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

Joint pain is considered to be one of the first few signs of aging. According to the science of Ayurveda, joint pain is triggered mainly by an accumulation of toxins in the body. These toxins can create an imbalance in the doshas which in turn can cause pain and inflammation on the joints. Along with joint pain, a person is likely to experience a loss of flexibility, weakness, tenderness and enlargement of the joints.

Unlike some popular forms of medication that focus on relieving the pain, Ayurveda addresses the root cause of the issue. Panchkarma aims at cleansing the body of toxins and clearing blockages in the body s digestive and circulatory system. This helps the vatta dosha flow easily through the body and reduces pain associated with arthritis etc. Panchkarma can be defined as a collection of five ayurvedic techniques. These are:

Vasti or Medicated Enema: Vasti aims at removing toxins and waste products from the body through the colon. In doing this, it cleanses the digestive channels and improves circulation of air or the vatta dosha in the body. With better circulation, joint pain is effectively reduced. An enema also nourishes the body and gives it the strength to rebuild tissues while boosting the immune system.
Abhyanga or Full Body Massage: This technique helps I the removal of toxins from deep tissues within the body. It pacifies the vatta and nourishes the body while simultaneously reducing stress and enabling better quality sleep. A full body massage also helps calm the body both physically and mentally.
Potli or Poultice Massage: As the name suggests, a potli involves massaging the body with medicated herbs tied together in a tiny bundle that has been warmed with medicated oils. This potli is then used to massage the entire body. This technique helps relax the muscles of the body and soothes the aggravated vatta dosha. It is very effective when it comes to providing relief from joint pains caused by arthritis, spondylitis, muscle cramps etc.
Pizhichil or Rich Oil Massage: A rich oil massage involves subjecting the body to streams of lukewarm oil that has medicinal properties while simultaneously softly massaging the body. This type of massage helps relieve tension and stress and is a very effective remedy against joint pains. It is highly recommended in the case of rheumatic diseases.
Svedana or Steam Bath: A steam bath helps cleanse the body both physically and mentally by aiding in the removal of toxins through sweat and calming the mind. It also helps soften the muscles and tissues and dilates the channels in the body.

Joint Pain - How Panchkarma Therapies Can Help You?

Knee pain or injuries are very common and have numerous causes. Knee pain can emerge from delicate tissue wounds like ligament sprains and muscle strains. Bone conditions like knee joint pain, Osgood Schlatters, and biomechanical dysfunction can also cause knee pain. Treatment can include basic knee mobilization techniques, taping, massages or knee strengthening exercises completely through a careful recovery method after knee replacement or reconstruction.

Physiotherapy can help you overcome the pain and increase your strength and flexibility. A physiotherapist can suggest you a number of treatments and also help you understand your issue and get you back to your everyday routine. Physiotherapists are said to be successful in getting rid of the source of the knee pain by diagnosing a cause. This includes tightness around the knee and treating it with stretching and exercises.

Following are some of the exercises a physiotherapist might generally recommend for knee pain:

Hamstring stretch: Stretching keeps you flexible and increases your scope of movement, or how far you can move your joints in different directions. It additionally helps you reduce your chances of injuries and pain. Continuously warm up with a five minute walk first. Lie down when you are prepared to stretch your hamstring. Circle a bed sheet around your right foot, use the sheet to pull the leg up and hold for twenty seconds and then lower the leg. Repeat twice and switch legs.
Calf stretch: Use a chair for balance. Bend your left leg. Step back with your right leg and gradually straighten it behind you. Press your left heel toward the floor. You should feel the stretch in the calf of your back leg. Hold for 20 seconds. Repeat twice and then switch legs.
Straight leg raise: It helps build muscle strength to give support to the weak joints. Lie on the floor. Twist your left knee, foot on the floor. Keep the right leg straight, toes pointed up. Tighten your thigh muscles and raise your right leg.
Quad set: With these, you don't raise your leg. Just tighten the thigh muscles, also called the quadriceps, of one leg at once. Begin by lying on the floor. Keep both legs on the ground, loose. Flex and hold the left leg tense for five seconds and then relax. Do three sets of ten repetitions. Switch legs after every set.
Cushion squeeze: This move strengthens your legs from the inside so that they can support the knees. Lie on your back, both knees facing inwards. Place a cushion or a pillow between the knees. Press your knees together, squishing the cushion between them. Hold for five seconds and then relax. Do three sets of ten repetitions. Switch legs after every set.
Heel raise: Stand tall and hold the back of a seat for support. Lift your heels off the ground and rise on the toes of both feet. Hold for three seconds. Gradually lower both heels to the ground. Do three sets of ten repetitions. 

Knee Pain - How Physiotherapy Can Heal Knee Pain?

Pain in the joint is an eventuality that only few can escape. It is an ailment that comes with age and promises to stay despite continued attempts at eradicating it. Being a problem that many are battling, it has provoked attempts at treating it. Various disciplines of medicines have tried in their own ways in dealing with this problem, but ayurveda with its strict reliance on natural products and aversion to chemicals has been most preferred. The various ways by which ayurveda treats joint pains are:
1. Massage: ayurveda focuses on massages as a remedial measure. Using few herbal oils and using them to massage regularly on the affected joints has been an accepted remedy for joint pains. A massage promotes blood circulation and creates a calming effect.

2. Hot and cold compresses: the effectiveness of this form of treatment has remained prevalent through generations. Extremely convenient and easy to use, you can use hot and cold compresses alternatively to ease the pain.

3. Fenugreek: fenugreek seeds have a long standing reputation of relieving you of pain. Boasting of antioxidant properties and the ability to reduce swelling, they must be finely grounded and swallowed with lukewarm water to enjoy best results.

4. Turmeric: in the hierarchy of ayurvedic medications, turmeric probably ranks the highest. It is packed with multiple benefits. Not only does it take care of the skin, it also helps in reducing joint pains. The most common way of having it is by mixing turmeric in a glass of warm milk and honey.

5. Apple cider vinegar: apple cider vinegar reduces joint pains by effectively eliminating the accumulated toxins. It is rich in magnesium and phosphorus and owing to its alkalizing effect, it has the ability to cure rheumatism.

Ayurveda and Joint Pain Remedies

Knee pain: causes and tips to manage knee pain

The knee is the largest joint of the body and is made up of upper and lower bones that are separated by two discs known as menisci. While minor knee pain may be experienced by many people, it should be handled with medical intervention when it becomes a serious and debilitating problem. Sudden injury or injury due to overuse as well as myriad conditions that affect the joints and muscles can bring about knee pain. Underlying conditions like osteoporosis or arthritis, which affect the bones and joints, can also cause knee pain. The symptoms include painful swelling and stiffness as well as severe discomfort. Let us learn more about the causes of knee pain and the ways in which it can be managed-

Injury: exercise and sports injuries are one of the most common causes that can be the start of acute knee pain, as well as chronic condition. These kinds of injuries can affect the ligaments and cartilage which leads to severe pain. The pain can even affect the way one functions in one's daily life. Knee ligament injuries can also cause this kind of pain. These ligaments are bands of tissues that connect the thigh bone with the lower leg bones. Sprains and tears in the acl or pcl are common in sports injuries, and may even require surgery in many cases. Knee cartilage tears can also take place in the hard yet flexible cartilage of the knee which can affect the meniscus around the knee. This condition may also require surgery.

Arthritis: this condition can affect the knees specifically and is one of the most common types of arthritis. This is a chronic condition which gets progressively worse over time and may even require surgery. Stiffness and inflammation are common symptoms. Rheumatoid arthritis is also a degenerative auto-immune disease that can affect the knees and cause knee pain. Furthermore, post traumatic arthritis can also be experienced after an injury. Osteoarthritis is another common condition that leads to knee pain. It basically occurs due to wear and tear of the knees over a prolonged period and is usually experienced by patients over the age of 50.

Managing knee pain: while pain medication and anti-inflammatory drugs may be prescribed for most cases, along with surgery in the long run, it is also possible to manage knee pain with the help of better lifestyle choices like regular knee and muscle strengthening exercises as well as rest - rest, ice, compression and elevation. These methods can help in relieving inflammation and pain. But very severe cases will require medical intervention, so it is imperative to get in touch with your doctor if the condition does not improve.

Knee Pain: Causes and Tips to Manage Knee Pain

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.



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