Evidence
Alert

Ongoing pain after knee replacement: people need support and encouragement to seek help

People with ongoing pain after knee replacement surgery may experience a sense of futility and believe nothing more can be done. A new study found that that one in five people report ongoing pain after knee replacement surgery, but many do not seek help in dealing with their pain.

The researchers say that improvements in the information given before surgery could help. And it is important that clinicians acknowledge pain at follow-up appointments. This may encourage people to seek help to manage their pain through services such as physiotherapy, surgery, or medication.

In this new study, researchers found that some patients did not want to undergo further treatment because they thought it would not work or be risky, or because they had other health problems to deal with. People were uncertain about what to do about their pain even after consulting their surgeon or GP.

What’s the issue?

In the UK in 2017, there were 112,836 first-time knee replacements. Most of these were to replace stiff and painful knees in people with osteoarthritis.

For many, this surgery reduces pain and improves the function of the knee. But around one in five people report ongoing pain after surgery. This pain can increase in intensity beyond the initial healing phase of a few months.

Currently, there is no clear referral pathway for these people. Research suggests many are unsure whether their experience is normal and do not know what to do about it. Some may feel abandoned by healthcare professionals, and some may struggle to make sense of their ongoing pain. They may also feel it is a normal part of getting older, or that nothing can be done.

Treatment options for chronic pain include physiotherapy, surgery, medication and psychological pain management. All are available through the NHS but many people recovering from knee replacement surgery do not receive the care they need.

This study set out to understand why these people do not seek help for their pain.

What’s new?

Researchers interviewed 34 people who had received a total knee replacement and were experiencing ongoing pain. They were between 55 and 93 years of age and had been operated on at one of two NHS hospitals. Surgery had taken place 14-68 months before the interview, but they had rarely or never spoken to healthcare professionals about their pain in the preceding year.

The core theme to emerge was a sense of futility amongst the interviewees. They believed nothing more could be done and were trying to manage their pain by themselves.

Many said that the response of surgeons and GPs had influenced their attitude towards their pain. If surgeons expressed satisfaction at post-operative follow‐up appointments, and could see no reason for ongoing pain, people were left feeling uncertain about the cause of their pain and whether it was part of normal recovery.

One patient was told her recovery would take time: “They just kept saying ‘give it a year and it should improve’ and it never did”. Another said, “The GP didn’t particularly want to help. He just wanted to give me stronger painkillers.”

Other factors that influenced the decision not to seek help included:

  • expectations about the effectiveness and risks of further treatment: “I remember [physiotherapist] saying to me, ‘The only way we can cure that is to take your leg off’”
  • not wanting to take on the burden of further treatment: after multiple operations, one patient felt that “enough is enough”
  • prioritising other health conditions: “I'm more anxious about my lungs when I'm short of breath … at the moment, for me, it's the lungs that are priority”
  • not feeling warranted in seeking help: “I’m extremely grateful to the NHS, I’ve had thousands of pounds spent on me … the fact that this is still painful just gives me something else to moan about really”
  • the changing nature and intensity of pain: “I’m not in as much pain now as I was before I had the operation … But I’m in sufficient pain to make it a nuisance and to make it difficult for the rest of my life”
  • acceptance of pain: “You ain't got 40 years to live have you … I don't see there's very much else left that I can do.”

Why is this important?

People with ongoing pain after knee replacement can become trapped in a futility loop. They do not seek help, despite believing they have a good reason to.

Improving the information given before knee replacement surgery could help. The authors recommend warning patients that they could experience ongoing pain. But patients need to be aware that while some pain in the healing period is normal, they should seek help if their pain persists.

It is also important that clinicians acknowledge and legitimise pain at follow-up appointments. This may encourage patients to return for care if their pain persists. Patients need information about how to access the healthcare services and treatments that could help them to manage their pain.

What’s next?

This research is part of a NIHR Programme Grant for Applied Research, in which researchers have developed a care pathway for chronic pain after knee replacement. It involves an assessment clinic and onward referral, with telephone follow-up as required. Researchers have carried out a clinical trial to test this pathway and will be releasing the results soon.

Further research could identify other kinds of support and treatment that might prevent people with pain from becoming stuck in the futility loop.

You may be interested to read

The full paper: Moore AJ and Gooberman-Hill R. Why don't patients seek help for chronic post‐surgical pain after knee replacement? A qualitative investigation. Health Expect. 2020;00:1-11

Website for the Support and Treatment After Replacement (STAR) programme, University of Bristol

Paper from healthcare professionals’ perspectives on chronic post-surgical pain: MacKichan F, and others. Pathways Through Care for Long‐Term Pain After Knee Replacement: A Qualitative Study With Healthcare Professionals. Musculoskeletal Care. 2015;13:127-138

Paper from the same research group that outlines a care pathway for people with chronic pain after knee replacement: Wylde V, and others. Development of a complex intervention for people with chronic pain after knee replacement: the STAR care pathway. Trials. 2018;19:61

Paper reporting on a planned clinical trial for the STAR care pathway: Wylde V, and others. Clinical- and cost-effectiveness of the STAR care pathway compared to usual care for patients with chronic pain after total knee replacement: study protocol for a UK randomised controlled trial. Trials. 2018;19:132

Funding

This research was supported by an NIHR Programme Grant for Applied Research programme.

Commentaries

Study author

People are often uncertain about their pain, whether it’s normal, and what can be done about it. Many also have low expectations about the effectiveness of further treatments but they need to know that asking for further support is entirely appropriate, and may help them to manage their pain and improve their overall well-being.

People are very aware that the NHS is under pressure. There’s an element of unwillingness to consult further because they feel they are contributing to the pressure or taking someone else’s share of care.

I was surprised that people often reported they were not aware in advance of the risk of chronic post-surgical pain. We should improve the information provided to people before they decide to have knee replacement surgery, including the risks of ongoing pain.

Andrew Moore, Research Fellow in Qualitative Health Research, University of Bristol

Member of the public

Education on pain management should be provided to the relevant staff, particularly to the surgeons and GPs who have face-to-face contact with patients. It’s important for clinicians to see how a dismissive attitude towards pain can adversely affect a patient’s twilight years.

Charlie Fallon, Bracknell

Researcher

It is so important that people in pain are believed and the health professionals remember that an operation is only successful if it works for the patient. Just because a scan says it is a success does not mean it is a success. This paper highlights this mismatch really well. Along with the consequences for people living with pain, who give up on seeking further help.

Moving away from the traditional model of ‘health professional knows best’ to one of collaboration, is seemingly difficult. Everyone – established health professionals and those in training – needs to focus on collaboration. And pain is so common it should be a core part of all health professional training.

Karen Rodham, Professor of Health Psychology, Staffordshire University, UK

Conflicts of Interest

None declared.