Dr. Adnan Badr's Physiotherapy Rehab Clinic

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:

1. 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.

2. 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.

3. 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.

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

5. 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.

6. 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.

The shoulder is one of the most important joints in the body that uses a ball and socket to join the arm to the rest of the body. Any pain can make it difficult to carry out motion in a comfortable manner. The shoulder consists of the long arm bone called the humerus, the collar bone or the clavicle, as well as the shoulder blade called the scapula.

A layer of cartilage provides essential padding to the bones in this area and its two main joints. There are a number of issues that can cause shoulder pain. Let us get to know the six most common ones. 

* Rotator Cuff Injury: This is the most common cause of shoulder pain and it occurs when the four muscles or the tendons are injured. These muscles and tendons usually control the movement of the arm. This injury can involve strains and tears which may also be caused by constant lifting of heavy objects. 

* Rotator Cuff Tendinitis: This condition affects the tendons and muscles that help in moving the arm freely. This usually happens due to inflammation in the tendons. It is commonly experienced by patients who are actively involved in sports and other heavy physical pursuits in their line of work. 

* Frozen Shoulder: This is a debilitating condition that restricts the free movement of the arm and is also known as adhesive capsulitis. When the shoulder tissues become too thick, it leads to the growth of scar tissue that hinders proper movement and causes pain. 

* Osteoarthritis: Osteoarthritis is a condition that comes as part of aging bones that also become hollow and brittle over the passage of time, which leads to joint and bone pains in various parts of the body. It is a degenerative disease that is caused due to prolonged wear and tear as well as other factors including family history and sports injury.

* Bursitis: This condition is known to affect the fluid filled sacs that lie in between the joints. These are known as bursae. When the bursae suffers from swelling, the effect usually shows up as pain in the joints. 

* Tendon Sheath Inflammation: The fibrous tissue that connects the bones and the muscles is called a tendon. The presence of the tendon makes it possible to pursue activities like running, jumping, lifting, gripping and more. It is protected by a sheath known as synovium, which also lubricates the same. Any injury or tear to this sheath can cause shoulder pain.

Acute and persistent pain that does not abate and gets even worse should be treated with immediate medical intervention.
 

Elbow pain may be caused due to a variety of reasons from injuries to fractures and ligament pulls or tears. This is most commonly experienced by people who are into sports, including those who play tennis, golf and other such sports that require intense arm movements.

So, let us look at the six most common reasons behind elbow pain:

1. Medial Epicondylitis: This condition creates pain in the inner tendon within the elbow and is usually termed as 'golfer's elbow'. It basically occurs due to the constant swinging and throwing motion that a sports person may indulge in. When these movements are repeated on a constant basis, there is wear and tear as well as acute pain in the area. Also, an injury to the wrist can cause this pain in the elbow.
2. Lateral Epicondylitis: This condition is commonly known as 'tennis elbow'. The affected area under this condition includes the outside tendons of the elbow. This is caused due to swinging, hitting, hammering and punching motions that are repeated too often. It is commonly experienced by cooks, artists, carpenters, automobile workers, and plumbers and people who use heavy tools.
3. Olecranon Bursitis: This condition is also known as 'student's elbow' and usually occurs due to constant writing and gripping motion which affects the bursae. These are small fluid filled sacs that lubricate the joints even as the protection happens. The symptoms include swelling and pain. There is also risk of infection and redness in this condition.
4. Osteoarthritis: The cartilage of the joints gets affected in this condition which is the connective tissue that exists in the joints. This condition causes wear and tear of the joints and bones which leads to pain in the various areas including the elbow. Medication and physiotherapy are good measures for treatment.
5. Fracture: Sometimes, dislocation or fracture may lead to pain in the outstretched arm or elbow. Dislocation may take place when a bone moves from its aligned spot. The symptoms will include obvious swelling and acute pain in the elbow.
6. Ligament Damage: Strains and sprains in the ligaments within the elbow joint can lead to this damaging condition. Torn or stretched ligaments are the most common outcomes in this kind of injury and damage.

To find out which reason may be the culprit behind your elbow pain, you will need to see a general physician or an orthopaedic specialist who will run you through a series of tests and examinations including X rays, MRI scans and others in order to ascertain the cause and treatment. 

Being flexible is not always about doing splits or doing some random bending. It is about achieving a level of mobility that will not hold you back from doing whatever you are able to do. Most people think that stretching or flexing your muscles and body as the first method to defend you from pain. But if stretching and flexing can be done correctly, it can lengthen one's muscles and give one relief from pains and aches. Stretching is also done to increase the functional range of one's joints and muscles. There are various ways by which one can stretch their muscles. However, the question which looms over here is which is the correct procedure and which is the wrong one.

The Wrong Vs the Right Way: Before discussing about the correct way, let us talk about the various wrong ways in which stretching can be done. The first rule is that if stretching is causing you pain or if it is hurting you, then you are probably taking it too far. A muscle needs to relax as much as possible, if it needs to stretch. If one is stretching so hard that he or she cannot relax then the muscle will not lengthen. Stretching should never be painful.

One should also avoid stretching for an insufficient length of time. Only a few seconds of stretching will not hold the therapeutic effects of stretching.

The following methods are few of the correct ways to stretch:

1. Always start with the warm muscles. Warm your muscles by doing some aerobic movement or by applying heat with the help of a warm bath.
2. After warming your muscles, monitor your level of discomfort. Let it go once you feel pain.
3. Hold any stretch for at least 30 seconds.

Stretching the Correct Muscle: There are muscles, which need to be stretched and there are muscles, which should not be. So getting to know the correct muscles to be stretched is as important as knowing the correct procedure to stretch your muscles. Every muscle, which does not hurt should not be stretched. There are different types of muscles that cause pain like stiff, tight, short muscles and long muscles. Muscles that are tight should only be subjected to stretching. Stretching muscles that are too long is not a good idea.

Using Physiotherapists: Most people who cannot determine which muscle should be stretched and which should not be should consult a physiotherapist. Physiotherapists can quickly and easily diagnose muscular issues. They will also show ways to stretch which are most effective for particular needs.

Stretching should be made a part of one's life. It is a way by which one can become their healthiest self and avoid muscular imbalances.

Total knee replacement is arguably one of the most successful of Orthopaedic surgeries. The success has been documented at various scientific platforms and Journals.

 However there are still many myths in the mind of the lay person who is suffering from this crippling problem and prevents them from getting treated for the same.

1. Myth :  Everyone suffers from Knee arthritis, I should learn to live with it.

Fact:  If the Knee pain due to arthritis is so much that is affects activities of daily life, and you find yourself refusing to participate in routine  social activities, Knee replacement could be the best option to bring back the lost zeal in your life.

1. Myth: I am too young for this surgery

Fact :  Joint Replacement is no longer  just dependent on the age. Recent advances in materials and design have vastly extended the boundaries for joint replacement.

1. Myth: I am too overweight for this surgery

Fact :  Surgery is not dependent on the weight,  but on the overall medical condition of the person. In fact after the surgery, the ease of movement means losing weight may become easier.

1. Myth: I should try to postpone the surgery as much as possible.

Fact :  Severity of Knee arthritis can sometimes be so crippling  that even small daily activities like going for a walk in the garden , shopping at the market or in the mall can become unbearable. This causes a great loss in the quality of life for that person. Pulling on in such circumstances is not only physically more challenging but may cause emotional issues and depression. In such circumstances joint replacement can be a life changing surgery