Opioids allow individuals to escape the feeling of being controlled by the pain and can provide tremendous relief of suffering. However, this relief is short-term, and opioids do not resolve the underlying problem causing the pain. In fact, extended use of opioids can result in increased pain and sensitivity. This will be an option for some patients with chronic knee pain, so it is important to understand the chronic nature of pain.
Unfortunately, other individuals may suffer from chronic pain, which persists despite the fact that an injury has healed. Pain signals remain active in the nervous system for weeks, months, or years. Some people with chronic pain can begin to feel that pain is its own entity, not just a result from a condition. They may feel that they are now prisoners to their pain. They may start to feel that the pain is controlling them, and they can no longer control the pain.
Chronic pain is different from acute pain. Acute pain is a normal sensation that alerts us to an injury or illness and may be described as sharp or severe. Acute pain resolves as the injury heals. Uncomplicated acute pain does not usually require treatment with opioids. Basically, treating the injury or illness will resolve the pain.
Chronic knee pain can change many aspects of your life, not just the way you walk. It can affect your work, your play, and your ability to relax and be comfortable. It can limit your independence and transform the very core of your being. It’s important to acknowledge your feelings about your knee pain. Understanding how knee pain affects our lives and how we cope with knee pain will help us develop a strategy to successfully manage our knee pain. This booklet will help you understand the chronic nature of knee pain and the impact knee pain can have on your life.
Understanding Chronic Knee Pain
Dr. Rubens’ definition of knee pain reflects the complexity of assessing the impact of knee pain amongst sufferers. It has psychological, social, and physical effects on a person, influencing almost every aspect of their life. Since the majority of knee pain is caused by osteoarthritis, advice is taken from the Arthritis Research Campaign to help provide a clearer understanding of knee pain amongst sufferers.
Dr. Symon Rubens, a current research fellow at the Rheumatology and Immunology Research Laboratory of the Singapore General Hospital, has defined knee pain as “a complaint that has different meanings for different people.” When the pain is long-lasting, it is usually due to chronic conditions such as osteoarthritis (80%). The prevalence of knee pain increases with age, and it affects 25% of adults at some stage in their lives. Singapore is faced with a rapidly greying population. A survey done by the Epidemiology of Arthritis in Singapore showed that elderly Singaporeans had a higher lifetime prevalence of knee pain compared to their younger counterparts.
Impact of Chronic Knee Pain on Daily Life
Unfortunately, the knee is a common site of arthritis which is a major cause of chronic knee pain. People often dismiss pain from arthritis as an expected part of aging, without realizing that there are many ways to manage the pain and many different treatment options to explore. The belief that nothing can be done is damaging in that it prevents people from seeking proper treatment. This defeatist attitude and lack of knowledge concerning the wide variety of treatment options is exactly what we aim to change through our work.
Chronic knee pain is quite different in that the pain and changes to the knee structure have become the problem. It is no longer a warning signal preventing further damage, but the damage itself. This situation usually arises due to the knee not being given adequate time to heal, or a predisposition to knee injuries often due to the structure of the knee, or a general bodily weakness.
To truly understand the impact of chronic knee pain, it is necessary to first understand what sets it apart from temporary knee pain. Everyone has had a minor knee injury or strain, which while painful, is often quickly remedied and forgotten. Short term pain is a clear bodily signal of injury or damage, the healing of which is usually relatively straightforward. In other words, your body knows something’s wrong and is confident that it can fix it. The pain is a warning signal and a key part of the body’s self-preservation mechanism. After an injury occurs, pain receptors signal the brain that there has been damage. In response, the body reflexively reduces the use of the injured part to prevent further damage. As the damage is healed, the pain subsides and normal function returns.
Furthermore, advancements in the medical field have made it so that knee pain can be treated with various methods. It is not necessarily a case of going straight for surgery. However, the lack of knowledge about these options means that many with chronic knee pain feel that there is no possible recourse for their situation. This is a preamble to a deeper discussion about the coping strategies in knee pain Singapore for people with chronic knee pain, and the social support available to them.
In Singapore, many seniors assume that knee pain is simply part and parcel of growing old. The belief is so entrenched that many don’t seek treatment, assuming that they have no choice but to live with the pain, or that knee replacement surgery is their only option. Yet knee pain is not something to be endured at any age: While the highest incidence of knee pain is in older adults, it can develop at any time and have a variety of causes.
Coping Strategies for Chronic Knee Pain
When it comes to dealing with knee pain, there are many different helpful techniques. Depending on the extent and severity of your knee pain, your doctor may recommend different things. Some common coping strategies for knee pain are medication and surgery. There are many different kinds of medication for knee pain. Some medications are over-the-counter and include NSAIDs, which help reduce swelling around the knee and therefore consecutively reducing pain. Some other over-the-counter medications include acetaminophen or aspirin, which helps relieve minor pain. If the over-the-counter medications are not working, you should talk with your doctor about prescription medications. These can include narcotics, which are a very strong pain killer, or corticosteroids, which is a steroid type medicine used to control inflammation. Another more drastic coping strategy for knee pain includes knee replacement surgery. Typically, this is only done if someone has a severe amount of damage done to their knee, if they are older, and if the other coping strategies were not effective. Another good method for coping with knee pain includes physical therapy and exercise. Physical therapy is a treatment used by some with the assistance of a professional and usually involves several different exercises and stretches in order to help strengthen the knee and increase flexibility. Physical therapy may also involve hydrotherapy, which is exercising in water. This is effective with knee pain as it does not put as much strain on the knee. There are also many different exercises that you can do at home that can help reduce the pain. Although there are many effective exercises, you should consult your doctor to see which ones are right for you, as some exercises may actually cause more harm than good.
Medication and Treatment Options
Medication and surgical intervention are two important means of pain control. Medications and recent technological advances have made it possible to delay surgery. Medications often prescribed for arthritis are analgesic (pain-relief) drugs, NSAIDs (anti-inflammatory drugs), steroids, DMARDs (disease-modifying anti-rheumatic drugs), and a group of drugs known as COX-2 inhibitors. Paracetamol is an example of an analgesic drug that can control mild pain effectively. For more severe pain, weak opioids such as codeine can be used. Stronger opioids require a special prescription and ongoing monitoring by the pain specialists and may only be used for the short-term. Opioids can be addictive and cause side effects, so it’s important to weigh the benefits and risks with the specialist. NSAIDs are commonly used for arthritis. They can be purchased over the counter at a pharmacy or prescribed in a stronger dosage by a doctor.
Physical Therapy and Exercise
Another important part of physical therapy is gait aid. This refers to the use of various devices that assist in walking and is often necessary for those with moderate to severe knee pain. This can vary from using a cane or crutch to something more complex, such as a brace, or trialing a device like a shoe insert to improve alignment of the lower limb. While it may seem trivial, the use of a gait aid is quite complex and if prescribed by a physiotherapist can be very effective in improving mechanics and decreasing pain in those with knee osteoarthritis.
When physical therapy and exercise are performed correctly, they have been shown to be very helpful in managing knee pain. Exercise is essential in increasing flexibility and strength. As a general rule, it is recommended to start with stretching, followed by an exercise that is low impact and gentle on the knees (e.g. swimming or using a stationary bike). Strengthening the muscles around the knee and lower limb has been shown to decrease the symptoms and slow progression of knee arthritis. This is largely due to the shock-absorbing effect of the muscles, which takes load off the knee joint. Aerobic and anaerobic exercise have many benefits and can be performed in a gym, at home, or under physiotherapist guidance. Types of exercises include using weights/machines and those that don’t require specific equipment, such as closed chain kinetic exercises. A physiotherapist is essential in prescribing the correct exercises and ensuring they are being performed in the correct way. They may also use other treatments such as taping, ultrasound, or manual therapy.
Assistive Devices and Lifestyle Modifications
Assistive devices and lifestyle modifications are the least invasive form of treatment for chronic knee pain and can help prevent further deterioration or injury in the affected joint. Some of these devices are designed to unload the weight from the knee, and others are used to stabilize the joint and improve alignment. Four studies of patients with osteoarthritis showed that brace use reduced pain and increased function in those with unicompartmental disease. Approximately 10 percent of patients with knee osteoarthritis are bowlegged and 10 percent are knock-kneed. Braces that correct alignment by shifting the load to the unaffected side of the knee can improve function and slow disease progression in these patients. Kinesiophobia (fear of movement because of pain or further damage to the joint) is common in patients with chronic knee pain, and the avoidance of physical activities can lead to muscle weakness and atrophy, which can impair joint stability and cause more pain. An assistive device such as a cane can help reduce pain and improve function by providing more stability during gait. Using a cane has been shown to decrease the load on the affected knee by 14 percent. This is especially important in patients who are waiting for joint replacement and have pain that is interfering with their mobility and quality of life. Choosing the correct type of device and learning how to use it properly requires guidance from a healthcare professional who can recommend the most suitable device and ensure a good fit and minimal adverse effects on the rest of the body. This can be accomplished by consultation with a physical or occupational therapist, or with the healthcare professional who is treating the knee condition.
Support and Resources in Singapore
Despite the increasing number of older persons with knee OA, there is currently no specialized geriatric or rheumatology rehabilitation services for the elderly population. This is in contrast to the western countries where there are well-established outpatient or community-based geriatric rehabilitation services usually provided or coordinated by a multidisciplinary team. An example is the recently published a multidisciplinary clinical practice guideline by the American Geriatrics Society and the British Geriatrics Society, recommending a structured approach to non-surgical management of hip and knee OA in older persons. The guideline highlights the importance of a comprehensive assessment and various targeted non-pharmacological and pharmacological interventions with the aim of optimizing physical function and reducing pain in older persons with hip and knee OA.
Public sector rehabilitation services in Singapore are mainly provided through the hospitals and polyclinics. Following surgery or consultation with a doctor, patients may be referred to a physiotherapist or occupational therapist at the hospital.
Support groups could be a useful resource for emotional support and information. There are currently several arthritis-related support groups in Singapore. However, they tend to cater to the elderly with generalized OA, and there are none specific for persons with knee OA or injuries. The internet may be a feasible alternative. Persons with knee OA who are internet savvy may choose to seek support and information from online communities. This may be particularly useful for the younger patients with knee OA who are looking to share experiences with others in similar situations.
When seeking support and resources, the majority of patients with chronic knee pain in Singapore will be referred by their general practitioner to a knee pain specialist for further management. They include orthopaedic surgeons, sports medicine doctors, and rehabilitation specialists. Persons with knee OA may access information on knee pain specialists from the Singapore Medical Association. More recently, there has been an increase in the number of sports medicine doctors and the availability of arthroscopy as a treatment for various knee injuries.
Finding a Knee Pain Specialist
Knee pain specialists are generally orthopedic surgeons, or less frequently, rheumatologists or sports medicine physicians. Training to become an orthopedic surgeon in Singapore entails obtaining a medical degree, followed by completion of a post-graduate degree in surgery, and entry into advanced training in orthopedic surgery. Unfortunately, not all orthopedic surgeons receive specialist training in knee surgery. Those who do can acquire certification in orthopedic sports medicine with subspecialty certification in surgery of the knee (acronym “CAQ” for certificate of added qualification). Currently, there are four orthopedic surgeons in Singapore with these qualifications, and all are members of the ESSKA. Ask your surgeon about his qualifications and experience in the treatment of your specific knee problem.
The knee pain specialist is your primary physician for knee pain. The role of the specialist is varied and includes accurate diagnosis of the problem, the development of a treatment plan, and the overseeing of your care and progress.
Support Groups and Online Communities
Living with chronic knee pain can be an isolating experience, but with social support, the psychological impact of chronic knee pain can be better dealt with. Social support is a key coping resource for persons with chronic conditions. The concept of social support refers to the resources provided by other people in order to help individuals cope better with stress. Social support can take many forms such as emotional, instrumental, informational, and appraisal. Social support has been negatively associated with emotional distress and functional limitations in those with osteoarthritis of the knee. Social support has also been found to have a positive impact on how patients with chronic knee pain adapt to their condition.
Accessing Rehabilitation Services
Rehabilitation can take many forms, and the first distinction to be made is between general strength and conditioning exercise and specific exercise based around a knee injury. Historically, the emphasis in medicine and physiotherapy was to avoid stressing a painful knee, with the belief that rest was the best way for an injury to heal. More recent research has supported the benefits of exercise for knee pain in a number of conditions. However, results from general fitness regimes have been mixed, and the best results have been seen from exercise which is specifically aimed at the condition. This could be a properly supervised ACL functional knee brace rehabilitation program or specific exercises for patellofemoral joint pain. If you have seen a specialist about your knee problem, then you should have a clear diagnosis and an idea about what is the best form of exercise for your condition. This should be relayed to your physiotherapist or exercise physiologist.
Rehabilitation is an essential and ongoing component of managing chronic knee pain. With a variety of healthcare practitioners offering services of differing intent and quality, it can be hard to know what rehabilitation is suitable for you. Changes to the health system in Singapore and increased understanding about the benefits of different forms of exercise and manual therapies mean there are more options than ever before. This section provides a basic guide to help you navigate the rough terrain of rehabilitation and to help you find a practitioner who is both competent and suitable for your needs.
