To gain insight into patients' experiences of adjustment to chronic pain following recovery from total knee replacement (TKR) surgery.
To gain insight into patients' experiences of adjustment to chronic pain following recovery from total knee replacement (TKR) surgery.
Participants were purposively sampled and comprised 28 individuals, 18 women and 10 men, ages 57–87 years, who had undergone a TKR between 2 and 5 years previously. Semistructured interviews explored participants' perceptions of their condition and its impact, including its causes and consequences. Thematic analysis, using the constant comparison technique, was used to identify and analyze patterns and themes from the transcripts.
Although some individuals expressed acceptance of their continuing pain, others reported that it caused them considerable distress. Variation in expressed acceptance and distress was not related to self-reported pain severity. Various factors relating to adjustment emerged, including perceived improvement or deterioration in circumstances since TKR, surgeon input pre- and postsurgery, and beliefs about pain in the context of an individual's life. Participants described a sense of abandonment following TKR and discussed the support they felt they should have received.
The data suggest that adjustment to chronic pain following recovery from TKR surgery is influenced by biomedical and psychosocial factors, including an individual's pain-related illness cognitions, beliefs, and their perceptions of their condition in a social context. Patient care could be improved by clinicians utilizing a biopsychosocial framework to acknowledge the impact of osteoarthritis of the knee as a multidimensional health condition.
Total knee replacement (TKR) is considered an effective intervention for the relief of chronic knee pain and restoration of functional ability. Such pain, most often caused by osteoarthritis (OA), affects between 7% and 33% of the adult population (1). TKR is one of the most common elective procedures, with more than 55,000 performed in the National Health Service (NHS) in the UK during 2008 (2). Predictions suggest that the overall need for joint replacement will continue to rise (3, 4) because of changes in patient demographics and widening indications for surgery (5).
Studies using surgeon-based measures and survivorship have shown TKR to be a highly successful procedure (1). However, those utilizing patient-based outcome measures reveal that 6–30% of patients continue to experience chronic pain after recovery from surgery (6, 7). Qualitative research investigating patients' experiences of TKR outcome suggests that even self-report measures may underrepresent actual pain levels: Woolhead et al (8) found, during interviews, that participants initially reporting good outcomes later acknowledged ongoing pain and difficulty with mobility. However, little additional research has investigated the patient experience of pain following TKR, and interviews in the Woolhead et al study were conducted just 6 months postsurgery, so pain may have resulted from a prolonged recuperative period, as rationalized by some participants.
Chronic pain has been identified as a complication following many other forms of surgery, with incidences ranging from 10–50% (9). The experience of such pain has been correlated with poorer quality of life (10), higher levels of neuroticism (11), and significant interference with diverse daily activities (12). Furthermore, independent of clinical factors, psychosocial factors such as depression and expectations are predictive of surgical outcome (13), and depression and stress have been identified as risk factors for the development of chronic pain after surgery (14). This indicates a need to go beyond the biomedical model, which views illness as resulting purely from biologic factors (15). The biopsychosocial model has been advocated for research and treatment of knee OA (16) and could provide a useful multidimensional framework for attempting to understand the experiences of individuals with chronic pain following TKR. This model conceptualizes pain as a dynamic process, both influenced by biologic (e.g., underlying disease mechanisms), psychological (e.g., thoughts and beliefs), and social (e.g., social support) factors, and also producing biologic, psychological, and social changes that in turn affect the experience of pain (17). This dynamic complex interaction needs to be considered when exploring the impact of chronic pain.
Research suggests that the impact of chronic pain does not result purely from pain severity, but also from how individuals adjust to cope with persistent pain (18–20). Various psychological and social factors have been implicated in adjustment to pain and OA, including social support, coping responses, role loss, illness beliefs, and acceptance (21–24). Acceptance is defined as acknowledging the presence of pain, ceasing unsuccessful attempts to control pain, behaving as though pain does not consequentially imply disability, and directing efforts into living a satisfying life, regardless of pain (19). Research has shown a negative relationship between pain acceptance and emotional distress (19, 20, 25–27) and an association between acceptance and less physical and psychosocial disability and better work status (19, 26). Acceptance has previously been linked to improved patient recovery from total hip arthroplasty: Fujita et al (28) suggest that realistic expectations of TKR are key to acceptance of postoperative pain and levels of physical function.
The current study was conducted to gain insight into patients' experiences of chronic pain after surgery, once sufficient time had elapsed for pain to be nonattributable to a prolonged recuperative phase. Qualitative methods were chosen to gain understanding of experiences and meaning. This study focuses on adjustment to chronic pain after TKR.
A qualitative approach with a semistructured interview design was adopted to gain an in-depth understanding of the participants' experiences and perceptions of chronic pain following TKR. Potential participants had undergone TKR surgery at a single UK NHS Trust at least 1 year previously and reported, in a questionnaire completed as part of another research study (29), continuing moderate to severe chronic pain. Exclusion criteria were not speaking English and having had revision surgery. Participants were purposively sampled to gain a diverse variety of experience; individuals of both sexes with a range of pain severities and ages were identified and contacted by mail.
Participants were asked to provide written informed consent to take part before face-to-face interviews were conducted by one of the authors (AEJ). Interviews took place at participants' homes or in a private office within the hospital and lasted from 30–100 minutes. Participants additionally completed the pain scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (30).
The interview schedule explored individuals' perceptions of their condition and its impact, including its causes and consequences. There was flexibility to pursue other areas of interest raised as the interview progressed. Interviews were audio recorded, transcribed verbatim, and anonymized, with each participant assigned a pseudonym.
Thematic analysis (31) using the constant comparison technique (32, 33) was used to identify and analyze patterns and themes from the transcripts. First, transcripts were read several times, with initial ideas noted and inductive codes assigned to segments of the data that provided insight into the participants' views and understanding of their experiences. New data were compared initially to previous data, and then to the properties of emerging categories that contained the main themes. The data were also scrutinized for negative cases, and reasons for the deviance were explored by comparison with the entire data set (32). A random subset of 10% of the transcripts was independently coded by two of the authors (AEJ and JPH); any discrepancies were discussed and resolved.
The study was approved by the local NHS Research Ethics Committee and the NHS Research and Development Office.
Fifty-eight patients were contacted and 30 (52%) indicated their interest to participate. Interviews were conducted until data saturation was reached, whereby no new themes emerged. This occurred after 28 interviews. Participants (18 women and 10 men, ages 57–87 years) experienced mild to extreme chronic pain in their replaced knee (WOMAC scores ranged from 9–23 of 25, with a lower score indicating less pain; mean 14.7) and reported using medication for pain relief. Patients were 2–5 years postsurgery (mean 3 years). Patient characteristics are shown in Table 1.
|Pseudonym||Age, years||Sex||Years since TKR||Occupation||Other joint replacements||Pain level|
|Alf||70||M||5||Retired, voluntary work||Other knee, both hips||Moderate|
|Donald||72||M||3||Retired, voluntary work||None||Extreme|
Analysis of the data revealed that although some individuals expressed psychological adjustment to their postoperative pain, for others it remained problematic. This was not related to perceived pain severity as measured by the WOMAC (Table 2). Various factors relating to adjustment emerged, including perceived improvement or deterioration since TKR and surgeon input pre- and postsurgery. Participants described a sense of abandonment following TKR and discussed the types of support they felt they should have received.
|Little emotion/much acceptance||Some emotion/some acceptance||Little acceptance/much emotion|
|Average WOMAC score*||14.3||16.2||14|
Interviews revealed much individual variation in feelings of adjustment to pain. Some participants expressed little or no emotion concerning their pain and described an accepting attitude toward their symptoms. Although not directly questioned about acceptance, participants voluntarily raised the subject. Acceptance was either discussed directly or conveyed when participants described pain as a part of their life to which they had become accustomed and did not spend undue time thinking about:
“…it's just a case of you've gotta face up to it and you've gotta get on with life and you've gotta accept it” (John, age 74 years).
“…Once again, it's part of my life, you know, I just don't, I don't think about it much…” (Phyllis, age 81 years).
Conversely, approximately half of the participants experienced difficulty adjusting to their pain. Some expressed much pain-related distress, including frustration, anger, and depression:
“Depressed, totally depressed, sad, miserable, charred off, all the things that go with that that you can think of” (Dennis, age 59 years).
“Oh I gets wild don't I. Gets mad” (Nelly, age 84 years).
Particularly high levels of pain-related distress were expressed by a few:
“… I just don't know what to do with it.… I was in so much pain I said to my husband, and it's only him I'd tell, I wouldn't tell the family, I said if I don't do something I shall, well I shall jump off the bridge” (Sally, age 75 years).
This indicates the emotional impact of the condition and the extreme difficulty some had in coping with postoperative pain. Others thought they should accept their pain, although they had been unable to consistently do so:
“…to a degree you learn to live with it, but there comes a time during the course of the day, when it does get a little bit on top of you” (Donald, age 72 years).
“Well I've just got to put up with it, I've just got to accept it, it's there and I'm stuck with it, um so there's nothing I can do about it so I'll just have to accept it…” (Julia, age 76 years).
These data suggest that, although all of the participants reported chronic pain, some were accepting of their pain, while others struggled to cope.
Variation in expressed emotion and acceptance was not related to WOMAC pain scores, suggesting that psychosocial factors may play an important role in postoperative pain adjustment. A number of illness beliefs emerged as significant in terms of acceptance: most universally, individuals' perceptions of improvement or deterioration in circumstances since their TKR. Those perceiving an improvement in pain or functioning expressed little distress and a more accepting attitude:
“…um, what I was ten years ago, I'm brilliant, whereas ten years ago I could hardly move, so, I gotta say touch wood thank you very much for what I've got. If it hadn't been for having two new knees I could have been in a wheelchair” (Edna, age 58 years).
Despite some remaining pain, the belief that the TKR had improved their situation led participants to feel satisfied with the outcome. However, those perceiving deterioration or no change in their situation since their TKR expressed more pain-related distress; this was often discussed in relation to expectations for outcomes that had not been met. For example, prior to her TKR, Emma only experienced pain at night, but subsequently she also had pain during the day, which affects her ability to perform daily activities:
“…It's disappointing because you think it's gonna be so much better after you've had it done, and really you're not, it's different but you're not the same as you were before, you've not got the problems that you had before but they've been replaced by other problems…it really has made me more handicapped than I was before” (Emma, age 77 years).
Individuals' beliefs about the impact of their TKR related to acceptance of their remaining pain.
Various other specific beliefs were related to acceptance. Some participants were only offered further surgery in response to their continuing pain, which they declined; this led to the belief that they were to blame for their pain and therefore must accept it:
“…I just accept it, because I don't choose to go and have it done again, or put right if they can't so it's my own fault so I just live with it” (Phyllis, age 81 years).
Others felt fortunate not to have a more serious condition and displayed stoicism, framing their situation in a positive light:
“It's just something you've got to accept isn't it. I mean I haven't got cancer or anything bad like that, so you just, just be grateful that you're able to get up and out, go out I suppose” (Rose, age 81 years).
Several retirement-age participants linked their pain experience to the aging process, viewing some pain as expected and almost inevitable:
“…everything is wearing out and I can't, you know, blame the operation…” (Peggy, age 77 years).
Feeling in a similar position to peers seemed to facilitate acceptance:
“…most of our friends have got pain anyway…one we know had two hip replacements, another one's had one, somebody else's had two knees and two shoulders, oh most of them have their aches and pains” (Joan, age 79 years).
Such normalization of pain in this context may be a means of coping with the condition. This contrasts to the experiences of younger participants who noticed their limited physical capabilities in comparison to peers. Some described frustration when friends and family did not understand mobility restrictions:
“…go shopping with my wife…she doesn't seem to appreciate, we go to that shop over there and then we come back to this one, that's a distance, it's no distance for the likes of you or her…” (Dennis, age 59 years).
This demonstrates the importance of social comparison when dealing with chronic pain.
Acceptance of pain was influenced by input from surgeons. This occurred in two ways: first, some participants described having been prepared by their surgeon for the possibility of experiencing some degree of pain following TKR:
“Well just because of what's been done to me, no I expect to have pain because of what they've had to do to fix the joints. ‘Cause I shouldn’t think if you have something like that fitted it's gonna be like a normal knee…it was explained to me before you have them done anyway, so I think I expected a certain amount of pain afterwards” (Jack, age 75 years).
Having been prepared for pain meant that when pain was experienced, it was viewed as normal, leading to greater acceptance of the condition.
Second, a number of participants disclosing their pain to surgeons in postoperative consultations reported encountering a reluctance to acknowledge pain as being important, to investigate further, or offer support. Participants thought that surgeons focused only on the functioning of their replaced joint and radiograph results:
“I can bend it, which is all the surgeons seem to worry about” (Sarah, age 72 years).
“…I mean it's all the surgeon is concerned with providing the x-rays are all perfect, everything's joined up together properly…” (Rose, age 81 years).
Being told that there was nothing wrong with their knee caused distress when participants were experiencing pain:
“…he said well there's nothing wrong and I said well tell my knee that please” (Phyllis, age 81 years).
However, frustration was also experienced when doctors in both primary and secondary care recognized a problem but did not investigate:
“…I've told my own doctor, there's a lady doctor that I go to, and she's very good but she said well, I think you'll have to put up with that…I says why should I?” (Nelly, age 84 years).
Such experiences left participants with a sense of being abandoned. Doris, for instance, explained the impact of her consultation with her surgeon:
“…you don't feel as if uh, not backing you but as if they're um not interested anymore, once they're done that's it…” (Doris, age 77 years).
She believed that having the opportunity to discuss her condition would ease the burden:
“And so you're left, really that is worse when you can't talk to somebody about things” (Doris, age 77 years).
Feelings of abandonment that were engendered exacerbated the negativity of an individual's already difficult situations.
Participants discussed the nature of the support they believed was needed. It was thought that a structure should be in place for ongoing treatment/consultation with physiotherapists and surgeons:
“After the operation I asked about physiotherapy, and they just gave me a sheet of paper and said do these exercises. When I queried this they said, um, that I'd have to take up physiotherapy with the consultant, at my next appointment. They never made me an appointment, I've never seen the consultant from that day to this” (Terry, age 60 years).
Additionally, a number of participants felt a practical approach should be taken regarding the cause of the pain and what could be done:
“I wanted some, you know for him to say it could be this is could be that, but no. Well it should be all right, I've [the surgeon] done everything properly, and that was it” (Ronald, age 75 years).
“…I don't want sympathy I just want um, practical help if I need practical help, because all the sympathy in the world is not gonna make it go away or make any difference” (Ethel, age 78 years).
Participants wanted their surgeons to acknowledge their pain, but to go further than offering a sympathetic response, and investigate the cause and offer practical advice and support. There was a sense that the wider context of the condition should be considered, for example, the impact of footwear and weight:
“…nobody said to me what shoes do you wear, nobody asks you that. Say well that's a stupid question. No it's not, because if your one leg was a little bit shorter or longer because of what you'd had, it would affect your shoes and that but nobody said that” (Doris, age 77 years).
“I think really they should say, well your size, you shouldn't be doing this and it won't last as long if you go on working…I just think they should be able to tell you that sort of thing” (Dennis, age 59 years).
These suggestions are practical in nature, but extend beyond the functioning of the knee itself. Participants wished to be able to easily access advice and support that were tailored to their individual needs and that considered their condition in the context of their lives.
Although all of the participants in the study experienced chronic pain requiring the use of medication, individuals' adjustments to their condition varied considerably. Variation in pain-related distress and acceptance did not result purely from pain intensity, but related to individuals' illness beliefs and their perceptions of their condition in a social context. This is in line with previous research showing the significance of psychological and social factors in adjustment to OA and to chronic pain (22–24). The findings demonstrate the need, when consulting with TKR patients, to consider the complex interaction of psychological and social, as well as biologic, factors consistent with the biopsychosocial model (15). This is also reflective of participants' views that they should receive support that considers their condition in the context of their lives.
A number of participants articulated an accepting attitude toward their pain, and these participants expressed little pain-related distress, consistent with previous research (19, 25). McCracken (19) theorized that, although efforts to reduce pain could lead to distress caused by attempting to control an uncontrollable occurrence, acceptance allows energy to be directed into achievable goals. Some potential facilitators of acceptance emerged from the current study: those who were accepting of their pain tended to perceive an improvement in their situation since TKR, in terms of pain or functional ability. Perceived improvement has previously been related to treatment satisfaction (34) and may act as a “buffer” against negative impact from pain. Surgeons may be able to help facilitate positive perceptions of outcome by attempting to instill realistic expectations prior to surgery, because holding unrealistically high expectations is likely to impact negatively upon outcome appraisal (35). Another facilitator of acceptance identified was the perception that pain was normal in the context of aging; such perceptions have been noted in previous research into OA (36–38). The seemingly greater ease in accepting pain when one's peers also have pain illustrates the significance of the social context to the interpretation of the experience.
Currently in the UK NHS, there are no standards for followup care following TKR; rather, it is determined by each surgeon. The present study suggests that patients can feel abandoned after disclosing their ongoing pain to clinicians and not being offered further support or advice. Patients' perceptions of surgeons' responses to pain disclosure in this study indicate the importance of acknowledging patients' pain in postoperative consultations to avoid causing further distress. This is consistent with previous research that has also demonstrated the significance of health care professionals acknowledging patient-reported symptoms (39), and suggested that failure to acknowledge pain reinforces the negativity of the pain experience, increasing negative emotions (40). However, health care professionals may not always be aware of continuing problems; previous research has suggested that patients may underreport pain following TKR due to factors such as gratitude for care received (8). Additionally, WOMAC pain scores in the current study did not relate to levels of acceptance and emotion expressed in interviews, suggesting that those with high levels of distress may not be identified through such self-report measures of pain intensity. In order to assist identification of these patients, more sensitive assessment measures should be used, encompassing not only the severity of pain but also the impact, such as the Intermittent and Constant Osteoarthritis Pain Questionnaire (41), which includes questions about frustration, annoyance, worry, and distress caused by pain and the impact of pain on sleep and quality of life, and may provide a more comprehensive reflection of an individual's experience.
While some participants reported having been offered further surgery, this was not always wanted and was sometimes turned down. Participants needed to have a wider range of options available to support them with their pain condition outside of the medical model. Some discussed a need for further information, some for practical support, and others believed that having no one to discuss their condition with made their situation worse. For those expressing emotional distress, psychosocial interventions may be of benefit, as previously advocated for people with arthritis pain (42). An acceptance-based program may be useful to help individuals to adjust psychologically to the experience of chronic pain after an end-stage surgical procedure specifically targeted to relieve initial pain. Such provision could be tied to a particular service, as suggested by Eisenach, who advocated the development of specifically dedicated facilities for individuals with chronic postsurgical pain (43). This would support surgeons by providing a referral route for their patients who experience distress.
The use of qualitative methods has allowed a detailed exploration of the views, beliefs, and experiences of patients reporting chronic pain post-TKR. However, because interviews were carried out at just one time point, we are unaware of how individuals' experiences may change over time; future research could employ a longitudinal design to explore this. The current study employed a purposive sampling strategy to achieve a diverse range of accounts specifically from patients experiencing chronic pain, and therefore is not representative of the normal population of TKR patients. Additionally, the study focused on one geographic location in the UK; although the hospital is a large, regional center, research has demonstrated inequity in the provision of TKR relative to need, according to geographic area (44). Despite the study being restricted to the UK, previous research has shown that following TKR, a subset of patients experience persistent pain regardless of their country (45); therefore, these findings will have relevance to other countries.
A number of practical applications arise from these findings. Surgeons have the potential to positively influence their patients' adjustment by 1) attempting to instill realistic expectations regarding the outcome of TKR, 2) acknowledging individuals' pain when it is disclosed after recovery from surgery, 3) using measures that assess not just pain intensity, but also the impact of pain and pain-related distress, and 4) providing a range of services outside of the medical model. By adopting the biopsychosocial model and taking into consideration the impact of psychological and social factors, as well as biologic factors, patient care may be improved for individuals who experience chronic pain following TKR.
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Ms Jeffrey had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study conception and design. Wylde, Blom.
Acquisition of data. Jeffery.
Analysis and interpretation of data. Jeffery, Horwood.
The authors would like to thank those who participated in the interviews. We thank Mr. Luke Brunton and Mr. Mike Whitehouse for comments on drafts of manuscripts.