiller and anti-inflammatory medicines, wearing knee braces, etc.

2. Physical Therapy - There are many stretching and strengthening exercise routines that help alleviate knee pain and treat the condition. Recovery is achieved by making the muscles around the knees stronger and increasing stability and flexibility.

3. Injections to the Knees - A number of anti-inflammatory substances and supplements, as well as lubricants, can be injected into the knee joint which helps reduce pain and makes the joint more supple.

4. Stem Cell Therapy - This involves drawing platelets from the patient's blood and injecting it into the knee joint for repairing damage caused to ligaments, tendons or cartilage.

5. Surgery - Surgical procedures for treating knee pain include partial or complete knee replacements.



What kind of treatment does your knee pain require?

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

Pain in the joints continues to bug mankind till this very day. There are different types of joint pains, which might occur all of a sudden, with no signs of receding. The most common of them all are arthritis, tennis elbow, frozen shoulder, back pain and repetitive muscular strain. These joint pains are sometimes impossible to diagnose properly by the regular modes of diagnosis. In those cases, resorting to the homeopathic mode of medication might be a good idea as it is a medication based on treating the actual cause of the disease and sustained use might result in complete remission of the pain.

Some commonly used homeopathic medications for pain in the joints are as follows:
1. Rhus Tox: This is the most commonly used in homeopathic preparation for severe joint pains, the symptoms of which include severe pain after relaxation, pain triggered by slightly wet weather and pain after walking or running for a long time.

2. Arnica Montana: When the symptoms are pain in every joint of the body resulting in body aches and pertaining injuries due to accidents, Arnica Montana serves as the perfect medication.

3. Actea Spicata: This medicine is primarily used as a remedy for pains in the small joints of the hands. The symptoms for which the medication can be implemented are rheumatoid arthritis in the joints of the finger and swollen wrists after usage of the hand.

4. Colchium: This medicine can be used in case of Rheumatoid Arthritis (inflammatory and chronic form of arthritis).

5. Bryonia Alba: This medication can work wonders if the symptoms include severe pain in the knee joints while walking, severe swollen joints and osteoarthritis (affects the flexible tissues present at the bone ends).

However, it is always advisable to take medication as prescribed by your doctor, as the potency and frequency can only be decided by your doctor.

Homeopathic Treatment for Pain in the Joints

Myths about Total Knee Replacement

Myth#1 - Knee replacement is a surgery for old people. “I’m too young for a knee replacement.”
Fact - Candidacy for a knee replacement is not based on age, but on the person’s level of pain and immobility. Living with a painful joint that prohibits you from working or participating in normal life activities is an outdated way of thinking. Age is not necessarily a limiting factor. Often times, a patient is actually fearful about the uncertainty of surgery. Once they are able to resume many of the activities they enjoyed before the surgery, with increased mobility and with less pain, they are very happy they had the surgery. The quality of life one achieves by living without knee pain is priceless.

Myth#2 - “I should wait as long as possible to undergo knee replacement surgery” 
Fact - You don't need to suffer by waiting until the pain is intolerable. The longer life of joint replacements enables people to consider surgery earlier and at a younger age. Osteoarthritis is a degenerative disease that continues to damage the joint and delaying surgery makes both surgery and return to activity more difficult. Delaying surgery lowers a patients’ quality of life not only before the operation, but even for up to two years following surgery.

Myth#3 - “I should continue with medications as long as possible”
Fact - Medicines including painkillers just give symptomatic relief for a temporary duration and prolonged usage is riddled with serious side effects such as renal failure, peptic ulceration  etc. All these medicines are NOT curable.

Myth#4 - Alternative therapies such as acupressure, ozone treatment, massage beds, oils, laser therapy, magnetic therapy; braces will cure my advanced arthritis and knee pain.
Fact - Till date there is NO cure for advanced knee arthritis and these alternate therapies are not backed by established scientific data. All these modalities give temporary pain relief in early to moderate arthritis for some duration only and are NOT curative. Often times, a patient who is actually fearful about the uncertainty of surgery lands up trying these in order to avoid surgery. 

Myth#5 - After a knee replacement, it takes months to recover.
Fact - Depending on the activity, most patients who undergo knee replacement are able to perform routine tasks within a few weeks. A return to rigorous activity takes only a few months. One becomes independent for himself before discharge from hospital. There’s no prolonged best rest required after the surgery.


Myth#6 - After knee replacement, I’ll have to give up some activities and sports.
Fact - You have a high probability of getting back to activities like brisk walking or cycling in 6 to 12 weeks. It will take a bit longer to return to more rigorous activities and contact sports. Squatting and sitting cross legged though possible but at best should be kept to minimal.

Myth#7 - Knee replacement surgery leaves a large scar that is noticeable.
Fact - Scarring is minimal compared to traditional surgery. In fact, the scar is typically only 3 to 5 inches long. As time passes, the scar will fade and become less noticeable.

Myth#8 - Knee replacement is a very painful surgery. There is lots of pain in post operative period.
Fact - With modern day pain management such as in a multimodal approach, ensures that the patient does not feel any pain in post op period and has a smooth recovery.

Myth#9 - Knee replacement is done one at a time.
Fact - Both the knees can be operated at the same time if the patient does not have significant co morbidities and is deemed fit to undergo the procedure by the doctor.

Myth#10 - The new knee lasts for 5-6 yrs. only.
Fact - With modern day precision including computer assisted knee replacement and advancement in biomaterials, the survivorship has increased considerably. Today's joint replacements last 25 years or longer and, for most people, will last a lifetime.

Myth#11 - Knee replacement cannot be done a second time.
Fact - Knee replacement can be done multiple times what is called as a revision joint replacement surgery with good survivorship.

Myth#12 - “I am obese, I cannot undergo Knee replacement surgery.”
Fact - Knee replacement can be successfully done in an obese patient though the recovery is somewhat prolonged and might require additional implants. However, patients who are morbidly obese and have restricted mobility primarily due to obesity are better off after a bariatric procedure.

Myth#13 “I have diabetes or hypertension or heart ailment, so  I cannot undergo Knee replacement surgery.”
Fact  - diabetes hypertension or heart.



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 13 Myths About Total Knee Replacement (TKR), Busted!

Your knee is a very complex structure consisting of bones, ligaments, cartilage, tendons, muscles and meniscus. Most people encounter knee pain at some point in their lives. If your knee pain is chronic in nature, then it may last for a prolonged period.

Many causes may be responsible for your knee pain. Some of the causes are stated as follows:
1. Your knee is very much prone to injuries. Knee injuries may happen due to accidents, falling down carelessly or while playing sports. The most common knee injuries that may be the cause for your knee pain are mentioned as follows: 
a) Fractures may cause you to feel pain in the areas of your knee bones.
b) Anterior Cruciate Ligament injury (ligament injury caused by twisting and a sudden motion) or Medial Collateral Ligament injury (injury to the tissue in the insides of your knee) is very common to sportspersons and may be the reason for severe knee pain.
c) Sometimes your knee bones may get dislocated from their usual alignment. This can also make you experience severe knee pain.
d) Ligament injuries, meniscus tear or tendon tear can also be responsible for your knee pain.

2. Sometimes pain in your buttock or foot region can also result in mild knee pain.

3. At times chronic problems like osteoarthritis that affects the cartilage can cause the problem of knee pain. Other chronic problems like Gout, rheumatoid arthritis can also cause severe knee pain.

4. Being overweight can also result in knee pain.
The symptoms of knee pain may be different in each case. The most common symptoms are mentioned below:
a) Stiffness of knee
b) Swelling of your knee
c) You may also feel unstable
d) Difficulty in walking or bending of your knee.
e) You may notice redness in your knee area.

Knee pain must not be ignored. It is highly recommended for you to seek advice from an orthopedic as soon as you encounter any of the above mentioned symptoms.

Suffering from Knee Pain - Know What Causes it? 

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