Supporting the management of patients with knee pain to alleviate symptoms

Introduction

Knee pain can significantly reduce individuals’ functional capacity, hinder their ability to carry out activities of daily living and have a detrimental effect on quality of life. Approximately one third of the UK population are living with a musculoskeletal condition (Versus Arthritis, 2023), with knee pain affecting between 19% and 35% of the population (Collier et al, 2023).

Knee pain can be initiated by local causes (for example, tendonitis, bursitis, tumour or injury), regional causes (for example, complex regional pain syndrome or referred pain from the spine or hip) or systemic causes (for example, inflammatory arthropathies (joint disease), hypermobility syndrome or skeletal dysplasia) (National Institute for Health and Care Excellence (NICE), 2022a).

Key risk factors for developing knee pain have been identified as older age, being overweight or obese, previous knee injury, occupations that require kneeling and heavy lifting, depression and mental distress and social deprivation (Versus Arthritis, 2023; NICE 2022a). Collier et al (2023) also identified that bilateral knee symptoms and lower levels of education were associated with persistent knee pain at 12 months follow-up.

While the underlying pathology may require specific treatment to address any structural or biomechanical problems, various generalised approaches can be adopted to give a holistic approach to managing knee pain.

Use of the Making Every Contact Count approach to behaviour change can help nurses to integrate health promotion with routine conversations, to help patients consider health risks and how they could make positive changes to improve their health and wellbeing (Public Health England, 2016). This approach can be used to educate patients on the importance of maintaining healthy joints and ways to achieve this, while offering additional support and resources to people requiring extra help.

Education is an essential to managing knee pain, either through shared decision making or information and strategies that empower individuals to manage their condition (McClinton et al, 2020). Nurses can support patients by providing information on the condition, treatment options and anticipated outcomes. They are also well-placed to explore beliefs around knee pain and factors that may contribute to anxiety around this, along with any avoidance behaviours. Identifying misconceptions about the condition and the effects of activity or pain can empower patients to engage with active treatments (McClinton et al, 2020).

For patients who are employed, an occupational health assessment can provide additional support with managing workplace evaluations and any necessary modification of duties or working environment, to improve productivity and reduce the likelihood of workplace absence.

Self-care

Self-care and symptom management are important, particularly for long-term knee conditions such as osteoarthritis (Fig 1). Exercise, weight management and psychological and behavioural techniques are key to managing knee pain and helping optimise function of the knee.

Exercise

Where an acute injury has been sustained, RICE principles (rest, ice, compression and elevation) may be helpful in reducing soft tissue swelling, sprains and strains (Brassington et al, 2023). Prolonged rest and immobility, however, may result in reduced lymphatic drainage (Scialoia and Swartzendruber, 2020) or deconditioning.

Individuals experiencing musculoskeletal discomfort are less likely to engage in activity and may avoid pursuits they fear will make pain worse (Tyneside Integrated Musculoskeletal Service, no date). However, regular physical activity is known to improve physical and mental health (Department of Health and Social Care, 2019). Furthermore, it is known that sedentary behaviour independently contributes to adverse health outcomes, making it important, wherever possible, to integrate inactivity with periods of activity (Park et al, 2020).

The use of walking aids, such as a walking stick, may be helpful in managing knee pain associated with osteoarthritis (NICE, 2022b), as they allow the person to transfer some of the weight through the aid and lessen the weight transferred through the joint. Walking aids must be of an appropriate height or they can cause discomfort, postural strain or poor balance. Research has shown that trekking poles can reduce joint loading through lower limbs by 16% and ground reaction force by 12% (Schwameder et al, 1999). Supportive shoes with cushioning may also help reduce the impact on knees and joints when walking or performing other load bearing activity.

Aids, such as long handled reachers, can help maintain independence when mobility is limited due to osteoarthritis of the knee (NICE, 2023a). Where home modifications may assist independence, referral to occupational therapy can be beneficial for advice on assistive aids, such as half steps, grab rails and home adaptations (NICE, 2023a). Nurses should advise patients on the benefits of exercise and its use for symptom relief and joint protection (NICE, 2023a). Although exercise may initially increase joint pain, regular exercise benefits joints and can reduce pain in the long term and help increase functioning and quality of life (NICE, 2022b). Where there are concerns about knee structure and function, referral to musculoskeletal specialists may be needed for advice on management. Physiotherapy can be beneficial in providing a bespoke exercise programme tailored to the aetiology of the knee pain.

Exercise is important for enhancing joint health and function, namely exercises that strengthen the muscles, enhance flexibility and balance and address ineffective movement techniques (McClinton et al, 2020; Raposo et al, 2021). Flexibility exercises (such as stretching and yoga) can alleviate stiffness and enhance the range of movement, whereas strengthening exercises (weight or resistance training) can improve the function of muscles surrounding the knee, enhancing stability of the joint. Low-impact exercises (such as swimming or cycling) can be useful in maintaining movement and cardiovascular health without placing excessive stress on the knees (Raposo et al, 2021).

Other options can include supervised therapeutic exercise sessions. This is recommended if there are concerns about frailty (Azzolino et al, 2021). Where individuals can exercise safely at home, online programmes such as ‘Let’s move with Leon’, by the charity Versus Arthritis (Box 1), can help increase strength, flexibility and fitness.

As exercise requires sustained participation to see the benefit, patients should be encouraged to start slowly and gradually increase the intensity and duration of activity over time. This will help prevent injuries and allow recovery between sessions. An activity tracker can help plan activity, track goals and achievements and note any challenges with achieving them.

Weight management

Maintaining a balanced and healthy diet is important to help reduce the risk of musculoskeletal conditions, such as osteoarthritis (Office for Health Improvement and Disparities (OHID), 2022). NICE (2022b) recommends weight management for individuals with osteoarthritis who are overweight or obese to help reduce pain and improve physical function and quality of life. A study by Messier et al (2022) showed how diet combined with exercise decreased knee pain in overweight or obese patients with knee osteoarthritis. Box 1 lists examples of NHS resources to help patients eat well and manage their weight.

Smoking is known to reduce levels of vitamin D and calcium absorption in the body and is associated with the development of chronic pain (Murray, 2014). Encouraging patients to stop or reduce their smoking will not only benefit their overall health and quality of life, but also their musculoskeletal health. Again, through the Make Every Contact Count approach, nurses can offer guidance in their day-to-day interactions with patients on smoking cessation, as well as referring people to smoking cessation services and offering support and encouragement to those already taking action to stop smoking.

Pain management

Patients commonly associate the presence of pain with joint damage (McClinton et al, 2020). It is, therefore, important to help patients understand that symptoms and function are not always consistent with the underlying pathology or damage, as this can be an important part of addressing fear-avoidance behaviours.

Cognitive behavioural therapy (CBT) approaches can be used to help individuals cope with pain by changing thoughts and behaviours relating to pain to improve quality of life (Macfarlane et al, 2021). CBT can be used to explore people’s attitudes and beliefs relating to knee pain, along with any fears, catastrophising thoughts or maladaptive strategies they may use. Targeted education is then used to help the person reframe their thoughts and replace negative thoughts with more positive, realistic and adaptive thinking.

Relaxation techniques, such as meditation, visualisation, breathing techniques and muscle relaxation, can also be used as non-pharmacological approaches to managing pain (Vambheim et al, 2021). These strategies aim to counter the stress response and, therefore, tend to have better effects when practised regularly (Vambhiem et al, 2021).

A recent review of mindfulness in chronic musculoskeletal pain suggested that results were comparable with CBT and superior to ‘no treatment’ for outcomes such as pain, depression, sleep quality and physical functioning, although the evidence was of low quality and gave mixed results (Cardle et al, 2023). Exercise that combines mindfulness with physical activity, such as yoga or tai chi, could be considered as a strategy to help promote overall wellbeing in patients with knee pain.

“Working with patients to establish clear and achievable goals helps patients and healthcare providers to work collaboratively on specific aspects of care, such as mobility, pain management or quality of life”

Pacing and goal setting

Pacing of exercise (regulated activity) may be necessary to manage symptoms that can occur due to overactivity (Antcliff et al, 2021). This involves balancing activity with rest to prevent exacerbation of pain and help individuals increase participation in meaningful activities. Over time, pacing can enable a gradual increase in regular and consistent activity, which can improve functionality (Edwards et al, 2021). Pacing can also help reduce any anxiety associated with activity and empower individuals to feel more in control of their condition and symptoms (Antcliff et al, 2021).

Working with patients to establish clear and achievable goals helps patients and healthcare providers to work collaboratively on specific aspects of care, such as mobility, pain management or quality of life. Goal setting and problem-solving techniques can be used as a patient-centred approach to enhance self-management and overcome any barriers to change (Gayton and Monga, 2023).

By personalising goals, patients are more likely to engage with treatment strategies, such as exercise, lifestyle modification or medication regimens. Setting goals that are SMART (specific, measurable, actionable, realistic and time-bound) will help track progress and create a sense of achievement when goals are achieved. Online resources, such as those created by Norfolk and Waveney Community Musculoskeletal Services (Box 1) can help patients and carers to plan their own goals and set realistic targets.

Pharmacological interventions

Knee osteoarthritis affects approximately 5.4 million people in the UK (Versus Arthritis, 2023). Where pharmacological interventions are required for pain and inflammation in individuals with knee osteoarthritis, these should be at the lowest effective dose for the shortest possible duration (NICE, 2022b). NICE (2022b) guidelines recommend use of a topical non-steroidal anti-inflammatory drug (NSAID), or oral NSAID if topical is ineffective or unsuitable. However, oral medication requires careful consideration of contraindications and risk to gastrointestinal, renal and liver function and requires use of a prophylactic gastroprotective agent, such as a proton pump inhibitor (NICE, 2022b).

NICE (2022b) only recommends using paracetamol or weak opioids for infrequent use for the short-term pain relief of knee osteoarthritis, and only where other pharmacological treatments are contraindicated or not effective. It advises that the risks of using strong opioids outweigh the benefits, but that intra-articular corticosteroid injections may be considered to support individuals to participate in therapeutic exercise.

Electrotherapy (for example, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS) and inferential therapy) is not recommended for managing osteoarthritis due to insufficient evidence that it is beneficial (NICE, 2022b).

For other causes of mild-to-moderate knee pain, NICE (2021) recommendations for a stepwise approach to pharmacological management of pain should be used (Box 2).

Other long-term management strategies

NICE recommends the foot-worn device, AposHealth (NICE, 2022b) as an option for managing knee osteoarthritis where non-surgical care has not proved satisfactory and the person meets the criteria for knee replacement but does not want to have surgery (NICE, 2023b). The device is worn for approximately one hour per day and helps redistribute the weight away from the painful area and improve the gait. NICE (2023b) estimates use of AposHealth could save £1,958 per person, compared with usual care, where knee surgery is delayed for five years. The device has been shown to improve pain, stiffness and function, but further research is needed to establish if the symptom reduction is clinically meaningful, or the cost savings apply in clinical practice (NICE, 2022b).

Insoles, braces or splints are not routinely recommended for people with osteoarthritis unless there is joint instability or abnormal loading that cannot be managed through therapeutic exercise (NICE, 2022b).

Public health perspective

Nurses have a central role in improving the health of the population through the promotion of health and wellbeing and prevention of ill health. While the strategies discussed in this article are helpful in managing knee pain, the principles of maintaining a healthy diet and exercise regime can also help maintain healthy joints and prevent injury. Identifying conditions or risk factors that may pre-dispose a person to knee pain can enable a proactive approach and raise awareness among patients of the importance of early detection and effective management (OHID, 2022).

Conclusion

Nurses have a central role in promoting health and wellbeing and minimising the impact of ill health through providing education and support to patients at different stages across health and social care settings. Effective management of knee pain requires a multifaceted and individualised approach to address the aetiology and impact of knee problems.

Key strategies to improve knee function and reduce pain include therapeutic exercise and maintaining a healthy weight and lifestyle. The use of goal setting and pacing can be helpful in improving functional capacity and enabling people to focus on meaningful activity. Education is important in empowering the patient to manage their own care, proactively reduce known risk factors and optimise function through interventions that align with their personal preferences and abilities.