Pain management: importance of managing pain after a TKR and the pain chart


Nurse Director
Jun 8, 2007
The North
United Kingdom United Kingdom
The process of pain/swelling/healing and all is this
In other words, it's not so much that pain causes swelling but that the after effects of surgery is swelling as the after effects of any trauma to the tissues is swelling. So you have a double causative effect (otherwise known as a vicious circle!) going on: the surgery causes pain and swelling; the swelling causes compression and stiffness which results in more pain; the increase in pain causes more swelling and stiffness - what David so eloquently described as "angry tissues"! Then along comes the PT and starts doing indescribable things to the joint which causes more swelling and therefore more pain, etc., etc.

All of this hinders recovery not healing, as the swelling ends up acting like a splint, prevents the knee from moving very well if at all. Then the patient gets frantic that they're not making progress and instead of cutting back on the exercise and activity, try even harder to get that elusive ROM which just makes matters worse. This anxiety results in the over production of adrenaline and cortico-steroids which cause more anxiety and even depression. It is indeed the ultimate vicious circle.

Stopping the cycle:
So to stop this cycle, you need first of all to treat the pain with appropriate medications and ice. With the pain under control, you can set about getting the swelling down by with rest, ice and elevation. When that is improving, those negative hormones will not be produced in such quantities and your mood will improve. Then you get the ultimate feel-good factor as endorphins start being produced, nature's own pain killers, which eventually will help you to start going longer between doses.

But in the early days you need to bear in mind is that if you leave too long a gap between doses, then the medication takes longer to work during which period the pain continues to get worse. I defined this in this graph


So you can see that pain meds don't hinder healing but the results of pain being inadequately managed will hinder recovery. Therefore, doctors who are urging their patients to get off pain meds early are actually defeating the object of their surgery.

The biggest issue in the US seems to be that of addiction and often times members have posted their concerns and their doctors concerns about this.

Now it should be noted it is possible for the body to become accustomed to the presence of a medication but this is a long way from an addiction. Addiction is taking a medication when there is no pain, in other words, purely for recreational use. Being accustomed to the drug, or having a dependency, just means that the individual needs to wean themselves off the medication over a period of weeks in order to avoid the 'withdrawal' symptoms. Provided this is done gradually, there should be no difficulties and certainly no lasting effects akin to addiction. But tailing off the pills is not something you need to dwell upon. As Jamie described, you'll find yourself naturally leaving longer gaps between doses, not because you plan to but because you don't have the pain to remind you to take them. Just do remember, you're not going to get addicted or become a pill junky because of taking a few pain killers for 3-4 months. Research has shown that this just doesn't happen when the meds are being taken for genuine pain.

However, if you should find yourself scouring the internet looking for ways to get the pills without going to your doctor or even considering buying them from a contact, then you have a problem! But the incidence of that happening is extremely small! In fact, research has shown that people really getting addicted to pain meds where there is genuine pain, is about less than 3 people in every 1,000 (0.27%)

Myth busting: on getting addicted to pain meds
Various types of pain.

Often when people say they have 'no pain' they are thinking of the arthritic pain they had before. Post-op pain is different and manifests itself as

You should take pain meds for this and maybe even apply an ice pack over the swollen area. Wrap it in a tea towel at first though - we don't want you getting freezer burn!

Pain meds and drug addiction
Another big issue seems to be about getting addicted to drugs: please read this Myth busting: on getting addicted to pain meds

You might also fine this chart useful

opioid conversion table 1.JPG

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