Singapore is a multi-ethnic Asian society with Western cultural influences. The coping strategies employed by its people are varied depending on individual ethnic background and level of acculturation to Western ideals. An understanding of the effectiveness of specific coping strategies for reducing psychological distress in knee pain Singapore patients will allow for the tailoring of psychosocial interventions to best suit the target group and ultimately improve patient well-being. This is particularly relevant in today’s medical climate, where the importance of addressing patient subjective well-being in addition to objective physical ailments is increasingly recognized. As such, there is a need to explore knee pain’s impact on mental health from the Western psychological perspective, as well as within the context of Asian societies. This will be the focus of the present review.
Understanding the Impact of Knee Pain on Mental Health
It is well assumed that knee pain makes people inactive. But whether physical inactivity in painful knee conditions is a psychological or a mechanical consequence of the pain has been unknown. It is well known that inactivity is associated with muscle weakness and is an important factor in the functional limitation of patients with painful joint conditions. Now we have shown that it is the psychological consequences of the pain that lead to inactivity, and that interventions that increase confidence in the ability to exercise and reduce the perception of disability could have substantial effects on public health. This is particularly pertinent to the current generation of young adults who have grown up with acute awareness of health issues, who are less tolerant of pain and limitation, and for whom negative consequences of pain may be modified. Such persons are more likely to monitor their symptoms and seek treatment than previous generations, and are candidates for interventions to modify the behavioral effects of their conditions.
Patients with knee pain experience a significant loss in function, and this leads to the development of feelings of depression, helplessness, and in some extreme cases, patients may suffer from complete psychological disability. Significant differences in mood have been found between persons with knee pain and those without. These findings point to the fact that knee pain is a significant problem for those who suffer its effects. This problem is compounded by the fact that primary care patients with knee pain have been found to have higher levels of comorbidity with psychiatric disorders compared with those with other forms of physical disability. The impact of knee pain on general health is better understood now with findings that persons with knee pain are more likely than others in the general population to develop functional limitations or frank disability over time.
Importance of Coping Strategies for Singaporean Patients
The coping self-efficacy theory is put forward as a theoretical basis for research and as a framework for clinical assessment and intervention. The relationships between self-efficacy and adaptive emotional and behavioral responses with respect to coping with a health threat are explored. The lack of attention to specific self-efficacy mechanisms and the failure to context specific cognitive and behavioral coping processes has limited the utility of the original health and illness self-regulation model. Incorporating these self-regulatory elements has led to the development of the coping self-efficacy theory. This theory is based on the concept of specific self-efficacy defined as beliefs in one’s capability to organize and execute the courses of action required to produce given attainments. High coping self-efficacy is held to result in better adjustment to a health threat as the consequence of more effective coping behaviors. These self-efficacy effects replace the direct effects of general self-efficacy implied in Bandura’s model, although it is assumed that coping self-efficacy will also have a reciprocal influence on perceived general self-efficacy. Global appraisal and generalized self-efficacy beliefs are seen to influence coping primarily in their impact on coping specific self-efficacy and by producing changes in coping tasks or plans. A range of cognitive and behavioral coping strategies are categorized in terms of the coping processes they involve, and in relation to specific self-efficacy principles. In spite of some supportive results and the seeming face validity of specific self-efficacy effects, research and clinical implications are limited by a lack of prospective research and by measurement issues.
Coping Strategies for Managing Knee Pain
Physical therapy and exercise are often recommended for people with knee pain, particularly those with osteoarthritis. It takes many forms and, in general, it should be aimed at maintaining or improving the strength and function of the affected joint. Specific exercises that are designed to increase the strength of the quadriceps and hamstrings can dynamically reduce the load exerted on the knee and can lessen the progression of knee osteoarthritis. Aquatic exercise has also been proven to be effective in improving lower extremity function for those with osteoarthritis. It has been shown that the resistance provided by water and the warmth of the water help to relieve pain and improve the function of people with osteoarthritis. In a study assessing the effects of an aerobic exercise program as well as strength and flexibility exercises, it was found that aerobic exercise was able to effectively reduce pain in people with osteoarthritis, as well as improve physical function. While the strength and flexibility exercises improved physical function, they did not effectively reduce pain. So the most effective type of exercise for those with knee osteoarthritis would be a combination of aerobic and resistance exercises. This could include activities such as walking, cycling, and Tai Chi.
An important aspect of knee pain management involves the coping mechanisms and strategies that a patient can use to manage and live with his or her knee pain. This section will explore various coping strategies to manage knee pain and how effective they are in managing the patients’ knee pain. Often times, these coping strategies involve a form of treatment at the same time and this depends on the severity of the knee pain, the person’s lifestyle, and the medical resources available.
Physical Therapy and Exercise
Physical therapy involves the use of range of motion exercises on the joint to stretch and strengthen the surrounding muscles. The use of electrical stimulation or hot/cold packs to relieve pain and reduce swelling is also commonly used by physical therapists. A study done earlier this year in Singapore showed that patients who received just 7 physical therapy sessions had less pain and stiffness and greater knee function than those who did not receive therapy. Additionally, the use of hands-on physical therapy, in which the therapist manipulates muscle and joint tissue, is beneficial for patients with severe pain and restricted range of motion. Another important factor to consider is the use of weight loss and exercise. According to a study funded by the National Institute of Health, overweight and obese patients with knee osteoarthritis who participated in an intensive program combining diet and exercise had less pain and better function than those who did not. This is due to the fact that extra body weight increases pressure on the knee, thus causing more pain and increasing the rate of deterioration. Physical therapy exercises are much less likely to cause further damage to the knee compared to strenuous day-to-day exercises, and so the use of exercises as a way to keep fit is much safer when the patient has knee pain. It is evident that physical therapy is a recommended method of treatment with various ways in which it can help to improve symptoms.
Pain Medications and Treatments
Corticosteroids are a class of hormone similar to cortisol, a natural substance produced by the adrenal glands. In the form of a pill, liquid, or injection, they are frequently used to reduce inflammation and pain in specific areas of the body. Corticosteroids are stronger than NSAIDs in reducing inflammation and are effective in treating acute pain. In patients with osteoarthritis, a corticosteroid injection into the arthritic knee joint reduces pain and swelling and improves function. Dangers of systemic absorption and dissemination of the drug to locations other than the knee can lead to significant side effects, and meant that the US Food and Drug Administration (FDA) issued a warning in 2009 regarding an increased risk of death from systemic use of corticosteroids. Corticosteroids have not been shown to prevent progression of knee osteoarthritis.
Above the age of 75, these side effects from NSAIDs are more common, but this age group is also less likely to use these medications. Long-term use of aspirin in doses greater than 300mg a day is associated with an increased risk of age-related macular degeneration. Patients who use blood thinning medications or who have diabetes, kidney disease, or a history of gastrointestinal bleeding are also at a higher risk for complications from NSAID use.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications used to relieve pain and reduce inflammation. They are available both over-the-counter and by prescription. There are several types of NSAIDs, including aspirin, ibuprofen, and naproxen. The pills or patches are usually effective in relieving pain and inflammation in the short term. However, potential side effects with long-term use (especially with higher doses) include peptic ulcers, stomach pain, and increased risk of heart attack or stroke.
Assistive Devices and Mobility Aids
Braces and splints are also commonly used to provide external stability to the knee joint and to reduce pain and swelling. There are many different types of braces which can be used to control and limit knee movement. They range from simple elasticated supports to complex hinged mechanisms which can be used to lock the joint. It is important that patients are given advice from a healthcare professional as to which type of brace is best suited to their specific problem. This can help to prevent problems such as further damage to the joint and muscle wastage, which can be caused by using the wrong type of brace.
Assistive devices are important in the management of knee pain and can be used to reduce the amount of stress on the joint by decreasing the weight borne by the affected limb. One example would be the use of a single crutch on the contralateral side of the affected knee. This method has been proven to decrease the load on the affected knee significantly. A study found that the load on the affected knee joint could be reduced by as much as 9% when using one crutch and by up to 15% when using two crutches. This has been proven to reduce pain and improve function in the knee. However, it is cautioned that crutches should not be used for prolonged periods of time as they may cause weakening of the leg muscles and may shift the load from the knee joint to the upper extremities, leading to problems in these areas.
Psychological Techniques for Mental Well-being
Through participation in CBT, patients can learn specific techniques to identify how their thoughts and behaviors are affecting their mood, and learn skills to independently manage their mood in the presence of further stress or life difficulty. An important aspect of CBT is thus that the individual is learning a set of skills that are transferable to different situations, and that they can use for prevention of mood disturbance in the future. This is an essential point for those with knee pain who are trying to self-manage their mood in the presence of what is known to be a chronic condition.
In the context of knee pain, an individual may have the negative thought “my knee is getting worse and there is nothing I can do to improve my situation,” which may lead to increased feelings of sadness and disability, and the behavior of avoiding activities that they believe can exacerbate their knee pain. By identifying and modifying the negative thought, the individual may be able to feel less sad and take steps to improve their knee pain. For example, an individual with the aforementioned thought set may attempt some form of exercise like swimming, which is less stressful on the knee. With a more positive frame of mind and an increase in activity, the individual’s confidence and mood can subsequently improve.
Cognitive Behaviour Therapy (CBT) is a psychological treatment that has been shown to be effective in reducing depression and psychological distress in the general population and it will be useful to patients who have suffered knee pain. CBT is based on the concept that individuals’ thoughts, feelings, and behaviors are interrelated, and that negative interpretations of events can lead to an affective and/or behavioral state that is unhelpful or even harmful. The ultimate aim of CBT is to help individuals identify and modify negative thoughts and behaviors in order to improve their mood and coping.
Cognitive Behavioral Therapy
CBT for pain involves helping the individual to make the link between how they think and how they feel, and how this affects what they do. This often involves encouraging people to be their own detectives and to observe themselves to see what they do when they feel more or less able to cope with their pain. Usually, people with chronic pain get into a vicious cycle that leads to more pain and distress – for example, giving up on activities they enjoy for fear of making the pain worse. But this results in them having more time to focus on the pain, and as they are not doing things that give them a sense of achievement, this lowers mood. By increasing awareness of what makes things better or worse for them, CBT aims to help people break this cycle. Once understanding has been gained about what might make someone’s pain worse or better, the therapy will then be focused on setting goals to do more of what makes them feel better and less of what makes them feel worse. Goals should be specific, and small steps towards achieving them should be planned. By making changes to what people do, there is then an opportunity to observe the effects these changes have had on how they feel and what they might be able to do differently again in the future.
Cognitive behavioural therapy (CBT) is an evidence-based psychological therapy that has been found to be effective in managing different types of chronic pain. CBT aims to reduce disability and distress by helping to develop skills to manage the pain, and to change unhelpful patterns of thinking and behaviour. A key premise of CBT is that the problems we experience are not caused by the situations themselves, but by the meanings we give to them. The way we think about a situation affects how we feel – so if we think negatively about a situation, that will make us feel worse. If we think differently about the situation, that will change how we feel.
Relaxation and Stress Management Techniques
Relaxation is essential for restoring health to the body and mind. It is counterproductive for the patient to undergo stress management and mental techniques if they are unable to relax. Various relaxation techniques such as breathing exercises, progressive muscle relaxation, and imagery have been shown to be beneficial for pain sufferers. Breath focus increases alpha brain wave activity, similar to activity during meditation, and promotes a state of calmness. If a pain flare-up is being experienced, it may be worthwhile for the patient to partake in an imagery exercise and take a mental vacation to a place that induces a state of relaxation and well-being. It is recommended that a pain sufferer practice a relaxation technique for 30 minutes per day for at least 3 weeks in order to gain the full benefits. Although it has been shown that 15 minutes a day is effective, it is urged to continue practicing for a longer duration as the benefits will be more lasting and profound. Progressive muscle relaxation has been shown to help those with acute and chronic pain by learning how to monitor tension and to recognize the body’s difference between tension and relaxation. This enables the patient to release muscular tension and elicits the relaxation response.
Mindfulness and Meditation
Loving-kindness meditation is a practice where the patient focuses on developing feelings of goodwill, kindness, and warmth for themselves and others. During guided imagery meditation, the patient is encouraged to use all of the senses to create positive and relaxing mental images.
Meditation is the focusing of the mind on a particular object with the purpose of understanding the nature of the object. It is a practice that develops single-pointed concentration to the point where the mind becomes tranquil and focused. There are several different types of meditation. During mindfulness meditation, the patient is taught to pay attention to the sensations of breathing in the abdomen, chest, and nostrils. When the mind wanders, the patient is instructed to bring it back to notice the countless distractions. This meditation cultivates awareness of the mind’s tendency to ruminate and wander, and also cultivates the ability to bring the mind back to a focal point.
Mindfulness and meditation originated from Buddhism and are considered to be the means to achieve liberation, enlightenment, and also attenuate several mental and physical states that lead to distress and suffering. The use of mindfulness and meditation for dissatisfaction caused by chronic illnesses is a relatively new area for cognitive-behavioral therapy. As a cognitive-based coping strategy, awareness and acceptance of the present moment experience with an attitude of non-judgment are used to increase coping with pain and life in general.
Support Systems and Resources for Singaporean Patients
There are specific resources catering for mental health in Singapore, relating to chronic pain and more general help such as counseling. Anxiety and depression are common feelings experienced by knee pain sufferers and can often be undiagnosed by health practitioners. There is a great deal of cross-over between the emotional burden of losing independence or inability to perform a sport that one loves, to the specific bio-mechanical issues affecting the knee. Patients begin to feel they are “going crazy” pain seems worse on some days but then feels better when a leftover movement to test knee was performed. Understanding the relationship between what they are doing and their knee pain is crucial in the self-management of their condition and symptoms. This understanding may require interaction with a mental health professional. This brings us to the current state of mental health care in Singapore. Unfortunately, the support is limited compared to other western countries and even less for elderly individuals. Many patients have expressed interest in a referral system from a health practitioner to a mental health professional who has an understanding of their knee issue. This would be an area where current healthcare in Singapore could be improved to benefit knee pain sufferers.
Similar to other long-term chronic conditions, patients dealing with knee pain can only benefit from additional understanding and knowledge of what they are dealing with. This can often get lost in mass medical consultations. Whether to understand their knee issue more or to appreciate the psychological impact suffered, the need is essential. Globally, there are a number of initiatives by reputable organizations as well as independent groups looking to enhance the understanding, treatment, and prevention of knee pain. Unfortunately, in Singapore, there are currently no organizations which have established a pathway for patient education. This would include details on what each different knee issue is, the methods of treatment, and prognosis. This information gives the patient confidence that they know what the health practitioner is talking about and helps them understand when returning to a normal activity is appropriate.
Support Groups and Peer Networks
Singaporean knee pain sufferers often face mobility issues. Those with knee pain tend to live a less active lifestyle. Due to the fact that knee pain is more prevalent in the older population, they would be most affected. They may face social isolation and become less connected with society. Support groups can provide these patients with an avenue to keep in touch with society and share their experiences with others in similar situations. Usually, it is run by some form of health professional, often a physiotherapist or occupational therapist. Occasionally, it is patient-run. The Arthritis Foundation Singapore runs patient-run support groups. Regular walking groups can double as a form of a support group, as well as a form of exercise. An example of this is ActiveSG’s Silver Impetus, which is partnered with the Singapore Health Promotion Board. This program organizes rambles and Nordic walking and is targeted at the elderly. This would not be classified as a support group, but it provides the above-mentioned benefits for knee pain sufferers. Although not specific to knee pain, it is an option for social knee pain sufferers to stay in contact with society.
Accessing Professional Help: Knee Pain Specialists
Rehabilitation after any treatment is an important issue. We have discussed conservative measures and mentioned physiotherapy. Physiotherapy is usually required both pre and post-operatively, and the manner in which it is carried out varies. For example, physiotherapy to strengthen the quadriceps muscles prior to ACL reconstruction surgery is different from post-operative physiotherapy focusing on regained range of movement in a patient who has had manipulation of a total knee replacement. Physiotherapists can liaise with specialists directly regarding a patient’s condition. They often provide informal updates on progress and when necessary to maximize recovery from surgery. This is beneficial for both the patient and knee pain specialist because the specialist can adjust treatment plans if necessary or provide a prognosis on expected recovery time to guide the physiotherapist.
Patients with knee pain can get referred to an orthopedic surgeon by their general practitioner. In some instances, the patient does not have a GP and thus can arrange to see a knee specialist by self-referral. Having a GP referral means that the GP provides information about the knee condition to the specialist. This includes past medical history, conservative treatments that have been performed, and investigations that have been carried out. Understanding the patient’s age and expectations helps the specialist plan a more tailored treatment. Younger patients expect to have normal or near-normal pain-free function in activities of daily living and sports. Those of older age may have low demands and may only wish to have pain relief. These are all important issues to consider and usually younger patients with knee pain and clearly defined diagnoses benefit more from surgical intervention. Older age, multiple co-morbidities, and those with arthritis do not fare so well from knee surgery and it’s generally better to pursue more conservative measures.
Online Resources and Self-Help Tools
Self-management is an important step for patients with chronic pain and illness. The ultimate aim is to empower patients to take control of their condition in a way that enables them to live a fulfilling life, taking the focus away from the illness itself. Self-management programs are specifically designed for patients with chronic conditions. They are often multi-component and target various aspects of the patient’s illness. Usually, they are run in a community setting. Unfortunately, there is currently no known self-management program specifically designed for people with knee OA in Singapore. However, an interesting and interactive self-management program has been developed in Australia for people with hip and/or knee OA called Osteoarthritis Online. This is an ideal program for people who have internet access and a good understanding of written English. This is the first web-based self-management program for osteoarthritis, and any trial participation would be contributing to the availability of more self-management programs for people with OA worldwide.
The nature of the internet has allowed instant access to health information worldwide. Online resources and self-help tools have the potential to play an important role in the way patients cope with and manage chronic illness. It can be a useful first step for those seeking information about a certain condition, as well as a way of widening their knowledge about coping strategies and treatments. During the course of their illness, patients may find that they solely communicate with their healthcare providers during consultations. Furthermore, there can be a lack of local services available to patients to which their healthcare provider can refer them. For these patients, online resources can be a way of learning more about their condition and a tool for taking more control over their health. It will also enable them to network with other people suffering from the same condition and share support and advice.
