Knee osteoarthritis patients with intact pain modulating systems may have low risk of persistent pain after knee joint replacement
-
Audun Stubhaug
In this issue of the Scandinavian Journal of Pain Tania Schjødt Jørgensen and co-workers in Aalborg and Copenhagen report an interesting clinical neurophysiological study on 10 knee osteoarthritis (OA) patients [1]. These OA patients were the bravest of 64 invited OA-patients to let the researchers provoke more pain in and around their OA-knee by having hypertonic or isotonic saline injected into their infrapatellar fat-pad. This was a randomized cross-over study with either the hypertonic saline causing extra pain or isotonic saline provoking none or only mild extra pain.
They found that the experimental pain from injection of hypertonic saline caused a significant lowering of the pressure pain threshold (PPT) and a significant fascilitation of temporal summation of pressure pain stimulation near the knee joint. They did not observe such changes after isotonic saline injection or in a control site on the arm on the opposite side of the body. The authors concluded that in these 10 patients with OA of moderate severity, the pain modulating systems appear to be intact.
1 Why can surgeons remove chronic pain with an artificial joint in about 80% of knee OA patients?
Osteoarthritis pain is not only pure nociceptive pain from the degenerative processes in and around an OA-joint; there are also components of nerve-damage pain, or neuropathic type pain, as well as “neuroplastic pain” [2] from increased peripheral excitability of nociceptors from mediators released from damaged joint tissues, as well as increased responses in spinal cord nociceptive pathways [2]. The Schjødt-Jørgensen study clearly documented that even though the patients had suffered from their knee OA for several years, their pain modulating CNS-systems appeared to react to experimental pain in similar ways as in persons without chronic OA-pain [1]. This is potentially important: when a surgeon removes the ongoing nociceptive stimuli from the degenerating knee joint, the CNS-pain sensing and modulating systems are ready to react normally to incoming non-nociceptive and nociceptive stimuli. They will have a low risk of developing persistent pain after joint replacement surgery. They are likely to be the “lucky” 80% who recover normal knee function without neuropathic pain after total knee arthroplasty (TKA) [3].
2 Why cannot surgeons remove chronic pain with their knife in about 20% of knee OA-patients [3]?
Similar studies from Aalborg have revealed that in knee OA patients with more severely degenerated and painful knees, there are increased pain sensitivity, estimated by facilitated temporal summation of pressure pain in and around the knee, but also in both arms, i.e. they have “widespread increased pain sensitivity” [4]. Their pain-sensing and pain-modulating CNS-systems clearly “over-react” [4]. Such patients who develop persistent postsurgical pain often have chronic pain in other parts of their body, such as migraine, other chronic headaches, low-back pain, fibromyalgia, or other chronic pain conditions [5].
Patients with severe OA often have at least two of 5 known major preoperative risk factors for developing chronic pain after any type of surgery: (1) they have pain in the area of planned surgery, and (2) they have chronic pain in other parts of the body [5]. They do have an increased risk of persistent postoperative pain after almost any type of surgery [5,6]. Three other well documented risk fact ors are (3) stressful life-events during the last 6 months, (4) severe anxiety before the surgery, (i.e. catastrophizing thoughts about outcome of the operation), and (5) expectation of severe acute pain after the operation [5,6].
This phenomenon, the “widespread increased pain sensitivity” is now well documented by the pain research teams in Aalborg, headed by Lars Arendt-Nielsen [4]. It may be used for prognostication, as “red flag” indicating that patients with widespread increased pain sensitivity before a necessary surgical intervention must get special attention by the surgical and anaesthetic teams. Unfortunately, there are no unequivocally proven pharmacological interventions for prevention of chronic pain after surgery. There is an urgent need for controlled studies. The most convincing studies are in support of using regional anaesthesia when appropriate, especially optimal thoracic epidural analgesia during and for several days after thoracotomy and major abdominal surgery [7,8], intravenous infusion of lidocaine (1.5 mg/kg/h) [7,9,10], a glutamate-receptor blocker [10], and pregabalin [6,11], and possibly an alfa2-receptor agonist [10].
Most important, however, is that these patients have appropriate relief of acute and sub-acute pain for as long as needed, also after being discharged from the hospital [8,12]. Suppressing pain hyper-sensitivity with pregabalin during the first two weeks after knee replacement appears to reduce the risk of persistent pain after this type of major knee surgery with an otherwise relatively high risk of persistent postsurgical pain [3,11], but these results need replication. Systematic reviews have conflicting conclusions, as often is the case.
Thus, assessing pain sensitivity before surgery by estimating the degree and distribution of facilitated temporal summation [1,4] is one promising way of selecting patients that must get special attention during and after surgery in order to reduce the risk of debilitating persistent postsurgical pain [1,4,6,8,12].
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.11.002
-
Conflict of interest None declared.
References
[1] Schjødt Jørgensen T, Henriksen M, Rosager S, Klokker L, Ellegaard K, Danneskiold-Samsøe B, Bliddal H, Graaven-Nielsen T. The dynamics of the pain system are intact in patients with knee osteoarthritis: an exploratory experimental study. Scand J Pain 2015;6:43–9.Search in Google Scholar
[2] Kidd BL. The mechanisms of chronic (joint) pain. In: Breivik H, Shipley M, editors. Pain: best practice and research compendium. London: Elsevier; 2007. p. 17–24.Search in Google Scholar
[3] Haroutiunian S, Nikolajsen L, Finnerup NB, Jensen TS. The neuropathic component in persistent postsurgical pain: a systematic literature review. Pain 2013;154:95–102.Search in Google Scholar
[4] Petersen KK, Lars Arendt-Nielsen L, Simonsen O, Wilder-Smith O, Laursen MB. Pre-surgical assessment of temporal summation of pain predicts the development of chronic postoperative pain 12 months after total knee replacement. Pain 2015 [in press].Search in Google Scholar
[5] Althaus A, Hinrichs-Rocker A, Chapman R, Arránz Becker O, Lefering R, Simanski C, Weber F, Moser KH, Joppich R, Trojan S, Gutzeit N, Neugebauer E. Development of a risk index for prediction of chronic post-surgical pain. Eur J Pain 2012;16:901–10.Search in Google Scholar
[6] Rashiq S, Dick B. Persistent post-surgical Pain - PPP syndromes: a review for the non-pain specialist. Can J Anaesth 2014;61:123–30.Search in Google Scholar
[7] Andreae MH, Andreae DA. Regional anaesthesia to prevent persistent pain after surgery. Br J Anaesth 2013;111:711–20.Search in Google Scholar
[8] Tiippana E, Nelskylä K, Nilsson E, Sihvo E, Kataja M, Kalso E. Managing post-thoracotomy pain: epidural or systemic analgesia and extended care - a randomized study with an “as usual” control group. Scand J Pain 2014;5: 240–7.Search in Google Scholar
[9] Grigoras A, Lee P, Sattar F, Shorten G. Perioperative intravenous lidocaine decreases the incidence of persistent pain after breast surgery. Clin J Pain 2012;28:567–72.Search in Google Scholar
[10] Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery (adults). Cochrane Database Syst Rev 2013;7:CD008307, http://dx.doi.org/10.1002/14651858.CD008307.pub2.Search in Google Scholar
[11] Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg 2010;110: 199–207.Search in Google Scholar
[12] Breivik H. Persistent post-surgical pain (PPP) reduced by high-quality management of acute pain extended to sub-acute pain at home. Scand J Pain 2014;5:237–9.Search in Google Scholar
© 2014 Scandinavian Association for the Study of Pain
Articles in the same Issue
- Scandinavian Journal of Pain
- Editorial comment
- Neuroinflammation and glial cell activation in pathogenesis of chronic pain
- Topical review
- Perspectives in Pain Research 2014: Neuroinflammation and glial cell activation: The cause of transition from acute to chronic pain?
- Editorial comment
- Outcome of spine surgery: In a clinical field with few randomized controlled studies, a national spine surgery register creates evidence for practice guidelines
- Observational study
- Results of lumbar spine surgery: A postal survey
- Editorial comment
- Partner validation in chronic pain couples
- Original experimental
- I see you’re in pain – The effects of partner validation on emotions in people with chronic pain
- Editorial comment
- Pain management with buprenorphine patches in elderly patients: Quality of life—As good as it gets?
- Clinical pain research
- Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights
- Editorial comment
- Invisible pain – Complications from too little or too much empathy among helpers of chronic pain patients
- Observational study
- Although unseen, chronic pain is real–A phenomenological study
- Editorial comment
- Knee osteoarthritis patients with intact pain modulating systems may have low risk of persistent pain after knee joint replacement
- Clinical pain research
- The dynamics of the pain system is intact in patients with knee osteoarthritis: An exploratory experimental study
- Editorial comment
- Ultrasound-guided high concentration tetracaine peripheral nerve block: Effective and safe relief while awaiting more permanent intervention for tic douloureux
- Educational case report
- Real-time ultrasound-guided infraorbital nerve block to treat trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine
- Original experimental
- Modulation of the muscle and nerve compound muscle action potential by evoked pain
Articles in the same Issue
- Scandinavian Journal of Pain
- Editorial comment
- Neuroinflammation and glial cell activation in pathogenesis of chronic pain
- Topical review
- Perspectives in Pain Research 2014: Neuroinflammation and glial cell activation: The cause of transition from acute to chronic pain?
- Editorial comment
- Outcome of spine surgery: In a clinical field with few randomized controlled studies, a national spine surgery register creates evidence for practice guidelines
- Observational study
- Results of lumbar spine surgery: A postal survey
- Editorial comment
- Partner validation in chronic pain couples
- Original experimental
- I see you’re in pain – The effects of partner validation on emotions in people with chronic pain
- Editorial comment
- Pain management with buprenorphine patches in elderly patients: Quality of life—As good as it gets?
- Clinical pain research
- Evaluation of the cost-effectiveness of buprenorphine in treatment of chronic pain using competing EQ-5D weights
- Editorial comment
- Invisible pain – Complications from too little or too much empathy among helpers of chronic pain patients
- Observational study
- Although unseen, chronic pain is real–A phenomenological study
- Editorial comment
- Knee osteoarthritis patients with intact pain modulating systems may have low risk of persistent pain after knee joint replacement
- Clinical pain research
- The dynamics of the pain system is intact in patients with knee osteoarthritis: An exploratory experimental study
- Editorial comment
- Ultrasound-guided high concentration tetracaine peripheral nerve block: Effective and safe relief while awaiting more permanent intervention for tic douloureux
- Educational case report
- Real-time ultrasound-guided infraorbital nerve block to treat trigeminal neuralgia using a high concentration of tetracaine dissolved in bupivacaine
- Original experimental
- Modulation of the muscle and nerve compound muscle action potential by evoked pain
