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Ai S, Wang Y, Niu P, Xiao W, Xu G, Zhu C. Pain Catastrophizing and Acute Post-Surgical Pain in Knee Arthroplasty Patients: The Moderating Role of Social Support. J Pain Res 2024; 17:3127-3136. [PMID: 39324012 PMCID: PMC11423833 DOI: 10.2147/jpr.s474652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 09/01/2024] [Indexed: 09/27/2024] Open
Abstract
Purpose This study aimed to investigate the correlation between preoperative pain catastrophizing and social support, and acute post-surgical pain in patients who underwent knee arthroplasty. The study also aimed to determine whether social support moderates the role of pain catastrophizing psychologically in acute post-surgical pain after knee arthroplasty. Patients and Methods This study recruited participants to survey a tertiary hospital in Dalian, China, between November 2022 and October 2023. Participants completed pain catastrophizing scales and social support reevaluated scales one day (T1) before they were confirmed to undergo knee arthroplasty, and finished the Numeric Rating Scale at 24h (T2), 48h (T3), and 72h (T4) postoperatively. Pearson correlation analyses were used to explore the relationship between social support, pain catastrophizing, and acute post-surgical pain, hierarchical regression analysis was used to test the moderating role of social support between pain catastrophizing and acute post-surgical pain. Results This study recruited 178 knee arthroplasty patients. The results of the t-test or one-way ANOVA indicated that there were statistically significant differences in gender, age, education, occupation, disease duration, whether the knee replacement was performed for the first time, preoperative pain scores, and operation time in patients with knee arthroplasty (P < 0.05). The correlation analysis of social support, pain catastrophization, and acute post-surgical pain in knee arthroplasty patients showed that social support was negatively correlated with acute post-surgical pain (r=-0.584, P<0.01), and pain catastrophizing was positively correlated with postoperative acute pain (r=0.601, P<0.01); The hierarchical regression analysis revealed that social support had a significant moderating effect on the relationship between pain catastrophizing and acute post-surgical pain (ΔR2=0.606, P<0.05). Conclusion The acute post-surgical pain of knee arthroplasty patients was affected by gender, age, education, occupation, disease duration, whether the knee arthroplasty was performed for the first time, preoperative pain scores, and operation time. Acute Post-surgical pain in patients with knee arthroplasty was affected by social support and pain catastrophizing, and social support had a moderating effect on the relationship between pain catastrophizing and acute post-surgical pain.
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Affiliation(s)
- Shanshan Ai
- Department of Nursing, Linping District Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yue Wang
- Department of Nursing, The First Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Pengli Niu
- Department of Nursing, The First Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Wenjun Xiao
- Department of Nursing, The First Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Guojun Xu
- Department of Nursing, The First Hospital of Dalian Medical University, Dalian, Liaoning, People's Republic of China
| | - Chang Zhu
- Department of Expanded Program on Immunisation, Linping District Centre for Disease Control and Prevention, Hangzhou, Zhejiang, People's Republic of China
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Lozano-Meca JA, Gacto-Sánchez M, Montilla-Herrador J. Movement-evoked pain is not associated with pain at rest or physical function in knee osteoarthritis. Eur J Pain 2024; 28:987-996. [PMID: 38186263 DOI: 10.1002/ejp.2236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/01/2023] [Accepted: 12/20/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Knee Osteoarthritis (KOA) is mainly characterized by pain. The assessment of KOA-related pain frequently focuses on different constructs subject to sources of bias or drawbacks, as the classical Pain at Rest (PAR). Movement-evoked pain (MEP), recently defined as 'pain during walking', emerges as a differential concept, since PAR and MEP are driven by different underlying mechanisms. Given the novelty of the MEP approach, its association with PAR or with different performance-based tests has not been studied in KOA yet. MATERIALS AND METHODS A cross sectional study was conducted. PAR was measured, alongside the performance of four mobility tests and their corresponding MEP: Timed Up and Go Test, 10-metre Walk Test, 2-Minute Walk Test, and 6-Minute Walk Test. Association and agreement were explored for MEP versus PAR, while the correlation of the tests versus each corresponding MEP-measure was assessed. RESULTS Neither association nor agreement were found in the duality MEP versus PAR. Also, the lack of association between the performance of a mobility test and the perceived level of pain during the development of the test was stated. CONCLUSION Movement-evoked pain is neither related to pain at rest nor to functional performance in subjects affected by knee osteoarthritis. The results from our study suggest that MEP and pain at rest measure and refer to different constructs in knee osteoarthritis. The implementation of MEP as an outcome in exercise-therapy could enhance the tracking of results, as well as the development of tailored interventions under different conditions. SIGNIFICANCE This research elucidates the relevance of MEP, recently defined as 'pain during walking', through the analysis of its association with PAR and with functional performance (measured through four mobility tests) in knee osteoarthritis. The results from our study highlight the absence of either association or agreement between MEP and PAR, fact that supports and endorses the idea that both concepts measure and refer to different constructs in knee osteoarthritis.
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Knezevic NN, Syed O, Kabir C, Patel A, Rao Shuai I, Tharian AR. The Impact of Acute Postoperative Pain in Developing Chronic Pain after Total Knee Arthroplasty. Neurol Int 2024; 16:459-469. [PMID: 38668131 PMCID: PMC11054509 DOI: 10.3390/neurolint16020034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
While total knee arthroplasties (TKAs) are performed with the intent to reduce pain, chronic postsurgical pain (CPSP) is one of the most well-documented complications that can occur following surgery. This study aimed to assess whether perioperative factors, focusing on acute postsurgical pain and perioperative opioid consumption, were associated with the development of chronic postsurgical pain. Under general anesthesia, 108 patients underwent TKA and were treated postoperatively with a multimodal analgesia approach. Numeric Rating Scale (NRS) pain scores at rest and with movement were recorded on postoperative days 0-3, 7, 14, and 30. Patients were sent a survey to assess chronic pain at months 22-66, which was examined as a single-group post hoc analysis. Based on the responses, patients were either classified into the CPSP or non-CPSP patient group. Chronic postsurgical pain was defined as an NRS score ≥ 4 with movement and the presence of resting pain. The primary outcome was a change in NRS. There were no differences in NRS pain scores with movement in the first 30 days postoperatively between patients with CPSP and without CPSP. Each unit increase in resting pain on postoperative days 3 and 14 was associated with significantly greater odds of CPSP presence (OR = 1.52; OR = 1.61, respectively), with a trend towards greater odds of CPSP at days 7 and 30 (OR = 1.33; OR = 1.43, respectively). We found that very intense pain in the initial phase seems to be related to the development of CPSP after TKA.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA; (O.S.); (I.R.S.); (A.R.T.)
- Department of Surgery, University of Illinois, Chicago, IL 60612, USA
- Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
| | - Osman Syed
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA; (O.S.); (I.R.S.); (A.R.T.)
- College of Osteopathic Medicine, Midwestern University, Downers Grove, IL 60515, USA
| | | | - Aisha Patel
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA; (O.S.); (I.R.S.); (A.R.T.)
| | - Isabel Rao Shuai
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA; (O.S.); (I.R.S.); (A.R.T.)
| | - Antony R. Tharian
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA; (O.S.); (I.R.S.); (A.R.T.)
- Department of Surgery, University of Illinois, Chicago, IL 60612, USA
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Ye J, Xie D, Li X, Lu N, Zeng C, Lei G, Wei J, Li J. Phenotypes of osteoarthritis-related knee pain and their transition over time: data from the osteoarthritis initiative. BMC Musculoskelet Disord 2024; 25:173. [PMID: 38402384 PMCID: PMC10893610 DOI: 10.1186/s12891-024-07286-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/16/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Identification of knee osteoarthritis (OA) pain phenotypes, their transition patterns, and risk factors for worse phenotypes, may guide prognosis and targeted treatment; however, few studies have described them. We aimed to investigate different pain phenotypes, their transition patterns, and potential risk factors for worse pain phenotypes. METHODS Utilizing data from the Osteoarthritis Initiative (OAI), pain severity was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. We identified the activity-related pain phenotypes and estimated the transition probabilities of pain phenotypes from baseline to the 24-month using latent transition analysis. We examined the risk factors at baseline with the 24-month pain phenotypes and the transition of pain phenotypes. RESULTS In 4796 participants, we identified four distinct knee pain phenotypes at both baseline and 24-month follow-up: no pain, mild pain during activity (Mild P-A), mild pain during both rest and activity (Mild P-R-A), and moderate pain during both rest and activity (Mod P-R-A). 82.9% knees with no pain at baseline stayed the same at 24-month follow-up, 17.1% progressed to worse pain phenotypes. Among "Mild P-A" at baseline, 32.0% converted to no-pain, 12.8% progressed to "Mild P-R-A", and 53.2% remained. Approximately 46.1% of "Mild P-R-A" and 54.5% of "Mod P-R-A" at baseline experienced remission by 24-month. Female, non-whites, participants with higher depression score, higher body mass index (BMI), higher Kellgren and Lawrence (KL) grade, and knee injury history were more likely to be in the worse pain phenotypes, while participants aged 65 years or older and with higher education were less likely to be in worse pain phenotypes at 24-month follow-up visit. Risk factors for greater transition probability to worse pain phenotypes at 24-month included being female, non-whites, participants with higher depression score, higher BMI, and higher KL grade. CONCLUSIONS We identified four distinct knee pain phenotypes. While the pain phenotypes remained stable in the majority of knees over 24 months period, substantial proportion of knees switched to different pain phenotypes. Several socio-demographics as well as radiographic lesions at baseline are associated with worse pain phenotypes at 24-month follow-up visit and transition of pain phenotypes.
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Affiliation(s)
- Jing Ye
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Dongxing Xie
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoxiao Li
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, Central South University, Changsha, China
| | - Na Lu
- Arthritis Research Canada, Richmond, Canada
| | - Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Wei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education, Xiangya Hospital, Central South University, Changsha, China
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jiatian Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China.
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Birnbaums JV, Ozoliņa A, Solovjovs L, Glāzniece-Kagane Z, Nemme J, Logina I. Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study. Front Med (Lausanne) 2024; 11:1330446. [PMID: 38420357 PMCID: PMC10900103 DOI: 10.3389/fmed.2024.1330446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
Background Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy. Objectives This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches. Materials and methods Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05). Results Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015). Conclusion ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.
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Affiliation(s)
| | - Agnese Ozoliņa
- Riga Stradins University, Riga, Latvia
- Riga East University Hospital, Riga, Latvia
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Piva SR, Switzer GE, Mikolic JM, Boudreaux-Kelly MY, Faruque S, Aloziem OU, Ibinson JW, Williams BA. Validity of the Modified Defense and Veterans Pain Rating Scale Supplemented With Items Germane to Total Joint Replacement: Secondary Analysis From a Randomized Trial. Mil Med 2023; 188:e3017-e3025. [PMID: 37208305 DOI: 10.1093/milmed/usad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/18/2023] [Accepted: 04/26/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Valid measures of pain are helpful to adjust treatment plans in real time after total joint replacement (TJR). We enhanced the existing Defense and Veterans Pain Rating Scale (DVPRS) with items related to pain at rest and movement, in specific reference to operative and nonoperative joints, creating the TJR-DVPRS. This manuscript is presented to validate the modified survey instrument. The aims of this psychometric study were to evaluate (1) the latent structure of the TJR-DVPRS, (2) the relationships among the pain dimensions represented on the TJR-DVPRS and the reference-standard Short-Form McGill Pain Questionnaire (version 2, SF-MPQ-2), and (3) the responsiveness of these two measures before and after TJR. MATERIALS AND METHODS This report involves a secondary analysis of pain surveys from 135 veterans undergoing TJR at one center who participated in a randomized trial. The study was approved by the institutional review boards from participating institutions. The TJR-DVPRS and SF-MPQ-2 were completed preoperatively, during postoperative day 1, and 6 weeks post-surgery. Standard psychometric evaluations included correlations, principal component analysis, and internal consistency of survey items and subscales, using preoperative baseline data as a frame of reference. Responsiveness analysis included assessing both effect size and thresholds of clinically important change for survey subscales using data from all three time points. RESULTS Two reliable subscales were identified for the TJR-DVPRS, one including items about pain intensity and interference related to the operative joint (Cronbach's α = .809) and the other including two pain items on the nonoperative joint. Combining the subscales indicated a two-factor solution: The first valid factor entailed the four subscales of the SF-MPQ-2 and the TJR-DVPRS operative joint subscales, indicating that these subscales validly represent the same pain dimension. The second valid factor entailed the TJR-DVPRS subscale addressing the nonoperative joint. Responsiveness analysis following accepted psychometric methods demonstrated significant decreases in pain from the preoperative period to 6 weeks postoperatively for all subscales. The TJR-DVPRS and SF-MPQ-2 subscales were similarly responsive, except for the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales, which were minimally responsive during the preoperative to 6-week period. CONCLUSIONS The TJR-DVPRS is valid for use among veterans undergoing TJR and poses significantly less respondent burden than does the SF-MPQ-2. The brevity and ease of use of the TJR-DVPRS make it a practical tool for use during surgical recovery to monitor pain intensity at rest and with movement in the operative joint, and to assess pain interference with activity, sleep, and mood. The TJR-DVPRS is at least as responsive as the SF-MPQ-2, but the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales were minimally responsive. Limitations of this study include the small sample size, under-representation of women (which would be expected in the veteran population), and using only veterans. Future validations studies should include civilians and active military TJR patients.
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Affiliation(s)
- Sara R Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15219-3130, USA
| | - Galen E Switzer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joseph M Mikolic
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240-1001, USA
| | - Monique Y Boudreaux-Kelly
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240-1001, USA
| | - Saurab Faruque
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15216, USA
| | | | - James W Ibinson
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, Pittsburgh, PA 15240, USA
| | - Brian A Williams
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, Pittsburgh, PA 15240, USA
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 12561, USA
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Perrot S, Anne-Priscille T. Pain in osteoarthritis from a symptom to a disease. Best Pract Res Clin Rheumatol 2023; 37:101825. [PMID: 37236892 DOI: 10.1016/j.berh.2023.101825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023]
Abstract
Pain is the most frequent symptom of osteoarthritis (OA), occurring much more commonly than stiffness or disability. Classically, OA-related pain has been considered to be a nociceptive pain condition and an alarm signal correlated to the intensity of joint degradation. However, OA-related pain is a specific disease, with a complex pathophysiology, including neuropathic peripheral and central abnormalities, together with local inflammation involving all joint structures. Clinical findings emphasize that it is not a stable and linear condition, that pain experience is poorly correlated to structural modifications, and that the quality of pain in OA is important to consider, aside from its intensity. OA-related pain is modulated by many factors, including the individual patient's psychological and genetic factors, as well as the theoretical role of meteorological influences. Recent findings have improved our knowledge about the central mechanisms of OA pain, especially in persistent cases. A specific questionnaire on OA pain is currently being developed to assess more precisely the patient's experience and target specific pain mechanisms. In conclusion, OA-related pain should be analyzed specifically aside from OA, taking into account the complexity of OA pain as a disease, distinguishing different OA pain phenotypes, to guide more precisely analgesic treatment and OA global management.
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Affiliation(s)
- Serge Perrot
- Pain Department, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Paris Cité University, INSERM U987, Paris, France.
| | - Trouvin Anne-Priscille
- Pain Department, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Paris Cité University, INSERM U987, Paris, France
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Overton M, Swain N, Falling C, Gwynne-Jones D, Fillingim R, Mani R. Activity-related pain predicts pain and functional outcomes in people with knee osteoarthritis: A longitudinal study. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2023; 3:1082252. [PMID: 36713644 PMCID: PMC9880771 DOI: 10.3389/fpain.2022.1082252] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/19/2022] [Indexed: 01/14/2023]
Abstract
Knee Osteoarthritis (OA) is a prevalent musculoskeletal condition, commonly resulting in pain and disability. However, pain and disability in this population are poorly related with the degree of structural joint damage. Underlying pain mechanisms, including activity-related pain and sensitization assessed via Quantitative Sensory Testing (QST), may better predict pain and functional outcomes of those with knee OA. Therefore, the aim of this study was to explore whether activity-related pain and sensitization assessed via QST predict future pain, function, fatigue, physical performance and quality of life outcomes in those living in the community with knee OA. Eighty-six participants with knee OA were recruited in Dunedin, New Zealand. Those eligible to participate underwent baseline testing including QST as well as measures of activity-related pain including Movement-evoked Pain (MEP) and Sensitivity to Physical Activity (SPA). Outcome measures exploring pain, function, fatigue and quality of life outcomes were collected at baseline, and two follow-up periods (two and nine weeks). Univariable linear regression models were developed followed by multivariable linear regression models for each prognostic marker adjusting for age, gender, BMI, OA duration, baseline pain intensity and socioeconomic status. Activity-related measures of pain, including MEP and SPA, demonstrated predictive associations with pain and functional outcomes prospectively in those with knee OA. Therefore, those demonstrating activity-related pain are at future risk of greater pain, disability and reduced quality of life. Larger, externally validated longitudinal studies are required which include individuals with more severe knee OA.
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Affiliation(s)
- Mark Overton
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand,Correspondence: Mark Overton
| | - Nicola Swain
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Carrie Falling
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - David Gwynne-Jones
- Department of Surgical Sciences, Otago School of Medicine, University of Otago, Dunedin, New Zealand
| | - Roger Fillingim
- Pain Research and Intervention Center of Excellence (PRICE), Department of Community Dentistry and Behavioural Science, University of Florida, Gainesville, FL, United States
| | - Ramakrishnan Mani
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Factors associated with persistent postsurgical pain after total knee or hip joint replacement: a systematic review and meta-analysis. Pain Rep 2023; 8:e1052. [PMID: 36699992 PMCID: PMC9833456 DOI: 10.1097/pr9.0000000000001052] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/08/2022] [Accepted: 09/14/2022] [Indexed: 01/27/2023] Open
Abstract
Studies have identified demographic, clinical, psychosocial, and perioperative variables associated with persistent pain after a variety of surgeries. This study aimed to perform a systematic review and meta-analysis of factors associated with persistent pain after total knee replacement (TKR) and total hip replacement (THR) surgeries. To meet the inclusion criteria, studies were required to assess variables before or at the time of surgery, include a persistent postsurgical pain (PPSP) outcome measure at least 2 months after a TKR or THR surgery, and include a statistical analysis of the effect of the risk factor(s) on the outcome measure. Outcomes from studies implementing univariate and multivariable statistical models were analyzed separately. Where possible, data from univariate analyses on the same factors were combined in a meta-analysis. Eighty-one studies involving 171,354 patients were included in the review. Because of the heterogeneity of assessment methods, only 44% of the studies allowed meaningful meta-analysis. In meta-analyses, state anxiety (but not trait anxiety) scores and higher depression scores on the Beck Depression Inventory were associated with an increased risk of PPSP after TKR. In the qualitative summary of multivariable analyses, higher preoperative pain scores were associated with PPSP after TKR or THR. This review systematically assessed factors associated with an increased risk of PPSP after TKR and THR and highlights current knowledge gaps that can be addressed by future research.
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10
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Whale K, Gooberman-Hill R. Development of a novel intervention to improve sleep and pain in patients undergoing total knee replacement. Trials 2022; 23:625. [PMID: 35918742 PMCID: PMC9344446 DOI: 10.1186/s13063-022-06584-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients. Methods Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis. Results Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches. Conclusion Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.
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Affiliation(s)
- K Whale
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK. .,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.
| | - R Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
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11
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Cuñat T, Martínez-Pastor JC, Dürsteler C, Hernández C, Sala-Blanch X. Perioperative medicine role in painful knee prosthesis prevention. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:411-420. [PMID: 35869007 DOI: 10.1016/j.redare.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 03/25/2021] [Indexed: 06/15/2023]
Abstract
Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.
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Affiliation(s)
- T Cuñat
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - J C Martínez-Pastor
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clinic de Barcelona, Barcelona, Spain
| | - C Dürsteler
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C Hernández
- Servicio de Anestesiología y Reanimación, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Barcelona, Spain
| | - X Sala-Blanch
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, Spain
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12
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Zhang Y, Li Z, Su Q, Ge H, Cheng B, Tian M. The duration of postoperative analgesic use after total knee arthroplasty and nomogram for predicting prolonged analgesic use. Front Surg 2022; 9:911864. [PMID: 35959127 PMCID: PMC9360610 DOI: 10.3389/fsurg.2022.911864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Total knee arthroplasty is currently a reliable treatment for end-stage knee osteoarthritis. However, chronic postsurgical pain (CPSP) is substantially thought to reduce patient satisfaction. NSAID-based oral analgesics were used to manage CPSP, but research on the duration of postoperative analgesic use (DAU) and prolonged analgesic use (PAU) are presently scarce. Methods Preoperative, perioperative, and one-year or above postoperative follow-up data were collected from 162 patients who underwent total knee arthroplasty between 1 June 2018 and 1 March 2019, and the DAU and the discontinuation time of each patient after discharge were recorded. Observational statistical analysis, diagnostic test, and predictive nomogram construction were performed on the collected data. Results The 3-month DAU has good diagnostic utility for poor outcome of postoperative months twelve (POM12). The constructed nomogram shows that gender, preoperative Numeric Rating Scale (NRS) movement pain scores, duration of surgery, postoperative days three (POD3) moderate to severe movement pain, and POD3 pain rescue medication were significant prognostic predictors of PAU after discharge. The area under the curve (AUC) of the 3-month, 6-month, and 12-month nomogram receiver operating characteristic (ROC) curves were calculated to be 0.741, 0.736, and 0.781. Conclusion PAU was defined as more than three months of NSAID-based oral analgesic use after TKA. Prognostic predictors of PAU after TKA were identified, and visualized nomogram was plotted and evaluated. The evaluation indicated that the prediction model had the good predictive ability and was a valuable tool for predicting PAU after discharge.
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Affiliation(s)
- Yi Zhang
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Orthopaedics, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zihua Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qihang Su
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Heng’an Ge
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Biao Cheng
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Correspondence: Biao Cheng Meimei Tian
| | - Meimei Tian
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Correspondence: Biao Cheng Meimei Tian
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13
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Tian M, Li Z, Chen X, Wu Q, Shi H, Zhu Y, Shi Y. Prevalence and Predictors of Chronic Pain with Two-Year Follow-Up After Knee Arthroplasty. J Pain Res 2022; 15:1091-1105. [PMID: 35450062 PMCID: PMC9017706 DOI: 10.2147/jpr.s345496] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
Abstract
Background Pain relief is the most important issue in the long-term outcome of arthroplasty surgery, with nearly one-third of patients still suffered persistent pain and caused dissatisfaction after the surgery. Methods A total of 713 patients underwent primary elective primary TKA and UKA were included consecutively between July 2018 and December 2019, using binary logistic method to analyze the data. Results The prevalence of CPSP at rest and on movement at 2-year was 12.1% and 37.7% respectively after primary knee arthroplasty and CPSP at rest factors included: age above 80 (odds ratio [OR]= 6.72, 95% confidence interval [CI] 1.58 to 28.56), BMI above 30 (2.339, 1.02 to 5.383), and moderate to severe pain variables: preoperative pain, (1.95, 1.11 to 3.41); APSP on movement, 4.9 (2.31–10.6); and follow-up contralateral knee pain-at-rest scores (12.6, 5.5 to 28.5). Factors associated with presence of CPSP on movement included: no smoking (2.59, 1.07 to 6.26); and moderate to severe pain variables: preoperative pain, (1.57, 1.073 to 2.30); APSP at rest, (1.85, 1.13 to 3.02); APSP on movement, 6.11 (3.82 to 9.78); and follow-up contralateral knee pain-on-movement scores, 3.22 (2.08 to 5.00). Factors to occurrence of moderate to severe CPSP on movement include: presence of COPD (12.20, 2.19 to 67.98); and moderate to severe pain variables: preoperative pain (2.36, 1.32 to 4.23); APSP on movement (4.68, 1.95 to 11.25); and follow-up contralateral knee pain-on-movement scores (2.71, 1.66 to 4.42). Conclusion Prevention strategies should be targeted to different types of pain, and the comorbidity of COPD undergoing knee arthroplasty should receive early identification and attention.
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Affiliation(s)
- Meimei Tian
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
- Department of Nursing, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Zihua Li
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Xujuan Chen
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Qiting Wu
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Huimin Shi
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Yuchang Zhu
- Department of Orthopedics, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
| | - Yan Shi
- Department of Nursing, Shanghai Tenth People’s Hospital, School of Medicine, Tongji University, Shanghai, 200072, People’s Republic of China
- Correspondence: Yan Shi, Tel +86 21 66307304, Fax +86 21 66307542, Email
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Williams BA, Ibinson JW, Mikolic JM, Boudreaux-Kelly MY, Paiste HJ, Gilbert KL, Bonant SA, Ritter ME, Ezaru CS, Muluk VS, Piva SR. Day-One Pain Reductions after Hip and Knee Replacement when Buprenorphine-Clonidine-Dexamethasone is added to Bupivacaine Nerve/Plexus Blocks: A Randomized Clinical Trial. PAIN MEDICINE 2021; 23:57-66. [PMID: 34730810 DOI: 10.1093/pm/pnab325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare pain outcome reports of patients undergoing hip or knee replacement who received single-injection nerve/plexus blocks with plain bupivacaine (BPV) to patients who received injections of buprenorphine-clonidine-dexamethasone (BCD) admixed with BPV. DESIGN Prospective, parallel arms, randomized, double-blind trial. SETTING A single Veterans hospital. SUBJECTS 98 Veterans, scheduled for total hip or knee replacement surgery, with spinal as the primary anesthetic. METHODS Participants were randomized to BPV-BCD or plain BPV groups. They underwent nerve/plexus blocks in the L2-L4 and L4-S3 distributions in advance of joint replacement surgery. The primary outcome was change in pain from baseline during the post-operative day assessed by the total pain score in the short-form McGill Pain Questionnaire-v2 (SF-MPQ-2). Secondary outcomes were pain during movement, pain interference, range of motion, mobility, and quality of recovery. RESULTS On post-operative day one, the SF-MPQ-2 total score for the BPV-BCD group demonstrated greater pain reduction compared to the plain BPV group (mean difference 1.8 points, 95% CI 0.6 to 3.0, P = 0.003). The BPV-BCD group also had larger reductions in pain during movement in the surgical joint and less pain interference, along with increased range of hip and knee flexion, compared to the plain BPV group. Outcomes of mobility and quality of recovery were not different between groups. CONCLUSIONS Preoperative BPV-BCD blocks in the L2-L4 and L4-S3 nerve distributions for hip and knee replacements led to less pain on post-operative day one and increased knee and hip range of motion, compared to plain BPV blocks.
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Affiliation(s)
- Brian A Williams
- Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA, USA
| | - James W Ibinson
- Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Joseph M Mikolic
- Data Manager and Statistician, StatCore, VAPHS Research Office, Pittsburgh, PA, USA
| | | | - Henry J Paiste
- Medical Student, and Foundation for Anesthesia Education and Research (FAER) Medical Student Summer Research Fellow, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karen L Gilbert
- Research Coordinator, Veterans Health Foundation, Pittsburgh, PA, USA
| | - Samantha A Bonant
- Clinical Trials Center Manager/Regulatory Coordinator, Veterans Health Foundation, Pittsburgh, PA, USA
| | - Marsha E Ritter
- Assistant Professor. Affiliation: Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Catalin S Ezaru
- Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Visala S Muluk
- Associate Professor of Internal Medicine, University of Pittsburgh, IMPACT Clinic, VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Sara R Piva
- Professor and Vice Chair for Research; Director of Physical Therapy - Clinical Translational Research Center Affiliation: Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
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Ohashi Y, Fukushima K, Uchida K, Koyama T, Tsuchiya M, Saito H, Uchiyama K, Takahira N, Inoue G, Takaso M. Adverse Effects of Higher Preoperative Pain at Rest, a Central Sensitization-Related Symptom, on Outcomes After Total Hip Arthroplasty in Patients with Osteoarthritis. J Pain Res 2021; 14:3345-3352. [PMID: 34707402 PMCID: PMC8542571 DOI: 10.2147/jpr.s322314] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/14/2021] [Indexed: 12/12/2022] Open
Abstract
Background In patients with hip osteoarthritis (OA), pain at rest, unlike pain on activity, is due to pain mechanisms that cannot be explained by nociceptive pain. However, it remains unclear whether central sensitization (CS) is one of the causes of exacerbated pain at rest in patients with hip OA. Therefore, we investigated the differences in causative factors and postoperative course of total hip arthroplasty (THA) between preoperative pain at rest and on activity in patients with hip OA. Methods In total, 120 patients (125 hips, 22 men and 98 women, aged 64.5±1.0 years) with hip OA were included. Preoperative pain at rest and on activity and CS were assessed using the visual analog scale (VAS) and CS Inventory (CSI), respectively. Postoperative assessments were evaluated using the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (JHEQ); pain, satisfaction, function, and mental scores were evaluated 6 and 12 months after THA. Results Multivariate regression analysis indicated the CSI score as affecting VAS for pain at rest (β=0.067, P=0.002) but not VAS for pain on activity (β=0.036, P=0.073). VAS for pain at rest had a weak negative correlation with satisfaction and pain scores at both 6 and 12 months after THA (satisfaction, r=-0.309, -0.278; pain, r=-0.202, -0.22). VAS for pain on activity was not correlated with JHEQ. The CSI score had a weak or moderate negative correlation with three scores other than the function score at both 6 and 12 months after THA (satisfaction, r=-0.266, -0.213; pain, r=-0.332, -0.203, mental, r=-0.427, -0.370). The function score was weakly correlated with the CSI score only 6 months after THA (function, r=-0.231, -0.190). Conclusion A higher level of preoperative pain at rest, a CS-related symptom, may affect postoperative pain persistence and dissatisfaction in patients with hip OA.
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Affiliation(s)
- Yoshihisa Ohashi
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Kensuke Fukushima
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Kentaro Uchida
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Tomohisa Koyama
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Maho Tsuchiya
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Hiroki Saito
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Katsufumi Uchiyama
- Department of Patient Safety and Healthcare Administration, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Naonobu Takahira
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopedic Surgery, Kitasato University School of Medicine, Sagamihara City, Kanagawa, 252-0374, Japan
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16
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Study Protocol Modeling Evoked Pain in Older African Americans With Knee Osteoarthritis. Nurs Res 2021; 70:391-398. [PMID: 33951704 DOI: 10.1097/nnr.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND African American (AA) older adults with knee osteoarthritis experience more severe chronic pain and advanced physical disability. One of the most prominent stimuli that provokes knee pain is movement. Research suggests that, compared to Whites, AAs report significantly higher movement-evoked pain (MEP) in the knee. However, little is known about the biopsychosocial-behavioral mechanisms underlying MEP. OBJECTIVES The aim of the study was to present a study protocol to (a) characterize the biopsychosocial-behavioral mechanisms that predict MEP in AAs with knee osteoarthritis and (b) develop a targeted, mechanism-based self-management intervention to reduce MEP and maximize movement. METHODS An observational, mixed-methods cohort study will enroll 90 AA/Black adults (ages 55-90 years) to understand intraindividual and interindividual effects on MEP. Participants will complete assessments of MEP, function and gait, biopsychosocial-behavioral questionnaires, quantitative sensory testing, and 7-day ecological momentary assessments of pain and related symptoms. For the qualitative phase, focus groups will be conducted to co-construct a mechanism-based pain self-management intervention. RESULTS We will develop phenotypes of MEP based on biopsychosocial-behavioral predictors and correlate measures of MEP with function. Our central hypothesis is that higher levels of MEP will predict lower self-reported function and poorer performance on functional tasks and that multiple biopsychosocial and behavioral factors will be associated with MEP and function. Predictors may serve as risk or protective factors for MEP and physical function. In targeting the biopsychosocial-behavioral mechanisms of MEP, we anticipate that older AAs may request that intervention components include culturally tailored self-management education, movement/physical activity training, treatment decision-making skills, coaching, spirituality, and social/kinship support. CONCLUSION Osteoarthritis is now the single most common cause of disability, mobility limitations, and persistent pain in older adults-especially AA older adults. To our knowledge, this will be the first study to systematically phenotype MEP in an older racial minority population with knee osteoarthritis and will be relevant for reducing knee pain and improving function.
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17
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Cuñat T, Martínez-Pastor JC, Dürsteler C, Hernández C, Sala-Blanch X. Perioperative medicine role in painful knee prosthesis prevention. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00142-0. [PMID: 34325900 DOI: 10.1016/j.redar.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 01/07/2021] [Accepted: 03/25/2021] [Indexed: 11/25/2022]
Abstract
Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.
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Affiliation(s)
- T Cuñat
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España.
| | - J C Martínez-Pastor
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Clínic de Barcelona, Barcelona, España
| | - C Dürsteler
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España
| | - C Hernández
- Servicio de Anestesiología y Reanimación, Hospital Sant Joan de Déu de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - X Sala-Blanch
- Servicio de Anestesiología, Reanimación y Tratamiento del dolor, Hospital Clínic de Barcelona, Barcelona, España
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18
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Early Postoperative Pain After Total Knee Arthroplasty Is Associated With Subsequent Poorer Functional Outcomes and Lower Satisfaction. J Arthroplasty 2021; 36:2466-2472. [PMID: 33744080 DOI: 10.1016/j.arth.2021.02.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There are few studies investigating the effects of acute postoperative pain on functional outcomes after total knee arthroplasty (TKA). The aims of this study are to identify perioperative factors associated with increased early postoperative pain and investigate the effects of acute postoperative day 1 and 2 pain on outcomes at 6 months and 2 years post-TKA. METHODS 1041 unilateral TKA patients were included in this retrospective cohort study. Patients were categorized into minor (visual analog scale: VAS <5) and major (VAS ≥5) pain groups based on postoperative day 1/2 VAS scores. Patients were assessed preoperatively, at 6 months and 2 years using Knee Society Knee Score and Function Scores (KSFS), Oxford Knee Score (OKS), SF-36 physical and mental component score (SF-36 PCS), expectation and satisfaction scores. Perioperative variables including age, gender, race, body mass index, American Society of Anesthesiologist status, type of anesthesia, and presence of caregiver were analyzed as predictors of postoperative acute pain. Wilcoxon two-sample test was used to analyze outcomes significantly associated with "major pain." Multiple logistic regression was used to identify predictors of "major pain." RESULTS Patients with "minor pain" had significantly better KSFS, Knee Society Knee Score, OKS, and SF-36 PCS scores at 6 months and significantly better KSFS, OKS, SF-36 PCS, and satisfaction at 2 years (P < .05). A significantly higher percentage of patients with "minor pain" met the minimal clinically important difference for SF-36 PCS at 6 months and KSFS at 2 years (P < .05). Women, Indian/Malay race, higher BMI, and use of general over regional anesthesia were independent predictors of getting "major pain" (P < .05). CONCLUSION Patients should be counseled about risk factors of postoperative pain to manage preoperative expectations of surgery. Patients should be managed adequately using multimodal pain protocols to improve subsequent functional outcomes while avoiding unnecessary opioid use.
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19
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Farzad M, MacDermid JC, Mehta S, Grewal R, Shafiee E. Early post-immobilization pain at rest, movement evoked pain, and their ratio as potential predictors of pain and disability at six- and 12-months after distal radius fracture. Arch Physiother 2021; 11:6. [PMID: 33641681 PMCID: PMC7919326 DOI: 10.1186/s40945-021-00101-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 02/08/2021] [Indexed: 01/07/2023] Open
Abstract
Background Removal of immobilization is a critical phase of distal radius fracture (DRF) rehabilitation, typically occurring by 2 months post injury. This study examined the extent to which pain at rest (PAR), movement evoked pain (MEP), or the ratio between those (MEPR) assessed at 2-months after DRF predicts the occurrence of chronic pain or disability at 6- and 12-months after the injury. Methods This secondary analysis of a prospective cohort study was done at the Hand and Upper Limb Centre (HULC), London, Ontario, Canada. A total of 229 patients with DRF (159 (69.4%) women) were included. Scores for the pain and function subscales of the Patient-Rated Wrist Evaluation (PRWE) were extracted for 2, 6 and 12 months after DRF. Logistic as well as nonlinear quartile regression examined whether PAR and MEP predicted the severity of chronic pain and disability at 6- and 12-months after DRF. Receiver Operating Characteristics Curve were plotted, where area under the curve (AUC) examined the accuracy of the PAR and MEP scores in classifying those who experienced chronic pain and disability. Results Scores of ≥3 (AUC of 0.77) for PAR or ≥ 6 (AUC of 0.78) for MEP at 2 months after DRF predicted moderate to severe wrist pain at 6-months, whereas scores of ≥7 (AUC of 0.79) for MEP at 2-months predicted ongoing wrist disability at 6-months after the injury. The MEPR of 2 ≤ or ≥ 8 at 2-months was associated with adverse pain at 6-months and functional outcomes at 6- and 12-months (R-square = 0.7 and 0.04 respectively), but prediction accuracy was very poor (AUC ≤ 0.50). Conclusion Chronic wrist-related pain at 6-months can be predicted by either elevated PAR ≥ 3/10) or MEP (≥ 6/10) reported at 2-months after the injury, while disability experienced at 6-months after DRF is best predicted by MEP (≥7/10) reported at 2-months. The ratio of these two pain indicators increases assessment complexity and reduces classification accuracy.
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Affiliation(s)
- Maryam Farzad
- Department of Health and Rehabilitation Sciences, Roth McFarlane Hand and Upper Limb Centre, University of Western Ontario, School of Physical Therapy, St. Joseph's Hospital, London, Ontario, Canada. .,Department of Occupational therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
| | - Joy C MacDermid
- Physical Therapy and Surgery, Western University, London, ON, Canada.,Co-director Clinical Research Lab, Hand and Upper Limb Centre, St. Joseph's Health Centre, London, Ontario, Canada.,Rehabilitation Science McMaster University, Hamilton, ON, Canada
| | - Saurabh Mehta
- School of Physical Therapy, Marshall University, Huntington, WV, USA.,Department of Orthopedic Surgery, Joan C Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Ruby Grewal
- Roth
- McFarlane Hand and Upper Limb Center, Department of Surgery, Western University, London, ON, Canada
| | - Erfan Shafiee
- Department of Health and Rehabilitation Sciences, School of Physical Therapy, University of Western Ontario, London, Ontario, Canada
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20
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Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement. Pain Manag Nurs 2020; 22:111-120. [PMID: 33353818 DOI: 10.1016/j.pmn.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 10/07/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients. DESIGN This was a systematic review and meta-analysis. DATA SOURCES The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies. REVIEW METHODS The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis. RESULTS In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis. CONCLUSION Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management. IMPLICATIONS FOR NURSING Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.
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L'Hermite J, Pagé MG, Chevallier T, Occean B, Viel E, Bredeau O, Lefrant JY, Cuvillon P. Characterisation of pragmatic postoperative PAin Trajectories over seven days and their association with CHronicity after 3 months: a prospective, pilot cohort study (PATCH study). Anaesth Crit Care Pain Med 2020; 40:100793. [PMID: 33359373 DOI: 10.1016/j.accpm.2020.100793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 09/09/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Reliable outcome measurement providing information both on early and late postoperative pain outcomes are still lacking. The purpose of this study was: 1) to characterise postoperative pain trajectories according to an innovative pragmatic concept: ideal pain trajectory (rapid and sustained pain relief) vs non-ideal pain trajectories (late, transient, or no pain relief); and 2) to assess the incidence of persistent post-surgical pain (PPSP) and the potential association between non-ideal pain trajectories and PPSP. METHODS This prospective observational pilot cohort study was performed from March until June 2016. A total of 344 patients undergoing major general surgery were invited to complete a self-assessment of pain intensity using numerical rating scale (NRS; 0 = no pain to 10 = worst pain) from day 1 until day 7 after surgery, in order to establish their pain trajectory. Three months after surgery, patients were screened for PPSP. RESULTS Rest pain score was analysed in 308 participants. Among them, 210 (68% - 95% CI: 63-73) had an "ideal" pain trajectory, while 98 (32% - 95% CI: 27-37) had "non-ideal" pain trajectories. Three months after surgery, 31% (95% CI: 26-37) reported PPSP. Multivariable analysis showed that "non-ideal" pain trajectories [OR 2.25; (95% CI: 1.26-4.01) P = 0.006] were significantly associated with PPSP. CONCLUSIONS The present study proposes an innovative pragmatic concept of postoperative pain trajectories: ideal vs non-ideal pain trajectories, providing information both on acute postoperative pain resolution and early identification patients at risk for developing PPSP. TRIAL REGISTRATION NCT02599233; November, 6, 2015, with clinicaltrials.gov.
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Affiliation(s)
- Joël L'Hermite
- Division of Anaesthesia Intensive Care Pain and Emergency, CHU Nîmes, Univ Montpellier, Nîmes, France.
| | - M Gabrielle Pagé
- Research Center of the Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada; Department of Anaesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Thierry Chevallier
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Bob Occean
- Department of Biostatistics, Clinical Epidemiology, Public Health and Innovation in Methodology (BESPIM), CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Eric Viel
- Division of Anaesthesia Intensive Care Pain and Emergency, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Olivier Bredeau
- Division of Anaesthesia Intensive Care Pain and Emergency, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Jean-Yves Lefrant
- Division of Anaesthesia Intensive Care Pain and Emergency, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Philippe Cuvillon
- Division of Anaesthesia Intensive Care Pain and Emergency, CHU Nîmes, Univ Montpellier, Nîmes, France
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Wang WE, Ho RLM, Gatto B, van der Veen SM, Underation MK, Thomas JS, Antony AB, Coombes SA. Cortical dynamics of movement-evoked pain in chronic low back pain. J Physiol 2020; 599:289-305. [PMID: 33067807 DOI: 10.1113/jp280735] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/13/2020] [Indexed: 01/22/2023] Open
Abstract
KEY POINTS Cortical activity underlying movement-evoked pain is not well understood, despite being a key symptom of chronic musculoskeletal pain. We combined high-density electroencephalography with a full-body reaching protocol in a virtual reality environment to assess cortical activity during movement-evoked pain in chronic low back pain. Movement-evoked pain in individuals with chronic low back pain was associated with longer reaction times, delayed peak velocity and greater movement variability. Movement-evoked pain was associated with attenuated disinhibition in prefrontal motor areas, as evidenced by an attenuated reduction in beta power in the premotor cortex and supplementary motor area. ABSTRACT Although experimental pain alters neural activity in the cortex, evidence of changes in neural activity in individuals with chronic low back pain (cLBP) remains scarce and results are inconsistent. One of the challenges in studying cLBP is that the clinical pain fluctuates over time and often changes during movement. The goal of the present study was to address this challenge by recording high-density electroencephalography (HD-EEG) data during a full-body reaching task to understand neural activity during movement-evoked pain. HD-EEG data were analysed using independent component analyses, source localization and measure projection analyses to compare neural oscillations between individuals with cLBP who experienced movement-evoked pain and pain-free controls. We report two novel findings. First, movement-evoked pain in individuals with cLBP was associated with longer reaction times, delayed peak velocity and greater movement variability. Second, movement-evoked pain was associated with an attenuated reduction in beta power in the premotor cortex and supplementary motor area. Our observations move the field forward by revealing attenuated disinhibition in prefrontal motor areas during movement-evoked pain in cLBP.
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Affiliation(s)
- Wei-En Wang
- Department of Applied Physiology and Kinesiology, Laboratory for Rehabilitation Neuroscience, University of Florida, Gainesville, FL, USA
| | - Rachel L M Ho
- Department of Applied Physiology and Kinesiology, Laboratory for Rehabilitation Neuroscience, University of Florida, Gainesville, FL, USA
| | - Bryan Gatto
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Susanne M van der Veen
- Department of Physical Therapy, College of Health Professions, Virginia Commonwealth University, VA, USA
| | - Matthew K Underation
- Department of Physical Therapy, College of Health Professions, Virginia Commonwealth University, VA, USA
| | - James S Thomas
- Department of Physical Therapy, College of Health Professions, Virginia Commonwealth University, VA, USA
| | | | - Stephen A Coombes
- Department of Applied Physiology and Kinesiology, Laboratory for Rehabilitation Neuroscience, University of Florida, Gainesville, FL, USA
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Dennis J, Wylde V, Gooberman-Hill R, Blom AW, Beswick AD. Effects of presurgical interventions on chronic pain after total knee replacement: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2020; 10:e033248. [PMID: 31964670 PMCID: PMC7045074 DOI: 10.1136/bmjopen-2019-033248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Nearly 100 000 primary total knee replacements (TKR) are performed in the UK annually. The primary aim of TKR is pain relief, but 10%-34% of patients report chronic pain. The aim of this systematic review was to evaluate the effectiveness of presurgical interventions in preventing chronic pain after TKR. DESIGN MEDLINE, Embase, CINAHL, The Cochrane Library and PsycINFO were searched from inception to December 2018. Screening and data extraction were performed by two authors. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane tool and quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation. PRIMARY AND SECONDARY OUTCOMES Pain at 6 months or longer; adverse events. INTERVENTIONS Presurgical interventions aimed at improving TKR outcomes. RESULTS Eight randomised controlled trials (RCTs) with data from 960 participants were included. The studies involved nine eligible comparisons. We found moderate-quality evidence of no effect of exercise programmes on chronic pain after TKR, based on a meta-analysis of 6 interventions with 229 participants (standardised mean difference 0.20, 95% CI -0.06 to 0.47, I2=0%). Sensitivity analysis restricted to studies at overall low risk of bias confirmed findings. Another RCT of exercise with no data available for meta-analysis showed no benefit. Studies evaluating combined exercise and education intervention (n=1) and education alone (n=1) suggested similar findings. Adverse event data were reported by most studies, but events were too few to draw conclusions. CONCLUSIONS We found low to moderate-quality evidence to suggest that neither preoperative exercise, education nor a combination of both is effective in preventing chronic pain after TKR. This review also identified a lack of evaluations of other preoperative interventions, such as multimodal pain management, which may improve long-term pain outcomes after TKR. PROSPERO REGISTRATION NUMBER CRD42017041382.
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Affiliation(s)
- Jane Dennis
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - A W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew David Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
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Whale K, Wylde V, Beswick A, Rathbone J, Vedhara K, Gooberman-Hill R. Effectiveness and reporting standards of psychological interventions for improving short-term and long-term pain outcomes after total knee replacement: a systematic review. BMJ Open 2019; 9:e029742. [PMID: 31806606 PMCID: PMC6924731 DOI: 10.1136/bmjopen-2019-029742] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To assess the effectiveness and reporting standards of psychological interventions for improving outcomes after total knee replacement (TKR). DESIGN Medline, Embase, and PsycINFO were searched from inception to up to 9 May 2019 with no language restrictions applied. Randomised controlled trials (RCTs) assessing the effectiveness of psychological interventions for short-term and long-term postoperative pain after TKR were included. Screening, data extraction, and assessment of methodological quality were performed in duplicate by two reviewers. The primary effectiveness outcome was postoperative pain severity and the primary harm outcome was serious adverse events. Secondary outcomes included function, quality of life, and psychological well-being. Reporting standards were assessed using the Template for Intervention Description and Replication (TIDieR) checklist for intervention reporting. RESULTS 12 RCTs were included, with a total of 1299 participants. Psychological interventions comprised music therapy (five studies), guided imagery and music (one study), hypnosis (one study), progressive muscle relaxation with biofeedback (one study), pain coping skills programme (one study), cognitive-behavioural therapy (two studies), and a postoperative management programme (one study). Due to the high heterogeneity of interventions and poor reporting of harms data, it was not possible to make any definitive statements about the overall effectiveness or safety of psychology interventions for pain outcomes after TKR. CONCLUSION Further evidence about the effectiveness of psychological interventions for improving pain outcomes after TKR is needed. The reporting of harm outcomes and intervention fidelity is currently poor and could be improved. Future work exploring the impact of intervention timing on effectiveness and whether different psychological approaches are needed to address acute postoperative pain and chronic postoperative pain would be of benefit. PROSPERO REGISTRATION NUMBER CRD42018095100.
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Affiliation(s)
- Katie Whale
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vikki Wylde
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - James Rathbone
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
- Pain Centre Versus Arthritis, City Hospital, University of Nottingham, Nottingham, United Kingdom
| | - Kavita Vedhara
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rachael Gooberman-Hill
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Booker S, Cardoso J, Cruz-Almeida Y, Sibille KT, Terry EL, Powell-Roach KL, Riley JL, Goodin BR, Bartley EJ, Addison AS, Staud R, Redden D, Bradley L, Fillingim RB. Movement-evoked pain, physical function, and perceived stress: An observational study of ethnic/racial differences in aging non-Hispanic Blacks and non-Hispanic Whites with knee osteoarthritis. Exp Gerontol 2019; 124:110622. [PMID: 31154005 PMCID: PMC6660381 DOI: 10.1016/j.exger.2019.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Knee osteoarthritis (OA) is a pervasive musculoskeletal condition, often exacerbated by movement-evoked pain (MEP). Despite established research demonstrating significant racial differences in OA pain, few studies have investigated ethnic/racial group differences in MEP and lower extremity function and their association with psychosocial factors, such as perceived stress. Therefore, the primary aims were: (1) to identify ethnic/racial group differences in persons with or at risk for knee OA pain based on MEP, physical performance, and perceived stress measures, and (2) to determine if perceived stress explains the relationship between MEP and function in non-Hispanic Blacks (NHBs) and non-Hispanic Whites (NHWs). METHODS A total of 162 NHB and NHW community-dwelling older adults (50-78 years of age) were included in this analysis from the Understanding Pain and Limitations in Osteoarthritic Disease (UPLOAD) cross-sectional cohort study. Demographic, anthropometric, pain and functional parameters were assessed using a battery of validated instruments. Descriptive statistics, parametric, and multivariate analyses were conducted to determine ethnic/racial differences in perceived stress, MEP, and function. RESULTS Our results support the hypothesis that among persons with knee OA pain, NHBs have significantly greater MEP and lower functional level, despite similar levels of perceived stress. However, perceived stress was more strongly related to MEP in NHB compared to NHWs. Differences in function were limited to walking speed, where NHWs demonstrated faster gait speed. CONCLUSIONS Our cross-sectional study demonstrated important ethnic/racial differences in MEP and function. Also, perceived stress had a stronger effect on MEP in NHBs, suggesting that perceived stress may more strongly influence pain with physical movement among NHB adults. MEP may be a clinically important pain outcome to measure in persons with OA, and these data warrant future research on the impact of stress on pain and functional outcomes in older adults, particularly in NHBs.
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Affiliation(s)
- Staja Booker
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA.
| | - Josue Cardoso
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Yenisel Cruz-Almeida
- The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA; The University of Florida, Department of Aging & Geriatric Research, College of Medicine, Gainesville, FL 32611, USA
| | - Kimberly T Sibille
- The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA; The University of Florida, Department of Aging & Geriatric Research, College of Medicine, Gainesville, FL 32611, USA
| | - Ellen L Terry
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Keesha L Powell-Roach
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Joseph L Riley
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | - Burel R Goodin
- University of Alabama at Birmingham, Department of Psychology, Birmingham, AL 35294, USA
| | - Emily J Bartley
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
| | | | - Roland Staud
- The University of Florida, Department of Medicine, Gainesville, FL 32608, USA
| | - David Redden
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, AL 35294, USA; University of Alabama at Birmingham, Department Medicine and Rheumatology, Birmingham, AL 35294, USA
| | - Laurence Bradley
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, Birmingham, AL 35294, USA
| | - Roger B Fillingim
- The University of Florida, Department of Community Dentistry and Behavioral Science, Gainesville, FL 32610, USA; The University of Florida, Pain Research and Intervention Center of Excellence, Gainesville, FL 32610, USA
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Williams MD, Sommer SL, Meyers RC, Valdivia J, Nolan MW, Lascelles BDX. A novel device to measure static hindlimb weight-bearing forces in pronograde rodents. J Neurosci Methods 2019; 328:108405. [PMID: 31465781 DOI: 10.1016/j.jneumeth.2019.108405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/22/2019] [Accepted: 08/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Joint pain is composed of both spontaneous and movement-induced pain. In animal models, static bodyweight distribution is a surrogate for spontaneous joint pain. However, there are no commercially-available instruments that measure static bodyweight distribution in normal, pronograde rodents. NEW METHOD We designed a Static Horizontal Incapacitance Meter (SHIM) to measure bodyweight distribution in pronograde standing rodents. We assessed the device for feasibility, repeatability, and sensitivity to quantify hindlimb bodyweight distribution. Mice and rats with unilateral inflammatory pain induced by subcutaneous injections of capsaicin or Complete Freund's Adjuvant (CFA) into the plantar surface of the left hind paw were used to measure static weight-bearing. The ability to attenuate inflammatory pain-associated weight-bearing asymmetry was tested by administering a non-steroidal anti-inflammatory drug, meloxicam. RESULTS The SHIM's ability to detect significant reductions in limb loading on the injected hindlimb in mice and rats was validated using both acute and sub-chronic pain models. Treatment with meloxicam partially reversed CFA-induced effects. COMPARISON WITH EXISTING METHODS In contrast with assays that measure kinetic or static weight-bearing forces (e.g., walking, or standing at a 45 ° incline), the SHIM allows evaluation of weight-bearing in rodents that are standing at rest in their normal pronograde position. CONCLUSIONS The SHIM successfully detected: (a) asymmetric weight-bearing in acute and sub-chronic pain models; and (b) the analgesic effects of meloxicam. This study provides a novel tool to objectively evaluate limb use dysfunction in rodents.
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Affiliation(s)
- Morika D Williams
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States; Translational Research in Pain Program, North Carolina State University, Raleigh, NC, United States; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - Samantha L Sommer
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Rachel C Meyers
- Translational Research in Pain Program, North Carolina State University, Raleigh, NC, United States
| | | | - Michael W Nolan
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States.
| | - B Duncan X Lascelles
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States; Translational Research in Pain Program, North Carolina State University, Raleigh, NC, United States; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States; Thurston Arthritis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Center for Translational Pain Medicine, Duke University, Durham, NC, United States
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27
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Gandek B, Roos EM, Franklin PD, Ware JE. Item selection for 12-item short forms of the Knee injury and Osteoarthritis Outcome Score (KOOS-12) and Hip disability and Osteoarthritis Outcome Score (HOOS-12). Osteoarthritis Cartilage 2019; 27:746-753. [PMID: 30593867 DOI: 10.1016/j.joca.2018.11.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 11/16/2018] [Accepted: 11/27/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop 12-item short forms (KOOS-12, HOOS-12) of the 42-item Knee injury and Osteoarthritis Outcome Score (KOOS) and 40-item Hip disability and Osteoarthritis Outcome Score (HOOS) that represent the full-length instruments sufficiently to provide joint-specific pain, function and quality of life (QOL) domain and summary joint impact scores. This paper describes KOOS-12 and HOOS-12 item selection. Subsequent papers will examine KOOS-12 and HOOS-12 reliability, validity and responsiveness. DESIGN Items were selected based on qualitative information from patients, clinicians and KOOS/HOOS translators and analysis of data from 1,395 knee osteoarthritis (OA) and 1,281 hip OA patients from the FORCE-TJR cohort who completed KOOS or HOOS before and after total joint replacement (TJR). Item response theory models and computerized adaptive test (CAT) simulations were used to identify items that best measured patients' levels of pain and function pre- and post-TJR. KOOS-12/HOOS-12 items were selected based on content, coverage of a wide measurement range, high item information, item usage in CAT simulations, scale-level properties (reliability, validity, responsiveness), and qualitative information. RESULTS KOOS-12 and HOOS-12 each included a pain frequency item and three items measuring pain during increasingly difficult activities (sitting/lying, walking, up/down stairs); function items about standing, rising from sitting, getting in/out of a car, and twisting/pivoting (KOOS-12) or walking on an uneven surface (HOOS-12); and the original 4-item QOL scale. CONCLUSIONS This study demonstrated the benefits of examining patient-reported outcome measures using modern psychometric methods, to create short forms with diverse content that provide domain-specific and summary joint impact scores.
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Affiliation(s)
- B Gandek
- University of Massachusetts Medical School, Worcester, MA, USA; John Ware Research Group, Watertown, MA, USA.
| | - E M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - P D Franklin
- University of Massachusetts Medical School, Worcester, MA, USA.
| | - J E Ware
- University of Massachusetts Medical School, Worcester, MA, USA; John Ware Research Group, Watertown, MA, USA.
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Lenguerrand E, Whitehouse MR, Beswick AD, Kunutsor SK, Foguet P, Porter M, Blom AW. Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales. THE LANCET. INFECTIOUS DISEASES 2019; 19:589-600. [PMID: 31005559 PMCID: PMC6531378 DOI: 10.1016/s1473-3099(18)30755-2] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/07/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022]
Abstract
Background Prosthetic joint infection is a devastating complication of knee replacement. The risk of developing a prosthetic joint infection is affected by patient, surgical, and health-care system factors. Existing evidence is limited by heterogeneity in populations studied, short follow-up, inadequate power, and does not differentiate early prosthetic joint infection, most likely related to the intervention, from late infection, more likely to occur due to haematogenous bacterial spread. We aimed to assess the overall and time-specific associations of these factors with the risk of revision due to prosthetic joint infection following primary knee replacement. Methods In this cohort study, we analysed primary knee replacements done between 2003 and 2013 in England and Wales and the procedures subsequently revised for prosthetic joint infection between 2003 and 2014. Data were obtained from the National Joint Registry linked to the Hospital Episode Statistics data in England and the Patient Episode Database for Wales. Each primary replacement was followed for a minimum of 12 months until the end of the observation period (Dec 31, 2014) or until the date of revision for prosthetic joint infection, revision for another indication, or death (whichever occurred first). We analysed the data using Poisson and piecewise exponential multilevel models to assess the associations between patient, surgical, and health-care system factors and risk of revision for prosthetic joint infection. Findings Of 679 010 primary knee replacements done between 2003 and 2013 in England and Wales, 3659 were subsequently revised for an indication of prosthetic joint infection between 2003 and 2014, after a median follow-up of 4·6 years (IQR 2·6–6·9). Male sex (rate ratio [RR] for male vs female patients 1·8 [95% CI 1·7–2·0]), younger age (RR for age ≥80 years vs <60 years 0·5 [0·4–0·6]), higher American Society of Anaesthesiologists [ASA] grade (RR for ASA grade 3–5 vs 1, 1·8 [1·6–2·1]), elevated body-mass index (BMI; RR for BMI ≥30 kg/m2vs <25 kg/m2 1·5 [1·3–1·6]), chronic pulmonary disease (RR 1·2 [1·1–1·3]), diabetes (RR 1·4 [1·2–1·5]), liver disease (RR 2·2 [1·6–2·9]), connective tissue and rheumatic diseases (RR 1·5 [1·3–1·7]), peripheral vascular disease (RR 1·4 [1·1–1·7]), surgery for trauma (RR 1·9 [1·4–2·6]), previous septic arthritis (RR 4·9 [2·7–7·6]) or inflammatory arthropathy (RR 1·4 [1·2–1·7]), operation under general anaesthesia (RR 1·1 [1·0–1·2]), requirement for tibial bone graft (RR 2·0 [1·3–2·7]), use of posterior stabilised fixed bearing prostheses (RR for posterior stabilised fixed bearing prostheses vs unconstrained fixed bearing prostheses 1·4 [1·3–1·5]) or constrained condylar prostheses (3·5 [2·5–4·7]) were associated with a higher risk of revision for prosthetic joint infection. However, uncemented total, patellofemoral, or unicondylar knee replacement (RR for uncemented vs cemented total knee replacement 0·7 [95% CI 0·6–0·8], RR for patellofemoral vs cemented total knee replacement 0·3 [0·2–0·5], and RR for unicondylar vs cemented total knee replacement 0·5 [0·5–0·6]) were associated with lower risk of revision for prosthetic joint infection. Most of these factors had time-specific effects, depending on the time period post-surgery. Interpretation We have identified several risk factors for revision for prosthetic joint infection following knee replacement. Some of these factors are modifiable, and the use of targeted interventions or strategies could lead to a reduced risk of revision for prosthetic joint infection. Non-modifiable factors and the time-specific nature of the effects we have observed will allow clinicians to appropriately counsel patients preoperatively and tailor follow-up regimens. Funding National Institute for Health Research.
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Affiliation(s)
- Erik Lenguerrand
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Setor K Kunutsor
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Pedro Foguet
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Martyn Porter
- Centre for Hip Surgery, Wrightington Hospital, Wigan, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
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Buvanendran A, Della Valle CJ, Kroin JS, Shah M, Moric M, Tuman KJ, McCarthy RJ. Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: a prospective cohort study. Reg Anesth Pain Med 2019; 44:rapm-2018-100036. [DOI: 10.1136/rapm-2018-100036] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 12/27/2022]
Abstract
BackgroundApproximately 15% of patients report persistent knee pain despite surgical success following total knee arthroplasty (TKA). The purpose of this study was to determine the association of acute-postsurgical pain (APSP) with chronic postsurgical pain (CPSP) 6 months after TKA controlling for patient, surgical and psychological confounding factors.MethodsAdult patients with osteoarthritis undergoing primary elective tricompartmental TKA, with the operated knee the primary source of preoperative pain, were studied between March 2011 and February 2017. Patients received standard operative management and a perioperative multimodal analgesia regimen. The primary outcome was CPSP at 6 months. The primary variable of interest was the APSP (weighted mean pain score) for 72 hours postoperatively. Patient, surgical and psychological confounders were assessed using binary logistic regression.Results245 cases were analyzed. The incidence of CPSP was 14% (95% CI 10% to 19%). Median APSP values were 4.2 (2.2–5.0) in the CPSP group and 2.8 (1.8–3.7) without CPSP, difference 1.4 (95% CI 0.1 to 1.8, p=0.005). The unadjusted odds for CPSP with an increase of 1 in APSP was 1.46 (95% CI 1.14 to 1.87, p=0.002)). After multivariable risk adjustment, the OR for CPSP for an increase of 1 in the APSP was 1.53 (95% CI 1.12 to 2.09, p=0.008).ConclusionsAPSP is a risk factor for CPSP following TKA even after adjusting for confounding variables such as pain catastrophizing, anxiety, depression and functional status. Studies are needed to determine if APSP is a modifiable risk factor for the development of CPSP.
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Porsius JT, Mathijssen NMC, Klapwijk-Van Heijningen LCM, Van Egmond JC, Melles M, Vehmeijer SBW. Early recovery trajectories after fast-track primary total hip arthroplasty: the role of patient characteristics. Acta Orthop 2018; 89:597-602. [PMID: 30350742 PMCID: PMC6300723 DOI: 10.1080/17453674.2018.1519095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Little is known about heterogeneity in early recovery after primary total hip arthroplasty (THA). Therefore, we characterized subgroups of patients according to their hip function trajectory during the first 6 weeks after THA in a fast-track setting. Patients and methods - 94 patients (median age 65 years [41-82], 56 women) from a single hospital participated in a diary study. Patients recorded their severity of hip problems (Oxford Hip Score, OHS) weekly for 6 weeks after THA. Latent class growth modelling (LCGM) was used to identify patients with the same hip function trajectory and to compare these subgroups on patient characteristics. Results - LCGM revealed a fast (n = 17), an average (n = 53), and a slow (n = 24) recovery subgroup. Subgroups differed on the estimated weekly growth rate during the first 2 weeks (fast: 9.5; average: 5.3; slow: 2.7), with fewer differences between groups in the last 4 weeks (fast: 0.90; average: 2.0; slow: 1.7). Patients in the slow recovery group could be characterized as women of older age (mean age =69) who rated their health as lower preoperatively, needed more assistance during recovery, and were less satisfied with the outcomes of the surgery. Interpretation - We identified distinct recovery trajectories in the first 6 weeks after fast-track primary THA which were associated with patient characteristics.
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Affiliation(s)
- Jarry T Porsius
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft;;
| | | | | | | | - Marijke Melles
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft;;
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Predictive Factors for Developing Chronic Pain After Total Knee Arthroplasty. J Arthroplasty 2018; 33:3372-3378. [PMID: 30143334 DOI: 10.1016/j.arth.2018.07.028] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 07/28/2018] [Indexed: 02/01/2023] Open
Abstract
Total knee arthroplasty offers substantial improvements for patients as measured by functional status and quality of life; however, 8% to 34% of patients experience chronic postsurgical pain following surgery (CPSP). In addition to disruption in daily activities of life caused by the pain itself, CPSP has been associated with an overall reduction in quality of life following surgery. Risk factors for CPSP can be broadly defined as potentially modifiable or unlikely modifiable. Unlikely modifiable risks include gender, age, medical comorbidities, and socioeconomic status. Potentially modifiable risks include perioperative pain, physical function, psychological state, surgical factors, and possibly genomics. Understanding risks and the magnitude of their effect on outcomes such as CPSP is desirable because interventions designed to affect these factors may be able to dramatically improve outcomes.
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Abstract
Despite a good outcome for many patients, approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Chronic pain after TKA can affect all dimensions of health-related quality of life, and is associated with functional limitations, pain-related distress, depression, poorer general health and social isolation. In both clinical and research settings, the approach to assessing chronic pain after TKA needs to be in-depth and multidimensional to understand the characteristics and impact of this pain. Assessment of this pain has been inadequate in the past, but there are encouraging trends for increased use of validated patient-reported outcome measures. Risk factors for chronic pain after TKA can be considered as those present before surgery, intraoperatively or in the acute postoperative period. Knowledge of risk factors is important to guide the development of interventions and to help to target care. Evaluations of preoperative interventions which optimize pain management and general health around the time of surgery are needed. The causes of chronic pain after TKA are not yet fully understood, although research interest is growing and it is evident that this pain has a multifactorial aetiology, with a wide range of possible biological, surgical and psychosocial factors that can influence pain outcomes. Treatment of chronic pain after TKA is challenging, and evaluation of combined treatments and individually targeted treatments matched to patient characteristics is advocated. To ensure that optimal care is provided to patients, the clinical- and cost-effectiveness of multidisciplinary and individualized interventions should be evaluated.
Cite this article: EFORT Open Rev 2018;3:461-470. DOI: 10.1302/2058-5241.3.180004
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Andrew Beswick
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK
| | - Ashley Blom
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK.,North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | | | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
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Tomaszek L, Dębska G. Knowledge, compliance with good clinical practices and barriers to effective control of postoperative pain among nurses from hospitals with and without a “Hospital without Pain” certificate. J Clin Nurs 2018; 27:1641-1652. [DOI: 10.1111/jocn.14215] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Lucyna Tomaszek
- Faculty of Medicine and Health Sciences; Andrzej Frycz-Modrzewski Krakow University; Krakow Poland
| | - Grażyna Dębska
- Faculty of Medicine and Health Sciences; Andrzej Frycz-Modrzewski Krakow University; Krakow Poland
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Miller J, Barber D, Donnelly C, French S, Green M, Hill J, MacDermid J, Marsh J, Norman K, Richardson J, Taljaard M, Wideman T, Cooper L, McPhee C. Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial. Trials 2017; 18:526. [PMID: 29121989 PMCID: PMC5680754 DOI: 10.1186/s13063-017-2279-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/10/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes. METHODS This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites. DISCUSSION If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas. TRIAL REGISTRATION ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.
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Affiliation(s)
- Jordan Miller
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada.
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Canada
| | - Catherine Donnelly
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Simon French
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Michael Green
- Department of Family Medicine, Queen's University, Kingston, Canada
| | | | - Joy MacDermid
- Physical Therapy, Western University, London, Canada
| | | | - Kathleen Norman
- School of Rehabilitation Therapy, Queen's University, 31 George Street, Kingston, Ontario, K7L 3N6, Canada
| | - Julie Richardson
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | | | - Timothy Wideman
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
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Wylde V, Beswick AD, Dennis J, Gooberman-Hill R. Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review. BMJ Open 2017; 7:e018105. [PMID: 29101145 PMCID: PMC5695416 DOI: 10.1136/bmjopen-2017-018105] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/24/2017] [Accepted: 09/15/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR). DESIGN The systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3 months postoperatively and pain at 6 months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6 months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR. RESULTS After removal of duplicates, 16 430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres. CONCLUSION This systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients' outcomes after TKR.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Iohom G. To block or not to block? Rom J Anaesth Intensive Care 2017; 24:83-85. [PMID: 29090258 DOI: 10.21454/rjaic.7518.242.ioh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Gabriella Iohom
- Consultant Anaesthetist/Senior Lecturer, Cork University Hospital/University College Cork, Cork, Ireland
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Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res 2017; 10:2287-2298. [PMID: 29026331 PMCID: PMC5626380 DOI: 10.2147/jpr.s144066] [Citation(s) in RCA: 625] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate μ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel μ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine.
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Affiliation(s)
- Tong J Gan
- Stony Brook University, Stony Brook, NY, USA
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Trouvin AP, Perrot S. Pain in osteoarthritis. Implications for optimal management. Joint Bone Spine 2017; 85:429-434. [PMID: 28889010 DOI: 10.1016/j.jbspin.2017.08.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/24/2017] [Indexed: 02/08/2023]
Abstract
Pain is an ubiquitous symptom in osteoarticular diseases, occurring much more commonly than stiffness or disability. OA of the knee, hand, or hip affects around 20% of adults in various populations and is dramatically increasing in many countries, mostly related to age and obesity, leading to an increased number of people having OA pain, and creating a huge burden related to disability and health care costs. OA-related pain, has been classically considered to be a nociceptive pain condition. Clinicians have considered pain to be an alarm signal, correlated to the intensity of joint degradation. In OA, most authors have focused their studies on joint architecture and local degradation, considering pain as only a symptom, a consequence of joint damage. However, OA-related pain is a specific disease, with a complex pathophysiology, including neuropathic peripheral and central abnormalities, together with local inflammation involving all joint structures. Clinical findings emphasize that it is not a stable and linear condition, that pain experience is independent of structural modifications, and that the quality of pain in OA is important to consider, aside from its intensity. OA-related pain is modulated by many factors, including the individual patient's psychological and genetic factors, as well as the theoretical role of meteorological influences. Recent neuroimaging findings have improved our knowledge about central mechanisms of OA pain, especially in persistent cases.
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Affiliation(s)
- Anne-Priscille Trouvin
- Pain Department, Cochin-Hôtel Dieu Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Inserm U987, Paris Descartes University, 75014 Paris, France
| | - Serge Perrot
- Pain Department, Cochin-Hôtel Dieu Hospital, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France; Inserm U987, Paris Descartes University, 75014 Paris, France.
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40
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Leung YY, Huebner JL, Haaland B, Wong SBS, Kraus VB. Synovial fluid pro-inflammatory profile differs according to the characteristics of knee pain. Osteoarthritis Cartilage 2017; 25:1420-1427. [PMID: 28433814 DOI: 10.1016/j.joca.2017.04.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The role of inflammation and pain in osteoarthritis (OA) is not fully understood. We evaluated the association between pro-inflammatory biomarkers and pain. METHODS We used baseline data and samples from a randomized controlled trial of colchicine for symptomatic knee OA. Severity of pain of the more symptomatic knee was assessed by National Health and Nutrition Examination Survey-I (NHANES-I) criterion and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain index. Pains on movement and at rest were self-reported on an 11-point Likert scale. Severity of radiographic tibiofemoral OA was assessed by Kellgren and Lawrence (KL) grade. Concentrations of synovial fluid (sf) IL-1β, IL-6, IL-8, TNFα, C-terminal telopeptides of Type I collagen (CTXI) and C-telopeptide of Type II collagen (CTXII), as well as urinary (u) CTXII were measured. RESULTS Of the 109 patients enrolled in the study, 70 patients (70% women) with synovial fluid obtained by direct aspiration were included for analysis. The mean ± SD age and body mass index (BMI) of the patients were 57.6 ± 8.3 years and 28.8 ± 5.2 kg/m2. After adjustment for age, sex, and BMI, sf IL-6 and IL-8 were statistically significantly associated with 11-point pain on movement, but not with pain at rest. No significant associations were observed with WOMAC pain scores. sf IL-1β (analyzed as detectable/non-detectable) was inversely associated with pain. In contrast, after adjustment, Sf TNFα was associated with WOMAC total pain and both pain on movement and at rest. sf/u CTXII was associated with radiographic severity, but not with knee pain. CONCLUSIONS This study provides indication that OA pain mechanisms may differ according to the characteristics of the pain.
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Affiliation(s)
- Y Y Leung
- Duke-NUS Medical School, Singapore; Department of Rheumatology & Immunology, Singapore General Hospital, Singapore.
| | - J L Huebner
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA.
| | - B Haaland
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, USA.
| | - S B S Wong
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore.
| | - V B Kraus
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA; Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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Lluch E, Nijs J, Courtney CA, Rebbeck T, Wylde V, Baert I, Wideman TH, Howells N, Skou ST. Clinical descriptors for the recognition of central sensitization pain in patients with knee osteoarthritis. Disabil Rehabil 2017; 40:2836-2845. [DOI: 10.1080/09638288.2017.1358770] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Enrique Lluch
- Department of Physical Therapy, University of Valencia, Valencia, Spain
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Pain in Motion International Research Group, Brussel, Belgium
| | - Jo Nijs
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Pain in Motion International Research Group, Brussel, Belgium
| | - Carol A. Courtney
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, USA
| | - Trudy Rebbeck
- Faculty of Health Sciences, Discipline of Physiotherapy, John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Vikki Wylde
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - Isabel Baert
- Pain in Motion International Research Group, Brussel, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Timothy H. Wideman
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Nick Howells
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - Søren T. Skou
- Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
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Sayers A, Wylde V, Lenguerrand E, Gooberman-Hill R, Dawson J, Beard D, Price A, Blom AW. A unified multi-level model approach to assessing patient responsiveness including; return to normal, minimally important differences and minimal clinically important improvement for patient reported outcome measures. BMJ Open 2017; 7:e014041. [PMID: 28733296 PMCID: PMC5577889 DOI: 10.1136/bmjopen-2016-014041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 05/10/2017] [Accepted: 05/19/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE This article reviews and compares four commonly used approaches to assess patient responsiveness with a treatment or therapy (return to normal (RTN), minimal important difference (MID), minimal clinically important improvement (MCII), OMERACT-OARSI [Outcome Measures in Rheumatology-Osteoarthris Reseach Society International] (OO)) and demonstrates how each of the methods can be formulated in a multilevel modelling (MLM) framework. DESIGN Cohort study. SETTING A cohort of patients undergoing total hip and knee replacement were recruited from a single UK National Health Service hospital. POPULATION 400 patients from the Arthroplasty Pain Experience cohort study undergoing total hip (n=210) and knee (n=190) replacement who completed the Intermittent and Constant Osteoarthritis Pain questionnaire prior to surgery and then at 3, 6 and 12 months after surgery. PRIMARY OUTCOMES The primary outcome was defined as a response to treatment following total hip or knee replacement. We compared baseline scores, change scores and proportion of individuals defined as 'responders' using traditional and MLM approaches with patient responsiveness. RESULTS Using existing approaches, baseline and change scores are underestimated, and the variance of baseline and change scores overestimated in comparison with MLM approaches. MLM increases the proportion of individuals defined as responding in RTN, MID and OO criteria compared with existing approaches. Using MLM with the MCII criteria reduces the number of individuals identified as responders. CONCLUSION MLM improves the estimation of the SD of baseline and change scores by explicitly incorporating measurement error into the model and avoiding regression to the mean when making individual predictions. Using refined definitions of responsiveness may lead to a reduction in misclassification when attempting to predict who does and does not respond to an intervention and clarifies the similarities between existing methods.
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Affiliation(s)
- Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - Jill Dawson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Beard
- Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Oxford, UK
| | - Andrew Price
- Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Nuffield Orthopaedic Centre, Oxford, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
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Blom AW, Artz N, Beswick AD, Burston A, Dieppe P, Elvers KT, Gooberman-Hill R, Horwood J, Jepson P, Johnson E, Lenguerrand E, Marques E, Noble S, Pyke M, Sackley C, Sands G, Sayers A, Wells V, Wylde V. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BackgroundTotal hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.ObjectiveTo undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.MethodsWe used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.ResultsSystematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.ConclusionsThe RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.Study registrationCurrent Controlled Trials ISRCTN52305381.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Neil Artz
- School of Health Professions, Faculty of Health and Human Sciences, Plymouth University, Plymouth, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Paul Dieppe
- Medical School, University of Exeter, Exeter, UK
| | - Karen T Elvers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Jepson
- School of Sport, Exercise and Rehabilitation Sciences, Birmingham, UK
| | - Emma Johnson
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Erik Lenguerrand
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Elsa Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sian Noble
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mark Pyke
- North Bristol NHS Trust, Bristol, UK
| | | | - Gina Sands
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Adrian Sayers
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Victoria Wells
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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