1268 J Med Assoc Thai Vol. 93 No. 11 2010
Nimmaanrat S, Department of Anesthesiology, Faculty of
Medicine, Prince of Songkla University, Hatyai, Songkhla
Phone: 074-451-651-2, Fax: 074-429-621
Expectations, Experiences and Attitudes of Orthopedic
Patients Undergoing Arthroscopic Cruciate Ligament
Reconstruction toward Postoperative Pain
and Its Management
Sasikaan Nimmaanrat MD, MMed (Pain Mgt)*, Boonsin Tangtrakulwanich MD, PhD**,
Thunchanok Wanasuwannakul MD*, Thanarat Boonriong MD**
* Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
** Department of Orthopedic Surgery & Physical Medicine, Faculty of Medicine,
Prince of Songkla University, Songkhla, Thailand
Objective: To evaluate expectations, experiences, and attitudes of orthopedic patients undergoing arthroscopic cruciate
ligament reconstruction in terms of postoperative pain and management.
Material and Method: This prospective study involved 115 patients. Preoperatively, patients completed a preoperative
questionnaire regarding expectations toward postoperative pain and management. Postoperatively, they completed a
postoperative questionnaire regarding exact pain experiences and attitudes in relation to their pain and management.
Results: Almost all expected (95.6%) and experienced (98.3%) pain. The median values of maximum and average pain
measured by a verbal numerical rating score were 7.7 and 5.6, respectively. Approximately 3/5 reported marked and
maximum relief from analgesics received. Only one patient was not satisfied with pain management while the rest were
satisfied in varying degrees. A large proportion showed incorrect conceptions concerning postoperative pain and management.
Conclusion: Postoperative pain management is still an area for improvement. Misunderstandings of patients should be
explored and corrected as they can pose a barrier for effective pain relief. Pain management should begin with preoperative
explanations and advice followed by good care intraoperatively and postoperatively.
Keywords: Expectations, Experiences, Attitudes, Arthroscopic cruciate ligament reconstruction, Postoperative pain,
Postoperative pain management
Although postoperative pain is common and
pain management has much improved, studies from
many countries(1-9) revealed consistent results of
insufficient postoperative pain relief. The problem is
Inadequately treated postoperative pain leads
to a considerable number of adverse consequences
physically and psychologically(10-12). Recovery is one
of the dimensions affected by postoperative pain,
and inadequate acute pain management can affect
negatively on the long-range quality of life(13). Acute
pain can also evoke long-term neuronal remodeling
and sensitization of the central nervous system(10).
Severe acute postoperative pain is one of the risk
factors predisposing to chronic postsurgical pain
(CPSP)(14-16), which has a substantial impact on quality
of life, and treatment of chronic pain is more time-
consuming and costly(17).
Optimal postoperative pain relief is not only
based on analgesics and interventional techniques(18),
but is also tied to patients’ attitudes and beliefs, and
cooperation(19). The present study aimed to evaluate
patients’ preoperative expectations toward post-
operative pain and its management as well as their
actual postoperative pain experiences and attitudes
regarding postoperative pain and management. The
results of this will be utilized to improve postoperative
J Med Assoc Thai 2010; 93 (11): 1268-73
Full text. e-Journal: http://www.mat.or.th/journal
J Med Assoc Thai Vol. 93 No. 11 2010 1269
Material and Method
The present study was performed in the
university-based medical school in the southern part
of Thailand, which is also the tertiary care center for
the region. The research scheme was approved by the
faculty ethics committee. Each participating patient
signed an informed consent form before entering the
Patients undergoing arthroscopic cruciate
ligament reconstruction between July 2007 and
November 2008 were included. Unwilling patients to
participate or those unable to communicate were
Within 72 hours prior to their scheduled
operation, each patient was contacted via telephone
to answer a preoperative questionnaire regarding
demographics, expectations toward postoperative
pain, the level of expected pain at which the patient
would request analgesics, and the expected extent
of pain relief from analgesics received. Twenty-four
hours following surgery, while the patients were still
admitted in the hospital, each patient completed
a postoperative questionnaire regarding their
actual pain experiences, analgesic requirements, and
pain relief effects. The second questionnaire also
comprehended items determining the patients’
attitudes toward postoperative pain and management,
together with whether they were satisfied or dissatisfied
with the provided pain care, and reasons for their
Data of the present study were recorded
with Epidata version 3.0 and analyzed using Program R
Demographic data were demonstrated as
percentages, median, mean, range, and standard
deviation. Levels of pain were measured using a verbal
numerical rating score [VNRS (0-10)] and a categorical
[verbal descriptive score (VDS)] rated as very mild,
mild, moderate, severe, and very severe.
Patients’ demographic data
One-hundred and fifteen patients participated
in the present study. The majority (102 in 115, 88.7%)
were male. The mean age was 31.8 years (range of 17 to
51). Seventy-eight patients (67.8%) had no history of a
previous operation. The average duration of surgery
was 62.2 minutes. Spinal anesthesia was performed
in nearly all of the participants (113 in 115, 98.3%)
while general anesthesia was carried out in the rest.
Postoperative pain relief was managed on an as-needed
basis with paracetamol, non-steroidal anti-inflammatory
drugs, morphine, or fentanyl.
Almost all (110 in 115, 95.6%) patients
expected postoperative pain. Their average expected
pain as measured by the VNRS was 5.7, and by the
VDS indicated 1.7%, 10.4%, 62.6%, 24.4%, and 0.9%
anticipated very mild, mild, moderate, severe, and very
severe pain, respectively.
The patients predicted they would ask for
analgesics when their VNRS reached 6.5, with 4.4%,
42.6%, 37.4%, and 15.6% estimating to request
analgesics when they had mild, moderate, severe, and
very severe pain, respectively.
Nearly all (113 in 115, 98.3%) actually
experienced postoperative pain with a median
maximum VNRS of 7.7, with 1.7%, 4.4%, 14.8%, 54.8%,
and 24.3% indicating they experienced pain at very
mild, mild, moderate, severe, and very severe levels,
respectively. The median average VNRS the patients
experienced was 5.6, with 2.6%, 13.0%, 45.2%, 38.3%,
and 0.9% reporting average levels of their pain as
very mild, mild, moderate, severe, and very severe,
The median VNRS at which the patients
requested analgesics was 6.5, with 38.3%, 59.1%, and
2.6% stating they required analgesics when their
levels of pain were moderate, severe, and very severe,
When asked about their opinions concerning
to what extent their analgesics actually relieved
their pain, 8.7%, 34.8%, 52.2%, and 4.3% rated the
effectiveness as little, moderate, a lot, and maximum,
Around 4/5 (81.7%) reported their sleep was
disturbed by pain, and approximately 2/5 wanted to
receive stronger analgesics (37.4%) or more frequent
Approximately half (58 in 115, 50.4%) indicated
they were markedly satisfied with their postoperative
pain management, while 7%, 36.6%, and 5.4% accounted
their satisfaction as maximum, moderate, and mild,
respectively. The reasons for their satisfaction are
demonstrated in Table 1. One patient (0.9%) indicated
dissatisfaction because he desired a higher dose of
1270 J Med Assoc Thai Vol. 93 No. 11 2010
Attitudes of the patients regarding
postoperative pain and its management are shown in
Correlation between expected and experienced pain
Approximately one-third affirmed their levels
of expected and experienced pain were identical. Of
those stating differences, 31.3% and 37.4% had less
and higher pain than their expectations, respectively.
The finding discovered that the participants
preoperatively expected postoperative pain and
actually experienced pain postoperatively. The mean
maximum pain quantified by VNRS was high and
the mean value of average pain was substantial. The
greater part satisfied with postoperative pain relief
in varying degrees. Their attitudes regarding post-
operative pain and management were interesting, as
many had misconceptions.
In the present study, almost all expected and
actually experienced postoperative pain. Expected
pain has been found to have a predictive value for
postoperative pain(20). Their mean value of maximum
pain reached 7.7, which is considered as severe(21).
It is interesting that although their pain levels were
high, the majority did not want to receive stronger
analgesics nor more frequent administrations, a
phenomenon also noted in another study(8).
Only one-third expected and experienced the
same levels of postoperative pain. Among these who
reported a disparity, more than 50% experienced higher
pain than expected. The result is different from another
study performed by Nimmaanrat S et al, in which 71%
of patients who reported differences between expected
and experienced pain had less pain than expected(8).
The present study demonstrated that
though the pain was severe, only one patient was
dissatisfied. The result is in conjunction with previous
studies(2-4,22-25). Satisfaction is multifactorial(26), the
relevance of satisfaction as an optimal outcome
measurement in quality assurance processes might be
“Staff-pleasing-factor”(22) must be taken into
account while interpreting patients’ satisfaction. It is a
factor commonly found in Thais, as they wish to pay
respect and be nice to people who help or take care of
them, but may be less so elsewhere.
The very high proportion agreed that
postoperative pain was something occurring naturally
Believed that postoperative pain was inevitable
Expected postoperative pain would be more severe than what was actually experienced
Understanding the reasons that led to postoperative pain
Knowing that postoperative pain was improving with time
Had experienced more severe pain
Wanted to please health care providers
Table 1. Reasons for satisfaction with postoperative pain management (114 participants)
Pain normally occurs after surgery
Postoperative pain improves as time passes by
Analgesics cannot relieve pain
Good patients should avoid talking about pain
Analgesics should be saved until pain gets worse
Patients can easily get addicted to analgesics
It is easier to tolerate pain than the side effects of analgesics
Table 2. Patients’ attitudes and beliefs toward postoperative pain and its management (115 participants)
J Med Assoc Thai Vol. 93 No. 11 2010 1271
as a result of surgery, in accordance with previous
studies(1,24). However, with available medical service,
such pain can be adequately controlled. Preoperatively,
advising the patient about postoperative pain
management options was suggested, and that it played
a major role in effective management. Preoperative
information has been shown to assist patients’ active
participation in their care, and thereafter may lead to
It is a master of concern that some patients
agreed that analgesics could not ease pain. Possible
reasons may be related to the patients themselves,
health care workers (negative attitudes, etc.) or the
system of health service (limited resources, etc.).
Education should be a priority for both health care
professionals(28,29) and patients(29).
It is very interesting that many of them agreed
that good patients should avoid complaining about
pain, which is in accordance with a previous study(8). It
is a feature of Thai culture that Thais think that they
should not waste the time of health care professionals
by complaining of their pain. They may feel their health
care professionals should not spend a lot of time on
their personal pain because they will then have less
time for other patients who may be in more need. It has
been found that culture can influence the expression
of pain(30) while ethnicity influenced experimental
pain(31). In chronic pain patients, race has been
found to affect pain reporting, opioid requirements(32)
and coping skills(33). Such attitude was considered
as an area to be addressed for improvement of pain
Some patients agreed that they could get
addicted to analgesics easily, in agreement with a
previous study(34). The duration of acute postoperative
pain is short so it is unlikely to get addicted to
A significant number believed that tolerating
postoperative pain was easier than to tolerate the side
effects of analgesics. It has been well recognized that
every patient has the right to effective postoperative
pain control, as well as to avoid and get relief from
other adverse effects. Multimodal analgesia has been
confirmed to improve the adequacy of postoperative
pain control while minimizing side effects(35).
The strengths of the present study are a
preoperative/postoperative study design, procedure-
specific and a large sample size (more than 100 patients).
It also provides cross-cultural data that could improve
the understanding of perceptions of postoperative
On the other hand, the present study has some
limitations. The studied patients may not represent
the population at large. The majority was male and it
has been clarified that men and women have a different
pain threshold and tolerance(36). Different ethnicities,
races, cultural traditions, types of surgery, varieties of
hospitals and health care services may lead to different
results. Additionally, attitudes, knowledge and
prescribing habits of physicians have also been
shown to affect adequate pain management(37). More
sophisticated and larger scale studies including a
wide variety of patients and health care providers are
suggested to advance the understanding and to help
improve the quality of the health care service.
In conclusion, the present study demonstrated
that the patients expected and truly experienced
postoperative pain following arthroscopic cruciate
ligament reconstruction. Their intensities of pain were
high measured by both the VNRS and VDS, but the
majority of them were satisfied with the pain relief
provided. Many of them held misconceptions toward
postoperative pain and its management. Postoperative
pain management is an area in which there is still
considerable room for improvement, particularly in the
way to deal with the patients’ knowledge, attitudes,
and expectations prior to surgery.
1. Warfield CA, Kahn CH. Acute pain management.
Programs in U.S. hospitals and experiences and
attitudes among U.S. adults. Anesthesiology
1995; 83: 1090-4.
2. Apfelbaum JL, Chen C, Mehta SS, Gan TJ.
Postoperative pain experience: results from a
national survey suggest postoperative pain
continues to be undermanaged. Anesth Analg
2003; 97: 534-40.
3. Rocchi A, Chung F, Forte L. Canadian survey of
postsurgical pain and pain medication experiences.
Can J Anaesth 2002; 49: 1053-6.
4. Donovan BD. Patient attitudes to postoperative
pain relief. Anaesth Intensive Care 1983; 11: 125-9.
5. Owen H, McMillan V, Rogowski D. Postoperative
pain therapy: a survey of patients’ expectations
and their experiences. Pain 1990; 41: 303-7.
6. Puig MM, Montes A, Marrugat J. Management of
postoperative pain in Spain. Acta Anaesthesiol
Scand 2001; 45: 465-70.
7. Idvall E, Bergqvist A, Silverhjelm J, Unosson M.
Perspectives of Swedish patients on postoperative
pain management. Nurs Health Sci 2008; 10: 131-6.
1272 J Med Assoc Thai Vol. 93 No. 11 2010
8. Nimmaanrat S, Liabsuetrakul T, Uakritdathikarn T,
Wasinwong W. Attitudes, beliefs, and expectations
of gynecological patients toward postoperative
pain and its managementt. J Med Assoc Thai 2007;
9. Karling M, Renstrom M, Ljungman G. Acute and
postoperative pain in children: a Swedish
nationwide survey. Acta Paediatr 2002; 91: 660-6.
10. Carr DB, Goudas LC. Acute pain. Lancet 1999; 353:
11. Joshi GP, Ogunnaike BO. Consequences of
inadequate postoperative pain relief and chronic
persistent postoperative pain. Anesthesiol Clin
North America 2005; 23: 21-36.
12. Carr EC, Nicky TV, Wilson-Barnet J. Patient
experiences of anxiety, depression and acute pain
after surgery: a longitudinal perspective. Int J
Nurs Stud 2005; 42: 521-30.
13. Wu CL, Richman JM. Postoperative pain and
quality of recovery. Curr Opin Anaesthesiol 2004;
14. Macrae WA. Chronic post-surgical pain: 10 years
on. Br J Anaesth 2008; 101: 77-86.
15. Yarnitsky D, Crispel Y, Eisenberg E, Granovsky Y,
Ben Nun A, Sprecher E, et al. Prediction of chronic
post-operative pain: pre-operative DNIC testing
identifies patients at risk. Pain 2008; 138: 22-8.
16. Akkaya T, Ozkan D. Chronic post-surgical pain.
Agri 2009; 21: 1-9.
17. Chuck A, Adamowicz W, Jacobs P, Ohinmaa A,
Dick B, Rashiq S. The willingness to pay for
reducing pain and pain-related disability. Value
Health 2009; 12: 498-506.
18. Popping DM, Zahn PK, Van Aken HK, Dasch B,
Boche R, Pogatzki-Zahn EM. Effectiveness and
safety of postoperative pain management: a
survey of 18,925 consecutive patients between
1998 and 2006 (2nd revision): a database analysis
of prospectively raised data. Br J Anaesth 2008;
19. Brydon CW, Asbury AJ. Attitudes to pain and
pain relief in adult surgical patients. Anaesthesia
1996; 51: 279-81.
20. Sommer M, Geurts JW, Stessel B, Kessels AG,
Peters ML, Patijn J, et al. Prevalence and predictors
of postoperative pain after ear, nose, and throat
surgery. Arch Otolaryngol Head Neck Surg 2009;
21. Australia and New Zealand College of
Anaesthetists and Faculty of Pain Medicine.
Acute pain management: scientific evidence. 2nd
ed. Canberra: ANZCA; 2005.
22. Svensson I, Sjostrom B, Haljamae H. Influence of
expectations and actual pain experiences on
satisfaction with postoperative pain management.
Eur J Pain 2001; 5: 125-33.
23. Strassels SA, Chen C, Carr DB. Postoperative
analgesia: economics, resource use, and patient
satisfaction in an urban teaching hospital. Anesth
Analg 2002; 94: 130-7.
24. Chung JW, Lui JC. Postoperative pain
management: study of patients’ level of pain
and satisfaction with health care providers’
responsiveness to their reports of pain. Nurs
Health Sci 2003; 5: 13-21.
25. Gunningberg L, Idvall E. The quality of
postoperative pain management from the
perspectives of patients, nurses and patient
records. J Nurs Manag 2007; 15: 756-66.
26. Lemos P, Pinto A, Morais G, Pereira J, Loureiro R,
Teixeira S, et al. Patient satisfaction following day
surgery. J Clin Anesth 2009; 21: 200-5.
27. Walker JA. What is the effect of preoperative
information on patient satisfaction? Br J Nurs
2007; 16: 27-32.
28. Wilder-Smith OH, Mohrle JJ, Martin NC. Acute
pain management after surgery or in the
emergency room in Switzerland: a comparative
survey of Swiss anaesthesiologists and surgeons.
Eur J Pain 2002; 6: 189-201.
29. Tzeng JI, Chou LF, Lin CC. Concerns about reporting
pain and using analgesics among Taiwanese
postoperative patients. J Pain 2006; 7: 860-6.
30. Hobara M. Beliefs about appropriate pain
behavior: cross-cultural and sex differences
between Japanese and Euro-Americans. Eur J
Pain 2005; 9: 389-93.
31. Watson PJ, Latif RK, Rowbotham DJ. Ethnic
differences in thermal pain responses: a
comparison of South Asian and White British
healthy males. Pain 2005; 118: 194-200.
32. Chen I, Kurz J, Pasanen M, Faselis C, Panda M,
Staton LJ, et al. Racial differences in opioid use
for chronic nonmalignant pain. J Gen Intern Med
2005; 20: 593-8.
33. Cano A, Mayo A, Ventimiglia M. Coping, pain
severity, interference, and disability: the potential
mediating and moderating roles of race and
education. J Pain 2006; 7: 459-68.
34. Beauregard L, Pomp A, Choiniere M. Severity and
impact of pain after day-surgery. Can J Anaesth
1998; 45: 304-11.