Pain Management for Total Knee Replacement

After Hospital Discharge

It is important that your pain is well managed and under control following discharge from hospital. The aim is to reduce your pain to a level that allows you to walk and perform activities of daily living soon after discharge without too much discomfort. Generally when you are resting, your knee should feel relatively comfortable, however you may experience an increase in pain with activities such as physiotherapy. Bending the knee is likely to be the most painful. Night pain and sleep disturbance may persist for several months but will steadily improve. Most patients will benefit from taking a balanced selection of pain medications including strong opioids during the first 2 to 6 weeks. Some patients will experience an increase in pain following discharge and will struggle to complete their physiotherapy.

If the pain becomes severe

• Reduce your activity, rest and elevate the leg and apply ice packs.
• Modify your exercises including physiotherapy that may be exacerbating the pain.
• Take extra pain relief when needed to allow you to maintain your comfort and mobility
• If you continue to experience severe pain contact us on 9386 3933

It is important that you understand what medications to use when you leave the hospital.

The First 2 weeks

1. Paracetamol (Panadol, Panadol Osteo) daily on a regular basis
2. Anti-Inflammatories (Mobic, Celebrex, Nurofen etc.) daily on a regular basis
3. Lyrica twice a day or just at night. Should you experience side effects such as excessive drowsiness, you can reduce your dose or take only at night. If you do not tolerate this medication it can be stopped.
4. Paexia SR (Slow release) twice daily until your mobility is not significantly affected by pain. The initial dose is usually 50mg twice daily. This may be increased for some patients up to a maximum of 200mg twice daily. Targin is an alternative which may be prescribed.
5. Paexia IR (Immediate release) 50mg as needed up to four times daily. This does not last long but may be useful for rapid onset pain relief before or after exercise. Endone (Oxycodone) is an alternative, which may be prescribed.

After 2 weeks

1. Continue PARACETAMOL (Panadol or Panadol Osteo) on a regular basis until you no longer need any other pain medication
2. Stop taking regular ANTI-INFLAMMATORIES if you are coping well. If you feel that you need to continue taking these please discuss with your doctor.
3. Stop taking LYRICA if your pain control is adequate and you no longer need PALEXIA. If pain at night is an issue it may be useful to continue taking Lyrica at night until this improves.
4. Reduce or stop using the PALEXIA once your pain is under control.

If you are still having difficulties with pain management after two weeks please consult your surgeon or GP for further advice and assessment.

How to reduce or taper strong opioids

The aim is to reduce then stop these medications completely.  This should commence once you are no longer experiencing severe pain and should be done in a gradual manner.

• Aim to reduce your daytime dose initially by about 25-50% per week until you are no longer taking any opioids during the day. If you experience setbacks you can temporarily increase your opioid use and start to reduce again when you feel ready, usually within a week.  It may be more difficult to cease at night and it is usually better to work on this once you have significantly reduced your daytime use.
• Opioids have different durations of action, such as Palexia SR (slow release) and IR (immediate release). The SR tablet has a slower onset but lasts longer whereas the IR tablet works quickly but does not last long. Typically a SR tablet is prescribed twice a day to provide ‘background’ pain relief with the IR tablet available if this is insufficient or if pain ramps up after exercise (breakthrough pain). The SR tablet is usually continued until the IR tablets are no longer needed. However you may find a preference for one tablet over the other and provided you understand the difference between the tablets you should be able to judge which combination is better for you.
• Side effects are very common at higher doses (please see chart). The SR tablets may have side effects that persist longer.
• Taking opioids at night may help with obtaining a good night’s sleep which will help with daytime pain management as well.
• Continuing or adding Lyrica at night may help you reduce your opioid requirements and assist with sleep however taking Lyrica during the day may make you feel drowsy and cause visual disturbance. This is fully reversible when you stop taking the medication.
• Adding or substituting opioids with Tramadol or codeine preparations such as Panadeine Forte may help but be careful not to take both Panadeine Forte and Panadol as both contain paracetamol. Side effect such as nausea or constipation may also be a problem with these tablets.

For more information visit www.betterpainrelief.org

For more information visit www.betterpainrelief.org