PAIN MANAGEMENT IN KNEE REPLACEMENT

ABSTRACT

Postoperative pain is a major concern after total knee replacement (TKR). It is severe in 60% of patients and moderate in 30%. Patients report a lack of information about pain-control measures and ineffective pain control. Nurses continue to rely on pharmacologic measures and tend to under-administer analgesics. The purpose of this study was to understand and evaluate the role of the nurse in effective management of pain in post-operative setting after TKR. It also sought to determine the significance of multimodalpain managementapproaches in post-operative pain management after TKR. An retrospective literature based design was used. A Scientific study of around 150 scholarly articles related to "post operative pain management after knee arthroplasty " which were presented in various medical journals was reviewed. Finally,14 articles were selected for the study based on the nature, type, volume and significance of the study and its influence on pain management in a post-operative setting following a major orthopaedic surgery. The findings highlighted the role of nurses, drugs and drug delivery system in effective management of post operative pain after knee arthroplasty. Effective communication, improvements in nurse education, accurate pain assessment and effective time management were some of the proposals of this study in effective pain management after TKR. Continuous femoral 3-in-1 block is considered the technique of choice to provide postoperative analgesia after TKA . Loco-regional analgesic technique (continuous 3-in-1 block and epidural analgesia ) is the best combination and provides better pain relief and faster knee rehabilitation than IV PCA with morphine. The study also highlighted the fact brought about by various other studies that transcutaneous electric nerve stimulation (TENS) has no significance of relieving pain in post-operative settings after TKR.

BACKGROUND

Osteoarthritis (OA) of the knee is a common cause of pain and disability in elderly patients. Total Knee Replacement (TKR) is a treatment option for osteoarthritis of the knee where other conservative measures have failed. In a minority of cases TKR is carried out following injury, deformity or instability in the knee. In 2004/2005 50,880 total knee replacements (TKRs) were carried out in NHS hospitals in England (Hospital Episode Statistics). Having this surgery requires admission to hospital and an inpatient stay to allow for recovery and rehabilitation. TKR is seen as both a cost-effective treatment and rates highly in patient satisfaction where the patient can expect reduced pain levels and increased joint mobility (Heck et al., 1998). Joint replacement surgery can alleviate pain and restore function but is associated with risks and discomfort. Though considered among the most beneficial of surgical procedures in terms of restoring quality of life and mobility knee replacement related post-operative pain may leave some patients initially questioning why they underwent the operation. Post-operative pain is the leading cause for delay of discharge from the hospital. Any operative condition is a stress to human body with liberation of endogenous substances from body and initiation of inflammatory cascade at surgical site leading to unpleasant experience of pain of varying intensity by patients. Pain is generated with stimulation of pain receptors in the body, and further conducted through nerves to spinal cord. From spinal cord pain is transmitted with the help of special tracts to thalamus in the brain where pain is perceived. Although pain is a defense mechanism of body, its detrimental effects on body leads physicians to control it by various means. Postoperative pain encompasses a complex phenomenon that involves physical, psychologic, social, cultural, and environmental factors that interconnect and affect how the pain is perceived, managed, and evaluated (International Association for the Study of Pain, 2003).A good nursing care is very important contributing factor for better outcome after major surgical procedure. Patients require high standard of nursing care particularly after orthopaedic surgery. Postoperative-pain has adverse systemic effects in the form of cardiovascular, pulmonary, thrombo embolic and gastrointestinal complication and local adverse effects. It also produces local complication in the form of weakness of limb, delayed wound healing, reflex sympathetic dystrophy. Uncontrolled pain can produce anxiety and sometimes depression creating a psychological trauma to patient. Its detrimental effects delays ambulation and physiotherapy consequently prolonging hospitalization and rehabilitation. TKA patients often experience moderate to severe postoperativepain. In the perioperative period the type of anesthesia, the surgical approach, and the use of local anesthetics and analgesics affect postoperativepain management.After TKA, postoperative pain relief can be achieved by a variety of techniques, such as IV patient-controlled analgesia (PCA) , epidural analgesia with narcotics and/or local anesthetics , and lumbar plexus blockade . javascript:newshowcontent('active','references');Non-steroidal anti-inflammatory drugs (NSAIDs) inhibit prostaglandin synthesis in the periphery and the spinal cord, therefore decreasing the post-operative hyperalgesic state. Non-steroidal anti-inflammatory drugs (NSAIDs), including over-the-counter aspirin and ibuprofen, are the most prescribed medications to relieve pain and reduce inflammation post-surgery. A lesser prescribed and more potent set of pain relievers are COX-2 inhibitors, a special category of NSAIDs. The use of NSAIDs and COX-2 inhibitors involve a risk/benefit ratio, and should be assessed by physicians on a case by case basis in light of each patient's specific conditions. The aim of this study was to understand and evaluate the role of the nurse and the significance of multimodalpain managementapproaches in effective management of pain in post-operative setting after total knee replacement (TKR). This retrospective study was mainly done to evaluate the most effective multimodal approach in post-perative pain management after (TKR) with combinations of systemic analgesics and/or regional analgesia, with or without opioids . It was also important to understand the transcutaneous electrical nerve stimulation (TENS) modality in the setting of postoperative relief of pain after TKA.

LITERATURE REVIEW

Many factors potentially affect the pain management after TKR. Evidence for the main causes described in the literature are summarised here. Are nurses still underestimating patients' pain postoperatively? Field L A replication and extension of Seers' (1987) study aiming to investigate nurses' accuracy in pain assessment. In Field's study the patient sample group was from an orthopaedic setting: 39 patients undergoing spinal surgery and the 78 nurses responsible for their care. A 5-point verbal pain rating-scale was used by patient and nurse on the first and fifth postoperative days and the results were analysed. Other areas included in the study were the type of operation, the gender of the patient and the nurses' previous experience. Results showed that nurses gave considerably lower ratings than their patients and the author argues that this leads to patients suffering unnecessarily. The author recommends the use of pain-assessment tools and improvements in nurse education relating to pain and pain management.

Postoperative pain management - the influence of surgical ward nurses

The management of postoperative pain continues to remain problematic and unsatisfactory and ward nurses play an important role for this task. The aim of the study was to compare pain levels reported by patients with those documented by ward nurses and to find out to what extent the amount of opioids given correlated with the pain level. Secondly, to study if pain management and nurses' approaches to this task had improved during a two-year period, including an educational pain treatment program for ward staff. The study was a cross-sectional, descriptive, two-part study based on survey data from both patients and nurses on two urology surgical wards. Part I of the study included 77 patients and 19 nurses. Part II took place approximately two years later and included 141 patients and 22 nurses. Data were collected the day after surgery by asking patients about 'worst pain' experienced. The pain scores given by the patients were compared with those documented in the patients' records and with the doses of opioids administered. Nurses' approaches to pain management were sought after, by using a categorical questionnaire. The results were that the the nurses' ability to assess pain in accordance with the patients' reports had increased slightly after two years even if and the number of documented pain scores had decreased. Forty per cent of the nurses reported that they did not use visual analogue scale and that they did not assess pain at both rest and activity, neither did one fourth evaluate the effect of given analgesics. The study was concluded showing a discrepancy in pain scoring between nurses and patients, where active treatment was related to nurses' documentation rather than to patients' scoring. The study shows a need for more accurate pain assessment, since the patient experiences and suffers pain and the nurse determines upon treatment.

Nurses' Strategies for ManagingPain

Acute pain is a significant problem in the postoperative setting. Patients report a lack of information about pain-control measures and ineffective pain control. Nurses continue to rely on pharmacologic measures and tend to under-administer analgesics. The purpose of this study was to determine the strategies nurses used to manage patients' pain in the postoperative setting. It also sought to examine the effect of context, including organization of care, nurses' prioritization of work activities, and pressures during a working shift, on their pain-management strategies. An observational design was used in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were identified as key periods for pain activities, each comprising a 2-hour duration. An observation period was examined at least 12 times, resulting in the completion of 74 observations and the identification of 316 pain cases. Fifty-two nurses were observed during their normal day's work with postoperative patients. Six themes were identified: managing pain effectively; prioritizing pain experiences for pain management; missing pain cues for pain management; regulators and enforcers of pain management; preventing pain; and reactive management of pain. The findings highlighted the critical nature of communication between clinicians and patients and among clinicians. It also demonstrated the influence of time on management strategies and the relative importance that nurses place on non pharmacologic measures in actual practice. This research, which portrays what happens in actual clinical practice, has facilitated the identification of new data that were not evident from other research studies.

Analgesia After Total Knee Arthroplasty

Bruce Ben-David Kevin Schmalenberger and Jacques E. Chelly followed a sample group of 12 consecutive patients, 5075 yr old, presenting for primary TKA who were managed according to our revised APS standard protocol for TKA. Our acute pain service's (APS) standard practice in providing postoperative analgesia after total knee arthroplasty (TKA) has for some time been the combined use of both continuous femoral (CFI) and continuous sciatic infusion (CSI) nerve blocks. In response to surgeons' concerns regarding postoperative sciatic block (e.g., difficulty in diagnosing peroneal nerve injury or an evolving sciatic nerve injury from compartment syndrome), we modified our standard protocol in an attempt to limit the use of CSI. It also includes placing single-shot blocks and perineural catheters at both sites, but infusing local anesthetic postoperatively only in the CFI. CSI is reserved for patients having poorly controlled posterior knee or calf pain. In the preoperative holding area an IV infusion of lactated Ringer's solution was started and monitoring was established with automated blood pressure and pulse oximetry. Patients received rofecoxib 50 mg PO with a "sip of water" and IV midazolam was titrated to achieve moderate sedation (total dose 15 mg). The results were that 10 of 12 patients required use of the CSI. Within 1 hr of a 510 mL CSI bolus of 0.2% ropivacaine and beginning an infusion of the same drug at 5 mL/h, patients' median pain by verbal analog scale decreased from 7.5 to 2.0 (mean scores from 7.3 to 2.4). It was possible to maintain this level of analgesia until the third postoperative day when catheters were discontinued. Our experience suggests that, in most patients, adequate analgesia after TKA cannot be achieved with CFI alone and that the addition of CSI renders a significant improvement in analgesia . To compare IV PCA with morphine with continuous epidural analgesia and continuous 3-in-1 block in terms of analgesic efficacy and postoperative knee rehabilitation after unilateral TKA. Franqois J. Singelyn, M. Deyaert, D. Jorist, E. Pendevillet, and J. M. Gouverneur assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). After TKA, postoperative pain relief can be achieved by a variety of techniques, such as IV patient-controlled analgesia (PCA) , epidural analgesia with narcotics and/or local anesthetics , and lumbar plexus blockade . Few studies compare the analgesic efficacy of these techniques and their influence on postoperative knee mobilization. . The aim of the present study was to compare IV PCA with morphine with continuous epidural analgesia and continuous 3-in-1 block in terms of analgesic efficacy and postoperative knee rehabilitation after unilateral TKA. Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with IV patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 months. We conclude that, after TKA, loco-regional analgesic techniques( continuous 3-in-1 block and epidural analgesia ) provide better pain relief and faster knee rehabilitation than IV PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. ManagementofPainAfterTotal Knee Arthroplasty Clifford W. Colwell Jr. Total knee arthroplasty (TKA) is successful for the treatment of severe osteoarthritis of theknee. However, TKA patients often experience moderate to severe postoperativepain. In the perioperative period the type of anesthesia, the surgical approach, and the use of local anesthetics and analgesics affect postoperativepain management. Optimumpain managementrequires action at all stages of the TKA process and begins preoperatively with patient education. Preemptive analgesia is used to prevent the pathologicpaincaused by incisional and inflammatory injury. Anesthesia is used to inhibit intraoperative neural impulses from reaching the central nervous system. The midvastus surgical approach has shown positive results in decreasing postoperativepainand in increasing functional outcome. Postoperativepainis potentially best managed with a multimodal approach that blockspain perception at a variety of sites in the peripheral and central nervous systems. Treatment options include combinations of systemic analgesics and/or regional analgesia, with or without opioids. Multimodalpain managementapproaches have proven effective by reducingpain, narcotic usage, length of hospital stay, and the side effects associated with anesthesia and narcotic analgesics. Bupivacaine bolus injection versus placebo forpain managementfollowingtotal knee arthroplasty The Journal ofArthroplasty,Volume 19, Issue 3,April 2004,Pages 377-380 Christopher Browne, Steven Copp, Lianette Reden, Pamela Pulido, Clifford Colwell Jr Following surgery,total knee arthroplasty(TKA) patients experience considerablepain. All available effective analgesia agents produce some unwanted side effects. Sixty consenting elective TKA patients were randomized to receive bupivacaine 20 mL 0.5% (100 mg) or 20 mL normal saline injected into the joint space after capsule closure. Patients were interviewed up to 24 hours after surgery forpainandpainrelief. Narcotic usage was recorded. The bupivacaine group had lowerpainscores and reduced narcotics during the 24-hour period, with a 23-minute shorter time to discharge from the postanesthesia care unit than the placebo group (P= .02). Although a bupivacaine bolus injected at capsule closure results in decreasedpainlevels (P= .07) and narcotic consumption (P= .09), it is not statistically significantly better than placebo. ControllingPainAfterTotalHip andKnee ArthroplastyUsing a Multimodal Protocol With Local Periarticular Injections: A Prospective Randomized Study The Journal ofArthroplasty,Volume 22, Issue 6, Supplement 1,September 2007,Pages 33-38 Hari K. Parvataneni, Vineet P. Shah, Holly Howard, Naida Cole, Amar S. Ranawat, Chitranjan S. Ranawat Table 1 Components of a Multimodal Approach for TKA Preoperative patient education/clarification of expectations Preemptive analgesia Anesthesia technique Surgical Technique Intraoperative agents (including use of a novel periarticular injection) Postoperative analgesia This prospective randomized study, patients undergoingtotalhip (THA) orknee arthroplasty(TKA) were randomized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block (TKA patients). All patients received a comprehensive multimodal perioperative protocol.Pain, recovery of functional milestones, and overall satisfaction were assessed. The THA study group demonstrated significantly lower averagepainscores and higher overall satisfaction than the control group. There was no significant difference inpain scores between the study and control groups in the TKA cohort. Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery. Periarticular injection with a multimodal protocol was shown to safely provide excellentpaincontrol and functional recovery and can be substituted for conventionalpaincontrol modalities. Transcutaneous electrical nerve stimulation for postoperativepainrelief aftertotal knee arthroplasty The Journal ofArthroplasty,Volume 19, Issue 1,January 2004,Pages 45-48 Robert Breit, Hans Van der Wall Transcutaneous electrical nerve stimulation (TENS) has been used to treat chronicpainsyndromes and has been reported to be of some utility in the treatment of postsurgicalpain. A randomized, blinded, placebo-controlled trial was designed to evaluate the utility of TENS aftertotal knee arthroplasty. Patients were randomly enrolled into patient-controlled anesthesia (PCA) alone, PCA plus TENS, or PCA plus sham TENS. The cumulative dose of morphine by PCA for each group was used as the end-point of the study. There was no significant reduction in the requirement for patient-controlled analgesia with or without TENS. We conclude that there is no utility for TENS in the postoperativemanagementofpainafterknee arthroplasty. Efficacy of Periarticular Injection of Bupivacaine, Fentanyl, and Methylprednisolone inTotal Knee Arthroplasty: A Prospective, Randomized Trial The Journal ofArthroplasty,In Press, Corrected Proof,Available online 21 December 2009 Arun Mullaji, Raj Kanna, Gautam M. Shetty, Vipul Chavda, D.P. Singhs We evaluated the efficacy of periarticular infiltration of corticosteroid, opioid, and a local anesthetic by comparingpainscores,kneeflexion, and quadriceps function on the day of surgery, first postoperative day, day of discharge, and 2 and 4 weeks after surgery between the infiltrated and the non infiltratedknee in 40 patients undergoing simultaneous bilateral computer-assistedtotal knee arthroplastywho were randomized to receive the injection in the right or left knee. In comparison to the non infiltrated side, the infiltratedkneeshowed significantly lowerpainscores, significantly greater active flexion up to 4 weeks, and superior quadriceps recovery up to 2weeks after surgery. This simple and inexpensive technique can significantly reducepainand hasten functional recovery in the first month aftertotal knee arthroplasty.

METHODOLOGY

Based on the review of around 150 scholarly articles related to "post operative pain management after knee arthroplasty " which was presented in various medical journals including 'the journal of arthroplasty , British Journal of Anaesthesia,Journal of bone and joint surgery, journal of clinical nursing', we zeroed to the articles based on the type of research study which includes whether it is a randomized double blind study, involved the most number of subjects, hospital's research network , hospitals knowledge with the latest drugs and techniques available in palliative care. The articles that were reviewed were dated from 1987 to the most recent published research report on 21st December 2009.The design of this study is basically a retrospective ,randomized ,literature based cohort study. Anypain managementapproach used should be the product of collaboration between physicians, nurses, pharmacists, and patients. After TKA, postoperative pain relief can be achieved through a step based multimodal approach which includes key strategies of a healthcare provider and pharmacologic measures in pain management post-surgically following TKR.

FINDINGS

The study has highlighted the role of nurses, drugs and drug delivery system in effective management of post operative pain after knee arthroplasty. It has suggested following measures to be taken by a healthcare provider in providing post-operative pain relief after TKR.

Strategies for Managing Postoperative Pain

What are the measures to be taken in improving the role of a healthcare provider in managing pain post-operatively after knee replacement surgery? Based on the review of literature of the above mentioned articles, the following measures were considered of importance; * critical nature of communication between clinicians and patients and among clinicians. * relative importance that nurses place on non pharmacologic measures in actual practice. * Improvements in nurse education relating to palliative care. * Prioritizing pain experiences for pain management. * Accurate pain assessment based on patient's verbal pain rating-scale. * Effective management of pain with medication-related or involved non-pharmacologic strategies. * To regulate pain control regimens without compromising patient's comfort. * To avoid missing pain cues for pain management. * Preventing pain. * Reactive management of pain. * Effective time management . Drugs play a key role in post-operative pain management , particularly after a major orthopaedic surgery like TKR which is more painful than hip replacement after operation. The following findings help in solving a few unanswered questions. Pharmacologic measures The review of various above mentioned articles reiterate the importance of multimodalpain managementapproaches that have proven effective by reducingpain, narcotic usage, length of hospital stay, and the side effects associated with anesthesia and narcotic analgesics. Although there are a large group of drugs that are available in the market, it is important for the healthcare provider to choose the best available treatment for his patient. Postoperativepainis potentially best managed with a multimodal approach that blockspain perception at a variety of sites in the peripheral and central nervous systems. Analgesic efficacy and safety of non-opiod analgesic in management of post-operative pain after knee replacement ? The median time to onset of analgesia with propacetamol was shorter than ketorolac without any statistical significance . However, compared with ketorolac 30mg, propacetamol had a shorter duration of analgesia. Propacetamol was not significantly different from ketorolac 15 mg and 30 mg with respect to the main analgesic efficacy variables during the 6-h assessment period. The most frequently reported adverse event with propacetamol was injection site pain . Compare the immediate postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement? There was no significant difference in maximal level of sensory block among the two groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine group. Overall satisfaction rates were better in the neostigmine group than in the morphine group. Compare patient-controlled extradural analgesia (PCEA) with extradural bupivacaine, fentanyl and the combination of both ,for postoperative pain relief? There was no significant difference between the groups in pain, nausea, motor block, pruritus or sedation. No patient had a ventilatory frequency less than 10 b.p.m. Hypotension (systolic AP < 100 mm Hg) occurred in 10% of patients in the fentanyl group, compared with 42% in the bupivacaine group and 48% in the combined group. Compare relatively the analgesic efficacy in of continuous femoral (CFI) infusion nerve blocks with continuous sciatic infusion (CSI) nerve blocks reserved for patients having poorly controlled pain after total knee arthroplasty (TKA) ? The results were that 83% of patients on CFI nerve blocks required use of the CSI. Within 1 hr of a 510 ml CSI bolus of 0.2% ropivacaine and beginning an infusion of the same drug at 5 ml/h, patients' median pain by verbal analog scale decreased from 7.5 to 2.0 (mean scores from 7.3 to 2.4). What is the efficacy of periarticular Injection of Bupivacaine, Fentanyl, and Methylprednisolone inTotal Knee Arthroplasty? The efficacy of periarticular infiltration of corticosteroid, opioid, and a local anesthetic was evaluated by comparingpainscores,kneeflexion, and quadriceps function on the day of surgery, first postoperative day, day of discharge, and 2 and 4 weeks after surgery between the infiltrated and the non infiltratedknee in 40 patients undergoing simultaneous bilateral computer-assistedtotal knee arthroplasty. They were randomized to receive the injection in the right or left knee. In comparison to the non infiltrated side, the infiltratedkneeshowed significantly lowerpainscores, significantly greater active flexion up to 4 weeks, and superior quadriceps recovery up to 2weeks after surgery. What is the role of Transcutaneous electrical nerve stimulation for post-operativepainrelief aftertotal knee arthroplasty ? A randomized, blinded, placebo-controlled trial was designed to evaluate the utility of TENS aftertotal knee arthroplasty(TKA). There was no significant reduction in the requirement for patient-controlled analgesia with or without TENS. Compare the analgesic efficacy of IV PCA with morphine, with continuous epidural analgesia and continuous 3-in-1 block in terms of analgesic efficacy and postoperative knee rehabilitation after unilateral TKA ? Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with IV patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C.

DISCUSSION

Postoperative pain is a major concern after TKA. It is severe in 60% of patients and moderate in 30%. When inadequately treated, it intensifies reflex responses,which can cause serious complications, such as pulmonary or urinary problems, thromboembolism,hyperdynamic circulation, and increased oxygen consumption . Moreover, it hinders early intense physical therapy, the most influential factor for good postoperative knee rehabilitation. The findings from this study advance our understanding of how nurses, drug and the choice of delivery system play an effective and a crucial role in management of Post surgical pain after a major orthopaedic surgery like knee replacement. Several key issues were evident. First, it was possible to examine the relative importance of the role played by nurses in post-operative pain management by effective communication with clinicians and patients . Second, postoperativepain after a knee replacementis potentially best managed with a multimodal approach that blockspain perception at a variety of sites in the peripheral and central nervous systems and safely provide excellentpaincontrol and hasten functional recovery. Third, no significant role of transcutaneous electrical nerve stimulation for post-operativepainrelief aftertotal knee arthroplasty. Although pain is a personal experience for patients ,it is influenced by the context in which it occurs. The context involves multiple facets and includes how health professionals communicate with each other and with the patient to determine which pain-management strategies to implement .The organization of care, nurses' prioritization of work activities, time constraints and pressures during a working shift, and integration of information to make clinical judgements about how to manage pain all affect such communication (Willson, 2000). Effective communication, between both patients and clinicians, and among clinicians, has been highlighted in the literature for many years as being beneficial to clinical relationships and patient outcomes (Archibald, 2003; Costa, 2001; Twycross, 2002). Interventions for management of pain effectively following a major surgery like Knee replacement were either medication-related or involved non-pharmacologic strategies including walking, giving patients ,hot baths, and applying heat compresses. Effective pain management required patient involvement in decision making, an evaluation of the medication administered or alternative strategies adopted, and an agreed on plan of what would be done for the patient's current pain situation. There has been significant discussion in the literature about the influence of workloads on nurses' decision making (Hoffman & Scott, 2003; McCaughan, Thompson, Cullum, Sheldon, & Thompson, 2002; Norrish & Rundall, 2001). It is evident that the ward environments had a high level of activity and that nurses were often interrupted or distracted from pain activities. Nurses pay little attention to pain cues, and the belief that some pain was bearable is a view held by both nurses and patients. Some researchers have advocated for pain to become the fifth vital sign to elevate the importance of treating it (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002; Federwisch, 1999; National Pharmaceutical Council & Joint Commission on Accreditation of Healthcare Organizations, 2001). Nurses do prioritize other activities that in essence trivialize patients' pain experiences, making them seem less important. Other nurse-initiated activities such as completing wound dressings, conducting vital sign observations, and checking wound sites and drainage tubes are perceived to be more important albeit painful( Manias ,Bucknall and Botti ,). Effective pain management involved rapid assessment of patient pain cues, obtaining appropriate medications to alleviate pain, and evaluating the effectiveness within an adequate time course. There was no differentiation in nurses' level of experience or qualifications and whether they delivered effective pain management(Manias ,Bucknall and Botti ).It is suggested that the problem with pain management does not lie with finding new strategies to manage pain but rather having health professionals use current scientific knowledge in their daily practice and communicate this knowledge effectively with other members of the health care team (Landers, 1990; Mac Lellan, 2004). Most of the nurses do not use visual analogue scale and assess pain at both rest and activity, neither do they evaluate the effect of given analgesics. There is a need for more accurate pain assessment, since the patient experiences and suffers pain and the nurse determines upon treatment(Ene KW,Nordberg G,Bergh I,Johansson FG,).Adopting a policing attitude toward patients to confirm that routine medications were given at specified times played a role in preventing pain. Nevertheless, nurses need knowledge and awareness of when and how the timing of medication can be shifted toward ensuring that patients' pain levels are kept to a minimum and not allowing the pain to peak because medications are held until the exact time of the doctors' orders(Manias ,Bucknall and Botti). The visual analog scale of pain is a 10-point method of assessing pain that has moderate reproducibility but requires some degree of training for accurate implementation. It is best suited to the situation of chronic pain management but has been implemented in the postsurgical setting with some success .It is difficult, however, to implement immediately postoperatively. The adequacy of pain management with the commonly used systemic narcotic agents is limited by the cardio-respiratory and central nervous system-depressive effects. It has led to a number of strategies to improve local analgesia from the level of the spinal cord down to the instillation of local anesthetics and narcotics into the joint itself . These techniques have enjoyed variable success, with no single method providing an outstanding result in the postoperative setting. Nevertheless, regional control of pain remains the most attractive method of analgesia because of a safer side-effect profile. Postoperative pain relief can be achieved by a number of techniques, such as IV PCA, epidural analgesia with narcotics and/or local anesthetics, lumbar plexus blockade and local periarticular infiltration . Multimodal pain management in total knee arthroplasty (TKA) has been shown to significantly reduce opiate requirement after primary TKA. Epidural analgesia with opioid and/or local anesthetics provides superior pain relief compared with conventional IM opioids or IV PCA with morphine. Although they all offer the aforementioned benefits of regional anesthesia, they have different risk profiles and require different levels of postoperative monitoring. The use of epidural catheters also precludes the use of certain anticoagulants such as the low-molecular-weight heparins. It is associated with side effects, such as nausea, pruritus, urinary retention, and respiratory depression with opiates, and bilateral motor blockade and arterial hypotension with local anesthetics. The use of nerve blocks with and without catheters has been proven to be very effective at controlling pain and minimizing narcotic requirements after THA and TKA. Continuous 3-in-1 block provides better pain relief than systemic (IM or IV PCA) opioids It is as efficient as epidural analgesia and induces fewer side effects; it is thus considered the analgesic technique of choice after open knee surgery. There are, however, several drawbacks, including the increased time it takes to place the blocks; the availability of skilled anesthesiologists to place them; and, perhaps most importantly, the associated motor blockade that limits functional recovery and delays rehabilitation. Nonetheless, several specialized centers have made continuous 3-in-1 femoral nerve blocks for TKA routine for all patients because of its excellent pain-relieving capability. Continuous 3-in-1 block and epidural analgesia provide better pain relief than IV PCA with morphine after TKA. Except in the immediate postoperative period (4 h), these loco-regional anesthetic techniques provide comparable analgesia. However ,continuous 3-in-1 block induces nearly 4 times fewer side effects than epidural analgesia which was recently confirmed in more than 500 patients (2). Thus, we can conclude that continuous 3-in-1 block is the technique of choice for providing postoperative analgesia after TKA. There has been a significant push in the marketing and promotion of minimally invasive surgery (MIS) for total joint arthroplasties. Recent literature has been unable to demonstrate objective advantages in terms of improved pain and functional recovery from MIS as has been marketed [1a,1b,1c]. The marketing claims made by MIS-THA and MIS-TKA proponents have given misguided perceptions to the public regarding the current standard of care. It appears that pain control plays a much larger role in functional recovery than incision length. After knee surgery, poorly managed pain may inhibit the early ability to mobilize the knee joint. This, in turn, may result in adhesions, capsular contracture, and muscle atrophy, all of which may delay or permanently impair the ultimate functional outcome (3). Compared with conventional IV or IM opioid treatment, epidural analgesia is associated with more rapid achievement of all postoperative rehabilitative milestones and, in some studies, a shorter hospital stay (4a,4b,5). Compared with IV PCA with morphine, continuous femoral nerve block improved the range of motion, but only in the early postoperative period. (6). After open knee surgery, pain can be associated with severe reflex spasms of the quadriceps muscle,causing further pain and impaired muscle function.Rather perplexingly, these spasms begin as soon as the patient begins to ambulate, and their mechanisms are unknown. Animal data suggest that the massive nociceptive input from stimulation of nociceptive afferents produces sensitization not only of the peripheral nociceptors, but also of dorsal horn neurons. This increased excitability in the spinal cord is strong and prolonged. Consequently, non-nociceptive input (e.g., touch, proprioception) triggers increased reflex excitability with consequent spasm of the muscles supplied by the same and adjacent spinal segments (7). With regional anesthesia, the massive afferent nociceptive input is blocked; consequently, these reflex responses do not occur. Thus, prevention of quadriceps muscle spasm could explain the prolonged beneficial effect with the loco-regional anesthetic techniques. However, this hypothesis should be confirmed by specific studies. Continuous 3-in-1 block and epidural analgesia equally allow better and faster postoperative knee rehabilitation (earlier fulfillment of discharge criteria [90 of knee flexion], earlier ambulation, no stiff knee) and shorter duration of hospital stay than IV PCA with morphine after TKA. Because it induces fewer side effects than epidural analgesia, a continuous 3-in-1 block is the technique of choice to provide postoperative analgesia after TKA. The concept of multimodal pain control(Table1.0) including local periarticular injection has received increasing interest in the recent literature [8-10], and published results are promising in terms of improved perioperative pain control,reduced need for narcotic medications, and reduced associated side effects [8,9]. Recent reports have used periarticular injections as a supplement to conventional pain control modalities including patient-controlled anesthesia (PCA) pumps and femoral nerve blocks(FNB's). Meticulous periarticular infiltration with the novel injection mixture (corticosteroid, opioid and a local anaesthetic ) produces early potent analgesic and anti-inflammatory effects. This injection forms the core of the advanced multimodal pain protocol. Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities. However ,there was no significant difference inpain scores between the study and control groups in the TKA . TENS is a system of analgesia based on the gating theory of pain . The technique has been tried and shown some efficacy in the setting of chronic pain syndromes]. Its use in the postoperative setting for acute pain was first explored by Cornell et al [11] for analgesia following foot surgery. This study showed a significant reduction inthe need for oral analgesics in the TENS group, but used historical controls and did not include a placebo group. Subsequently, Arvidsson et al [12] used it in the postoperative management after knee surgery. However, this study was flawed by lack of adequate controls and small numbers of patients (n = 15). However, it showed that the placebo use of TENS did not lead to significant analgesia, while showing a weak analgesic effect for high-frequency TENS. In contrast to the earlier studies in a similar setting, this study by Robert Breit and Hans Van der Wall[] did not show any statistically significant benefit from TENS across the population tested. The study was designed with a placebo group, while providing alternate PCA. The reduction in alternate analgesia in the form of PCA was therefore a direct measure of the true utility of TENS.

CONCLUSION AND RECOMMENDATIONS

This retrospective literature based study has highlighted the role played by nurses in the management of post-operative pain after knee replacement. Effective communication, improvements in nurse education relating to palliative care, accurate pain assessment and effective time management are the measures that were considered of importance in improving nurse's ability to manage pain effectively. Six themes were identified in effective management of pain in the postoperative settings after a major surgery like knee replacement. They were effective management of pain, prioritizing pain experiences , regulation of pain control regimens without compromising patient's comfort, avoid missing pain cues, preventing pain, and reactive management of pain(13). Knee replacement was found also to be more painful than hip replacement after operation. This study has reiterated the importance of multimodal approach in pain management that has proven effective by reducingpain, narcotic usage, length of hospital stay and hastened functional recovery. It is achieved by a number of techniques, such as IV PCA, epidural analgesia with narcotics and/or local anesthetics, lumbar plexus blockade and local periarticular infiltration. Continuous 3-in-1 block and epidural analgesia equally allow better and faster postoperative knee rehabilitation and shorter duration of hospital stay than IV PCA with morphine after TKA. Because it induces fewer side effects than epidural analgesia, a continuous 3-in-1 block is the technique of choice to provide postoperative analgesia after TKA(20). Transcutaneous electrical nerve stimulation( TENS) is a system of analgesia based on the gating theory of pain .There was no significant reduction in the requirement for patient-controlled analgesia with or without TENS. Thus, there is no utility for TENS in the postoperativemanagementofpainafterknee arthroplasty(24).

LIMITATIONS

The study is based on the information published by various articles related to the above topic of study and is limited by the resources and credentials of that particular study. Since the study is mostly based on review of various literature in different hospital settings, it may not be generalized. As the study does not involve any observational design, the report is purely based on the evidence of the articles published in various medical journals. The study is basically a convolution of various findings in different case-control studies and is limited by the old proved evidence. It has no new research finding except for a conflux of evidence integrated in the most scientific manner.

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