Given the prolonged nature of the inflammatory response after injury or following surgery, pain in these circumstances might be affecting psychological health without the patient being aware of the connection. The humoral and neural pathways postulated to be involved in the development of various forms of arthritis, such as osteoarthritis, produce outcomes on the brain leading to changes in mood, motivation, and motor function. Knee pain that is vague and background occurring in episodes but with no overt inflammatory signs is found to affect mood and physical function more than pain with a clear onset and offset. And pain-related avoidance behavior, besides being a result of poor function, has been shown in a longitudinal analysis to be a significant predictor of developing disability in older adults with recently diagnosed knee pain. The ways in which individuals cope with knee pain can have a significant impact on their level of disability, treatment outcome, and mental well-being. Although coping strategies are considered to be situation-specific and are influenced by personal and social factors, identification of unhelpful and potentially harmful pain-related coping strategies has led to the development of interventions specifically designed to alter these behaviors in an attempt to improve physical and psychological health. Cognitive-behavioral therapy, which aims to change pain behavior by changing thought processes, has shown to be effective in the management of chronic musculoskeletal pain. But to date, there are no published research on knee pain and mental health regarding coping, nor are there studies involving intervention for patients with knee pain and co-existing depression.
Coping Strategies for Mental Health and Knee Pain
Mindfulness techniques involve the practice of constantly being aware and living in the present moment. Mindfulness is a skill that can be taught, and when it is practiced often, it can reduce knee pain and mental health symptoms by making it easier to disengage from pain and stop avoiding behaviors that are exacerbating the effects of pain. This is achieved by learning to observe sensations non-judgmentally, which results in knee pain being experienced as less intense and intrusive. Also, mindfulness involves an acceptance of the present moment instead of being stuck in the past or trying to change the future. This is epitomized by Kabat-Zinn’s definition of mindfulness: “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.” By accepting the present moment, knee pain patients are less likely to have thoughts that they cannot do anything they want to and that life is bleak and joyless. Mindfulness is particularly effective for mental health because psychological suffering is often caused by fighting with the present moment or wanting it to be different. Mindfulness can make distressing thoughts and feelings less threatening, and it can teach patients to detach themselves from negative thought patterns.
Mindfulness techniques
Mindfulness practice will help the patient to break this cycle of avoidance and provide an alternative strategy for coping with the experiences that are being avoided. By intentionally engaging with the present moment experiences of low intensity, taking an objective stance, and observing these experiences with an open curious mind, the patient will learn to see that these are just unpleasant sensations and thoughts and they are not an indication that further damage is being done to the knee.
If the patient chooses to stay in bed due to these uncomfortable experiences, the avoidance behavior will provide short-term relief, and thus a strong conditioning factor that links walking with unpleasant experiences. This will increase the patient’s conviction that they have a damaged and vulnerable knee and will reduce their confidence in their physical ability. In the long-term, this avoidance is likely to lead to muscle atrophy and further physical deterioration of the knee joint.
It is common for patients with chronic knee pain to avoid engaging with the sensations and emotions associated with their pain. This avoidance often leads to an exacerbation of negative cognitive and emotional experience. For example, if a patient is due to take a gentle walk which they know is good for their knee mobility and health, they may experience a negative thought of how much it will hurt and what a nuisance it is that they have this problem. This will probably evoke an unpleasant emotion and/or a physical tension or stress response.
Kabat-Zinn has defined mindfulness as “moment-to-moment non-judgmental awareness”. When individuals are mindful, they are actively aware of and present with their experiences in the moment. This means paying attention to experiences as they affect the body through the five senses and the mind through thoughts and emotions. All of this is done without reacting to or judging the experiences that are occurring.
Buddhist meditation practices involving both mindfulness and concentration have long been used to develop equanimity and to reduce psychological disturbances that disturb mental well-being. More recently, these mindfulness-based interventions have been used to help patients cope with a variety of physical and psychological problems. It has been suggested that the practice of mindfulness in the context of physical pain might beneficially alter the experience of the pain that is associated with long-term illness.
Cognitive-behavioral therapy
Once the cycle has been broken, patients can begin to confront activities that they have avoided, which will coincidentally improve the situation linked with the onset of the problem. This is achieved by setting goals and working through a process of graded exposure. CBT is an attractive option for many people, as it is an active, short-term, and structured treatment. CBT is also focused on the present and problem-solving, so patients do not need to spend a long time in therapy. This has been reflected in the research, which has shown CBT to be a cost-effective treatment. For example, a recent randomized controlled trial has shown CBT to be more cost-effective than usual treatment in patients with persistent low back pain.
For example, a person who is experiencing knee pain may feel low in mood and may turn down an invitation to go out with friends. This, in turn, can affect the knee pain by intensifying the focus on the problem and leading to avoidance of enjoyable activities. A CBT therapist will work to break the vicious cycle by identifying the negative thoughts, feelings, and behaviors and challenging them. This is done using a variety of cognitive and behavior-changing techniques.
Cognitive-behavioral therapy (CBT) has been proven to be effective in treating a wide range of psychological disorders. Essentially, the premise for CBT is based on the idea that our thoughts about a situation affect how we feel (emotionally and physically) and how we behave in that situation. The way we feel and behave affects the event in turn, thus beginning a cyclical process.
Pain management strategies
Patients who are able to use self-regulatory techniques have been shown to exhibit less disability when faced with pain. This may take the form of trying to increase the amount of time they can sustain a particular activity or maintaining a positive mindset so as not to avoid certain movement patterns for fear of increased pain. Though it can be a gradual process, self-regulation and the setting of achievement-oriented goals in order to increase the patient’s perception of control are fundamental to slowing functional decline. Goal setting is a procedural method whereby a patient will determine a particular task to be accomplished, with the help of a healthcare professional, and should be realistic and set in correspondence with the patient’s level of self-efficacy. An increase in self-efficacy and patient-perceived control can result in a pain-free task simply due to the patient’s confidence in carrying out the task and knowing it will not result in further damage to the knee.
Land’s companion theory suggests that movement patterns change when the body perceives a threat to the knee, and this results in unloading the affected area, taking the pressure off the affected area. And though this may be beneficial in the short term, in the long term, these movement changes result in further disability. Pain catastrophizing is also linked to patients with chronic pain conditions and has been found to be a risk factor for patients undergoing a total knee replacement. Pain catastrophizing is described as an “irrational negative mindset brought to bear during painful experience” and involves magnification of the potential for an eventuality and feelings of helplessness. The target of diverting from a negative to a positive mindset during a painful experience is something which is of great benefit to catastrophic patients, and cognitive-behavioral therapeutic techniques aim to do this. Studies have shown that an improvement in a patient’s catastrophizing mindset results in a decrease in pain intensity and psychological disability in those with chronic musculoskeletal pain.
Support groups and counseling
Therapy groups consisting of four to five patients met weekly for a 1-hour session. The same weekly curriculum was followed for 2 years. Cognitive-behavioral pain coping skills training and arthritis education intervention conditions are compared to a wait-list control condition in a random-assignment clinical trial. Outcome measures assess changes in patients’ arthritis knowledge, coping strategies, and emotional and functional status over time. Discussion addresses intervention development, and the costs and benefits of various research strategies to long-term clinical/societal relevance. Dose and format of arthritis education and skill training is likely to impact long-term patient outcomes, but has not been well studied. Other areas needing further research are delineated.
Before their assignment, Arthritis Foundation patient educators participated in a two-day training workshop led by the research team and a psychologist. The workshop provided a theoretical overview of the protocol, demonstrations of intervention techniques, and practice of key skill-building techniques. The workshop included instruction in cognitive-behavioral coping skills and arthritis education, and demonstration and practice of intervention delivery. Psychology doctoral students and master’s-level mental health professionals were trained through the same procedures. Investigators monitored therapist adherence and competence using a modified version of the Cognitive Therapy Scale. A total of 10 psychologists or mental health professionals were employed as interventionists. No differences in patient outcomes were detected among interventionists.
Lifestyle Changes for Mental Health and Knee Pain
Exercise and physical activity are an essential aspect of lifestyle modification, and can lead to great improvements in both mental health and knee pain. Aerobic exercise, such as walking or swimming, has been shown to reduce symptoms of depression and anxiety, while also being beneficial for weight loss and overall improvement of knee pain. Strong evidence also supports that strengthening the quadriceps is beneficial for reducing knee pain. This may also involve weight loss in overweight patients, leading to improvement in body image and self-esteem, and further reductions in depression and anxiety. However, some patients may have difficulty in finding suitable exercises for knee pain due to limited mobility or comorbidities. In these cases, referral to a physiotherapist is advisable. At present, Dr. Keng has an ongoing research grant to develop a home-based exercise program suitable for older adults with knee pain, which may be a suitable alternative for some patients.
Exercise and physical activity
Once you have consulted with a medical professional and are cleared to start an exercise program, it is important to find the right exercise for you. Different forms of exercise can help or worsen knee pain, and it is important to find the right one. High-impact sports such as running are known to worsen knee pain, while others may find their knee pain is worsened by sitting or lying for long periods. Swimming is often considered a good form of exercise for those with knee pain, as it is both a good aerobic workout and is not weight-bearing. Other good exercises include using a stationary bike, or if you prefer to exercise outside, then a regular bike, as cycling is also not weight-bearing. A strengthening and flexibility program will also help many people with knee pain. This can be achieved using either bodyweight (i.e., yoga, pilates), resistance bands, or weight machines. Aerobic exercises are also important in a well-rounded exercise program. These should be low-impact and joint-friendly. Examples include using an elliptical trainer and using the rowing machine. Regular aerobic exercise not only has physical benefits but also has a significant impact on mental health. Aim for 20-30 minutes of exercise 3-4 times a week. It is also important to take short walks throughout the day.
Healthy diet and nutrition
A healthy diet is an essential aspect for achieving optimal mental and physical health, and for managing knee pain. Unfortunately, very little research has been conducted specifically on diet and its effects on knee pain. However, general nutritional advice is available which would also be appropriate for those suffering knee pain. Weight reduction has been found to have very positive effects on knee pain. A loss of 11 pounds has been shown to decrease the risk of developing osteoarthritis in women by 50%. A reduction in weight also reduces the forces through the joint during weight bearing activities such as walking and going up and down stairs. Studies have shown that during walking, forces through the knee are reduced by 4 times the body weight for each step taken. Simple arithmetic shows that every pound lost results in a 4 pound reduction in force through the knee. Therefore, for weight reduction to be successful a diet aimed at losing weight is required. However, crash dieting is not recommended as this results in muscle wastage which is something we wish to avoid due to its importance in maintaining lower limb function. Instead, a gradual and steady weight loss is recommended.
Stress management techniques
Relaxation therapy achieved a small-to-moderate effect on pain and a small, though not significant, effect on disability in a recent systematic review. Relaxation is likely to be more effective when practiced regularly, and adherence can be promoted by strategies such as scheduling, identifying cues for practice, and keeping a log to monitor practice time and the presence of any changes in outcome. A separate analysis found limited evidence that relaxation increased function in knee osteoarthritis. Mindfulness meditation, one of the fastest growing areas of mind-body research, has not yet been investigated in knee pain populations, but has demonstrated efficacy in a range of chronic pain conditions. A small trial of mindfulness in patients with rheumatoid arthritis found significant improvements in pain and psychological distress. Stepwise group MBSR instruction has been in demand by populations with chronic illness and limited physical function, and thus may be suitable for patients with advanced knee osteoarthritis who are awaiting joint replacement.
Stress is common among patients with knee pain, with 70% reporting that it significantly affects their pain level. Of various forms of stress management, cognitive-behavioural therapy (CBT) has been shown to be effective for chronic pain. By helping to restructure negative thought patterns, CBT promotes problem-solving and reduces helplessness – an important outcome, as perceived helplessness has been found to mediate the effects of pain on depression and disability over time. A course of CBT was recently found to improve the ability to cope with pain in elderly patients with osteoarthritis, with an associated decrease in depressive symptoms.
Seeking Professional Help for Mental Health and Knee Pain
There has been very little research into concordance of physical and mental health treatments in Singapore, but in the UK, Gask and co-workers found problems with information sharing between general practitioners and mental health professionals, which led patients with chronic conditions being referred back and forth between the two, but never actually receiving treatment for their mental health condition. GPs were often unclear about the roles of mental health professionals and how to access them. This suggests a need for better integration of physical and mental health services, and greater awareness of each other’s roles among healthcare providers.
The Singapore-based knee pain specialist and mental health professional, whether in private practice or associated with healthcare organizations, belong very much to the global community of professionals who are not accustomed to working beyond the confines of their own discipline, and the patient may receive conflicting advice from each of these professionals. This state of affairs can be very confusing for the patient.
Patients with mental health issues and knee pain may find that they need to consult more than one healthcare provider to do complete justice to their health conditions. The different needs may mean that the patient receives treatment for the physical ailment from healthcare providers who do not attribute much significance to psychological factors, and so proposes treatment that does not take into account the mental health condition. These patients can be excused for being fatalistic concerning the potential for successful treatment.
Consulting a knee pain specialist in Singapore
Those with chronic or severe knee pain might find it beneficial to seek professional help from a knee pain specialist in Singapore. The role of this specialist is to accurately diagnose the cause of the knee pain and find an appropriate treatment plan which aligns with the recovery of both the knee problem and any psychosocial issues that might be present. As mentioned previously, a knee injury can lead to depressive symptoms, and a knee pain specialist who is experienced in dealing with mental health issues has a greater potential of helping the patient. The knee pain specialist might suggest ways to make it easier for the patient to manage their knee pain, such as altering the way they work or providing letters to employers. They can also aim to strengthen the patient’s knee to improve function, as well as provide guidance in weight loss for obese patients to reduce knee joint loading. Any findings from the treatment plan can be reported to the mental health professional who is monitoring the patient in order to keep them informed of the patient’s progress. This integrated approach between healthcare specialists can be a very effective way of resolving both the knee problem and mental health issues.
Mental health professionals and resources
Numerous studies have shown cognitive-behavioral therapy (CBT) to be an effective form of treatment for people suffering from chronic pain. It is a goal-oriented approach that may require some homework in between sessions. CBT is a collaborative effort between the therapist and the patient with the aim of changing problematic thinking patterns and, in turn, cognition. By recognizing negative thoughts, understanding how they affect feelings, and pinpointing behaviors that are associated with the thoughts, patients may be able to break the cycle by undoing beliefs about particular events. The overall aim is for changes to be made, resulting in an improvement in emotional well-being and a decrease in the initial depressive and/or anxious state. Given that emotions can be affected by a change in physical health, a change in process may improve mood and therefore the pain it was originally associated with. CBT is a practical strategy, focusing on the here and now, problem-solving, and putting it into action. This form of therapy creates an outlined path, clear objectives, and may well be easier for a patient to monitor progression and change.
There are many healthcare professionals and resources available in Singapore, from consulting a knee pain specialist to using helplines, the internet, support groups, and seeking help for mental health. Showing your healthcare provider that there is a strong connection between your knee pain and your emotional health is important. This may guide them to seek help from mental health professionals on how to help you or refer you to mental health services. With a growing recognition of the importance of mental health compared to previous years, patients may find it easier now to seek help from mental health professionals. Always ensure that the professional is aware of your knee pain, the way it may affect your mental and emotional health, and the therapies or medications you are undergoing. Treatment from either a mental health professional or a primary care physician should always be monitored and linked with an improvement in your knee pain and overall condition.
