The Psychology of Knee Pain: Coping Strategies for Singaporean Patients

A comparison between ethnic groups has yet to be conducted in Singapore, but it is relevant given the multi-ethnic nature of the society.

Control over the pain experience has been cited as a reason for ethnic differences in the use of alternative and complementary medicine by arthritis sufferers. The assumption being that the Western medical model has found little in the way of cure for arthritis and its treatment is largely palliative, texture and chiropractic therapies are often used as a means to control pain at specific times of functional need.

The understanding of cognition and pain has evolved from the study of the psychopathology of pain patients, to the modeling of the pain experience, and more recently, the study of ways in which the individual can control their pain experience. This last aspect is particularly relevant to the study of coping and coping strategies.

This model can be used to understand aspects of knee OA; however, it has limitations in understanding the coping strategies used by the lady at each stage to avoid or minimize the outcome. An increased understanding in this area could help to avert the chronic nature of the pain and disability associated with knee OA.

An example of how this model applies to knee OA would be an elderly Chinese lady who has to stop going to the market to buy her groceries (biological factor – she has pain in her knees, which leads to an excess load and consequent damage to the joint). Her husband then takes over the grocery shopping (psychological factor – she feels guilty about not being able to fulfill her role and is anxious about communicating this to her husband). The lady then becomes socially isolated (social factor – she is not interacting with her friends at the market). As a result of these changes, there is increased pain and further functional loss in her knees.

Chronic pain, as a phenomenon, tends to be probed in terms of a linear causal model. This model looks at the biological, psychological, and social factors of pain and how they lead to the experience of pain, the behavioral and emotional responses, and ultimately, how these responses lead to an increase in the disability and distress that is associated with the pain.

Understanding Knee Pain

In understanding the prospective causes of knee pain, the first step is to elucidate the anatomical and physiological factors which make the knee vulnerable to various injuries and diseases. The knee is essentially a hinged joint which is held together by the medial and lateral collateral ligaments. These prevent the knee from deviating too far from the normal flexion and extension plane. The cruciate ligaments, which are found deep inside the joint, provide anterior/posterior stability and prevent the femur from sliding on the tibia and vice versa. These four ligaments, along with the 2 menisci of the knee joint which act as shock absorbers, are prime factors in the mechanical stability of the knee. Any injuries to these said structures will lead to instability of the knee and a feeling of one’s knee ‘giving way’. This will lead to increased wearing of the joint surface and cause degeneration of the knee, producing pain from various activities. Any extreme sports can cause fractures and dislocations of the knee due to sudden trauma, and these too can cause instability and pain in later life.

The knee is one of the central joints in the human body, often threatened by injury or disease. An acute injury may cause severe pain to prevent proper movement, while certain systemic diseases, such as gout or pseudogout, can lead to recurrent attacks of knee pain. The complex anatomy of the knee and the fact that it is an active joint are factors that increase the likelihood of various types of knee problems. On the whole, the knee is the largest joint in the body, and the chief articulation of the lower limb with the thigh, so it is not surprising to find that knee pain is the most common musculoskeletal complaint with over one third of all Americans reporting it in any given year. Knee pain has a wide variety of specific causes and treatments. An accurate diagnosis and its prompt correction are a necessity to prevent serious damage of the knee and to relieve pain.

Causes of Knee Pain

The knee is a complex joint, which is often subjected to both acute and chronic trauma that can result in damage to the structures of the knee. Acute knee injuries often occur when people overextend themselves physically, such as in a sporting event, or through direct trauma to the knee. This can result in tears or ruptures to the ligaments and cartilage in the knee. People may also experience medical conditions such as arthritis in the knee or a gradual wearing down of the cartilage in the knee that can lead to pain and discomfort. Gender has also been shown to affect the prevalence of knee pain, with women being at higher risk. It has been shown that muscle strength may be a factor in this case, since it is important in preventing knee injury, and women have less muscle strength than men. There is also a psychological link in that often events such as ACL ruptures, which are a very traumatic event and incidence, leading to higher fear-avoidance beliefs in patients who have an episode of acute pain. This can then lead to avoidance of activity and, in the longer term, disuse and deconditioning, which then results in chronic knee pain.

Impact of Knee Pain on Mental Health

goes on to say that ‘the patient’s interpretation of pain as harmful and his lack of understanding of the relationship between pain and the health of the tissue, may cause him to undertake quite inappropriate avoidant behaviour, which may seriously exacerbate his problems’. This is seen all too often in knee OA patients who become afraid to move the joint into painful positions and so limit their joint mobility. and both discuss how reduced joint mobility leads to muscle weakness and an overall reduction in functional ability. This ultimately leads to some level of physical disability, deformation of the joint and mal-alignment of the lower limb, all of which induce and perpetuate pain. It is at this stage of the disease process that patients suffering with pain in OA joints develop the overwhelming feeling that their health is beyond their control and this causes them to feel helpless and sometimes depressed.

The next chapter discusses the psychological effects of pain that are now well-recognized and widely accepted, particularly in Western culture. describes how the understanding and interpretation of pain has changed from the seventeenth century when it was perceived as a short-term, intense sensation that was synonymous with the diagnosis and prognosis of the condition, to the mid-nineteenth century when it began to be regarded as dissociable from the disease process, but was still seen as a sensation rather than an emotional experience. Now, pain is understood as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. This is particularly relevant to knee OA as pain, whether acute or chronic, is an inescapable symptom of the condition.

Coping Strategies for Managing Knee Pain

Specific types of exercise (i.e. quadriceps strengthening) were advised by healthcare professionals, and there is a plethora of information in the current medical guidelines as to what types of exercise are suitable for patients with specific knee conditions. The patients in IE1 wished for a structured, individually tailored progressive exercise program that used behavioral and goal-oriented strategies to increase adherence to the exercise prescription.

Heat therapy was perceived to be more beneficial than cold therapy. The population sample viewed non-aquatic exercise to be healthier for their knee, and appropriate form of exercise was viewed as a long-term investment in order to improve musculoskeletal function such as alignment and better control of knee movement. It was suggested that aerobic exercise may need to be reduced and used as a last option for symptom management in elderly patients with knee osteoarthritis. Swimming was recommended as the most suitable form of exercise as it will improve fitness without aggravating knee pain.

Manual therapy was said to produce positive outcomes and involved the physiotherapist manipulating soft tissue and joint structures to improve the patients’ musculoskeletal function. This was said to be most effective when the number of manipulations was kept to a minimum. TENS machine was said to give pain relief when used during activity and was used as a substitute for medication. Responses regarding acupuncture were varied as to its effectiveness at pain relief. The general view was that the intervention had not produced any negative effects on the symptoms, and a few patients reported some temporary pain relief.

The most common indicated coping strategy was to use physical therapies and exercises to help manage the patients’ knee pain. It was suggested by the participants that the use of physical therapies and exercise is most beneficial when prescribed and monitored by a healthcare professional, such as a physiotherapist. Physical interventions included manual therapy, electrotherapy, and thermal modalities.

Physical Therapies and Exercises

Physiotherapy sessions are often focused on the improvement of specific movement in the joint and muscle strengthening. Static quadriceps contractions and straight leg raises are examples of simple exercises used to contract the quadriceps to improve muscle strength around the knee joint. A research study of 250 individuals who had knee osteoarthritis, did therapeutic exercise, and decreased their calorie consumption concluded that both exercise and weight reduction provide a 40% reduction in symptomatic mobility disability. This is due to the effect of reducing loads on the lower limb, which can prevent or slow the progression of knee osteoarthritis. Another form of therapy called hydrotherapy has been documented to improve self-efficacy in patients and provide a social environment to interact with people with similar conditions. However, the benefits of hydrotherapy in comparison to land-based exercises have not been largely investigated.

One of the common medical prescriptions for knee pain is a referral to a physiotherapist, and often the patient has a belief that a certain medical keyhole procedure or surgery is the only solution to rectify the knee problem. According to a study, after an education session regarding the benefits of physiotherapy and exercise, the patient delayed the surgery for 14.5 months compared with the group of patients who did not receive the education. This demonstrates how an effective coping strategy can influence the decision-making of the patient. The education of delaying the surgery to engage in physiotherapy and exercises seems to be a positive sign in enhancing the self-efficacy of the patient in terms of improving or maintaining the knee condition. A qualitative study interviewing osteoarthritis patients regarding their self-efficacy in coping with the condition has identified five main themes. These include a focus on the physical and psychological benefits of exercise, setting realistic goals for exercise, finding the right type of exercise for osteoarthritis, adopting a positive mindset, and using social role models of exercise.

Previously, readers were informed of the importance of seeking medical attention early in the event of knee pain and how their beliefs can influence their coping strategies. One of the common recommendations from the knee pain specialist will be to suggest physiotherapy and provide some information on it. Due to the allocation of words for physiotherapy, this present section will encompass both physiotherapy and exercises.

Mind-Body Techniques

Last but not least, learning these techniques has a consistent psychological effect of internal locus of control, meaning feeling that I am in charge of my disease and not vice versa. This, along with its effect on self-esteem, is discussed in the next chapter by a patient who has effectively used these techniques. The patient explains the importance of creating a supportive mind-body environment in which medicine will act. And mind you, this is not mere placebo. Various research studies have shown that many of these techniques have a high effect size, comparable to regular drug treatment. And with the recent concern of side effects of some medicines, these techniques can be considered as a safe and effective alternative for pain relief.

The next technique, generally done in group sessions, involves expressing emotions related to pain through art, writing, or talking. It has been shown to decrease pain intensity and improve joint mobility. This is due to a decrease in guarding behavior and muscle spasm, which occur involuntarily with pain.

The basic science behind it is that pain pathways are modulated up to 30% at the spinal cord level by higher centers in the brain. This means that the brain can to some extent increase or decrease the intensity of pain. It has been observed that during pain, certain higher centers in the brain become activated and over time, their activity becomes restricted to pain pathways. For example, anxiety and fear related to worsening of pain or pathological damage to the body. These centers can become independent of pain and start a vicious cycle by increasing pain intensity. Therefore, by relaxing and diverting attention from pain, one can decrease its intensity. This is exactly what techniques like progressive muscle relaxation, deep breathing, meditation, guided imagery, biofeedback, self-hypnosis, and tai chi aim to achieve. Complete details and methods to practice these techniques are given at the end of the chapter. Here, we can simply say that they induce a relaxation response and help decrease pain and associated distress.

In this section, we are discussing pain and its management through various coping strategies. Coping strategies are different ways people handle the problem of pain. We need to establish a logical and physiological basis for choosing mind-body techniques for our patients. This may not sound very scientific and convincing to many people, but recent research in neuroscience has provided ample evidence that these techniques can be effective.

Support Groups and Peer Counseling

This contrasts with using two sticks or crutches, which, although effective, can impact a patient’s mental well-being due to the stigma attached to using these devices. A patient might not feel like using walking aids initially, but it can often be shown experimentally by a therapist that there is less pain and fatigue at the end of the activity.

Next are activity simplification, which is largely finding less stressful ways to achieve the same end, and activity pacing, which breaks an activity into manageable portions with rest between each segment. Both of these techniques are very effective for knee pain coping, but often require a session with a physiotherapist who can provide targeted advice. The use of walking aids, such as a single stick, may be highly recommended because it reduces pressure through the affected joint. A stick in the opposite hand to the affected knee is used since it is more natural. Therefore, by walking with the affected side and the stick together, the abnormal gait caused by the knee pain is prevented.

This category of knee pain coping involves again the fabric, but rather than rebuilding style, it may be altered in such a way to offer therapeutic consequences. A patient with part ache can also find it impractical, as much as possible, but lying down with the affected side in the air is ready and beneficial. This position may be adopted for the purpose of icing the knee and can be easily modified so that the necessary activities, using pillows for support, are made easier.

Lifestyle Modifications

A recent literature review by Piva et al. (2012) highlighted the lack of specific evidence-based guidelines for activity modifications for individuals with PFP. Given that activity modification is a strategy intended to reduce symptom provocation, it is essentially an avoidance coping strategy. Individuals using this strategy may have difficulty in identifying when it is working, as there is no clear marker of success other than a reduction in symptoms.

An interesting qualitative study by Paterson (2003) investigated activity modification behaviors of patients with knee pain and found that they used a process of trial and error to arrive at activities that minimized pain and maximized or maintained their life roles. He also found that patients often received little guidance on how to modify activities and that those who were unsuccessful in doing so felt a sense of loss due to the changes in activities that were meaningful to them. This study suggests that the use of activity modification is a relevant coping strategy for patients with knee pain and can be examined further with respect to PFP.

The Arthritis Foundation makes numerous recommendations for patients with knee pain, though these suggestions are not specific to individuals with PFP. They advocate the use of canes or other assistive devices, sitting on high chairs or stools to avoid bending the knees past 90 degrees, using a raised toilet seat, shower chair, and hand-held showerhead to make bathing easier, and sleeping with a pillow between the knees or under the knees to support leg alignment. While these are viable suggestions, they are the result of expert opinion and not scientific evidence.

Recommending that patients modify their daily activities in an effort to minimize knee pain symptoms is a common suggestion from healthcare providers. The rationale behind this is that certain activities may exacerbate symptoms, while others are better tolerated. Despite the widespread use of this coping strategy, only limited information is available about how patients should approach making activity modifications.

Seeking Professional Help

Following diagnosis, it is important for patients to be given clear information about their condition, the nature and purpose of treatment, and what they should expect as an outcome. Realistic expectations of intervention or treatment can help to encourage and maintain active patient involvement in their own care and potential rehabilitation. This is especially pertinent to the decision-making process involving surgical intervention. With an increase in readily available medical information, greater autonomy in decision making has been noted among patients regarding the choice of treatment. Therefore, it is essential that there is open and clear communication between specialist and patient in order to make an informed choice of management. An informed choice of management has been shown to result in greater satisfaction with the ultimate decision and outcome of treatment. This information should be made available in such a way that it is easily understood, as knee pain patients have been shown to understand medical conditions and their treatment better when information is both verbal and written. Written information also provides a useful point of reference for patients at a later stage.

In seeking professional medical assistance, patients report receiving an initial diagnosis of their knee pain without the request for further information on the nature or cause of their condition or prognosis. From there, they are typically referred to an orthopedic specialist for further management of their condition. The process of diagnosis, it seems, could be more thorough and involve the patient more, leading to a better understanding of their condition and what is required to manage it.

Finding a Knee Pain Specialist in Singapore

Begin your search by asking friends or family for recommendations, especially those who have sought treatment for similar conditions. By doing so, it will allow you to gauge the clinician’s attitudes and beliefs, which would likely affect the outcome of the treatment. Such clinicians would be easier to communicate with, hence more likely allowing you to express concerns or ask questions that you might have in mind. It is also essential to find a clinician that is both experienced and is a specialist in the area of your condition. General practitioners (GPs) would be able to manage and treat many different types of knee conditions. Seeing a GP might be a viable option if it is of lower severity. They would then be able to refer you to a specialist if the current treatment provided is ineffective. However, it is suggested to see the specialist directly if the condition of the knee is of higher severity. Seeing a specialist would ensure that you are receiving the best type of care that is available. Finally, funding can be a problem when deciding on a particular clinician. Find out whether the clinician and the treatments provided are covered by insurance. Seeing a clinician that is not covered by insurance would hold a larger hole in your pocket.

Treatment Options Available

A study examining the management of knee pain in older adults in primary care in the United States found that the following treatment options were commonly used and were often tailored to individual patients: medication (paracetamol, NSAIDS), intra-articular steroid injections, physiotherapy and manipulation, brace prescription and in some cases referral to an orthopedic surgeon. Other conditions such as ligament or meniscal injuries may be managed with different interventions including surgery. Hence, it can be seen that treatment options for knee pain are varied and it is often difficult to determine the best course of action for each individual patient.

Treatment options for knee pain are very much dependent on the cause and severity of the pain. The many different diagnoses for knee pain have not been covered in this study but it is well established that accurate diagnosis of the underlying cause is essential for effective treatment. A study of Singaporean orthopedic surgeons found that the most commonly provided interventions for medial knee osteoarthritis were patient education and weight loss, which are supported by evidence as being beneficial interventions. This was followed by prescription of simple analgesia and non-steroidal anti-inflammatory drugs as well as physiotherapy. Referral for consideration of total knee arthroplasty was usually only made for severe cases of osteoarthritis.

Knee pain Singapore sufferers are not short of professional help. Orthopedic doctors and sports physicians are two groups of specialist doctors who treat knee pain. General practitioners (GP) are often the first to be consulted and are able to diagnose many different causes of knee pain. The availability of physiotherapy and traditional Chinese medicine (TCM) is widespread and many patients obtain treatment from these practitioners. Severe and persistent knee pain may be assessed by an orthopedic surgeon for possible surgical intervention. Rheumatologists and neurologists are other specialist doctors who may be involved in the treatment of patients with certain diagnoses. Hence, the type of professional help sought often depends on the diagnosis as well as the accessibility and affordability of the various treatment modalities.

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