Multidisciplinary treatment in patients with persistent pain following total hip and knee arthroplasty

Risk factors for pain after total hip arthroplasty: a systematic review

BACKGROUND

Approximately 23% of patients develop hip pain after total hip arthroplasty (THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgical planning.

METHODS

Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preoperative modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently.

RESULTS

Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes.

CONCLUSIONS

Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management.

Investigation of Risk Factors for Pain Chronification in Patients Suffering from Infections of the Spine

Background: Spinal infections represent a therapeutic challenge. The often protracted course of the disease is accompanied by pain, which can lead to a chronic pain experience even after the infectious disease has been treated successfully. The aim of this study was to investigate possible risk factors of pain chronification. Methods: In a prospective study, 14 patients with spinal infections were examined at admission (T1), at discharge from inpatient therapy (T2), and three to eight months postoperatively (T3) byquestionnaires on risk factors for pain chronification and by quantitative sensory testing (QST). Results: In-patient treatment lasted on average 45.3 days (±33.13). The patients complained of pain for 3.43 months (±2.77) prior to inpatient treatment. The visual analogue scale (VAS) for pain (0–10) and the Oswestry Disability Index detected significant improvement in the course of the study. However, patients also reported catastrophic thinking, as well as fear of movement and (re)-injury. Conclusion: In summary, our results demonstrate that patients with spinal infections did not suffer from pain chronification, but might benefit from an interdisciplinary therapeutic approach, which emphasizes promoting active pain-coping strategies, as well as addressing fear of movement and catastrophic thinking.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

BACKGROUND

Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively.

OBJECTIVES

To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks.

DESIGN

An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process.

SETTING

Orthopaedic departments in NHS secondary care.

PARTICIPANTS

Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers.

INTERVENTIONS

Occupational advice intervention.

MAIN OUTCOME MEASURES

Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost.

RESULTS

A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff.

LIMITATIONS

Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it.

CONCLUSIONS

The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention.

FUTURE WORK

The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.

STUDY REGISTRATION

Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

[Predictors for persistent pain and dissatisfaction after total knee arthroplasty]

BACKGROUND

A substantial number of patients patients suffer from persistent pain or are unsatisfied after total knee arthroplasty (TKA).

OBJECTIVES

This work aims to present the frequency of postoperative persistent pain and/or dissatisfaction as well as known causes and predictors.

MATERIALS AND METHODS

The current literature is studied regarding the subject and is reviewed narratively.

RESULTS

Most postoperative problems did not arise from operation details, but from patient-related criteria, a lack of patient education and selection. The satisfaction correlates most strongly with the reduction of preoperative pain.

CONCLUSION

For a successful TKA, care should be taken that the following aspects are met preoperatively: clinically and radiologically advanced osteoarthritis, a patient age preferably older than 60 years, sufficient psychosocial resources to cope with postoperative stress, no opioid medication and realistic expectations after TKA. Postoperatively, patients with persistent pain or dissatisfaction should be checked for any prosthesis-related problems. If no prosthesis-related problems could be detected, the patients should be referred for interdisciplinary therapies.

Impact of attachment behavior on the treatment process of chronic pain patients

Background

Insecure attachment patterns are related to the onset and development of chronic pain. However, it is less documented on how short- and long-term effects of pain therapy might differ with the attachment style in interaction with specific pain conditions. We therefore examined how two different groups of chronic pain patients differ in their treatment trajectories and in regard to attachment.

Method

N=85/76/67 (T1/T2/T3) patients with medically unexplained musculoskeletal pain (UMP group) were compared to n=89/76/56 patients with joint pain from osteoarthritis (OA group), using multilevel modeling. UMP patients received a multimodal pain program, and OA patients received surgery. Pain intensity before (T1) and after (T2) treatment and at a 6 months follow-up (T3) was assessed by using a visual analog scale of pain.

Results

Pain patients report a significant reduction in pain intensity upon the completion of the treatment compared to T1. Over the next 6 months, the pain intensity has further declined for patients with low attachment anxiety. In contrast, patients with highly anxious attachment report an increase in pain intensity. This main effect of anxious attachment on pain is significant when predicting changes both in acute treatment and during follow-up while controlling for group effect. In addition, there is also an interactive effect of group by avoidant attachment. In the UMP group, high scores in avoidant attachment were associated with the lower reduction in pain severity, while in the OA group, high scores in attachment avoidance were associated with a steeper reduction in pain severity.

Conclusion

The results indicate that insecurely attached patients with pain symptoms only benefit from a multimodal pain therapy in limited ways in regard to posttreatment trajectories. Maintaining positive results over a period of 6 months is a challenge, compared with securely attached patients.

Significance

The results of this study suggest the importance of direct and indirect mechanisms of attachment and its relevance for the management of pain experiences. Therefore, to include the individual attachment patterns in the treatment may be a promising way to enhance the treatment prospects.

Quantitative sensory testing in physically active individuals and patients who underwent multidisciplinary pain therapy in the longitudinal course

Objective

The aim of this study was to evaluate possible differences of quantitative sensory testing (QST) results in healthy individuals (group control, n=20), physically active individuals (group sport, n=30) and in patients suffering from chronic musculoskeletal pain (group pain, n=30).

Methods

Thermal detection thresholds, thermal pain thresholds and blunt pressure pain thresholds were measured at various sites (T0). Additionally, group pain was treated in multidisciplinary pain therapy for 4 weeks. All groups were retested after 4 weeks to evaluate the reliability of QST measurements and to investigate possible early changes following treatment (T1).

Results

Importantly, QST-measurements showed stable test results for group sport and group control at both time points. Athletes demonstrated the highest pain thresholds in general (cold pain threshold mean in degree Celsius for the hand: 5.76, lower back right: 7.25, lower back left: 7.53; heat pain threshold mean in degree Celsius for the hand: 46.08, lower back right: 45.77, lower back left: 45.70; and blunt pressure pain mean in kilograms for the hand: 3.54, lower back right: 5.26, lower back left: 5.46). Patients who underwent therapy demonstrated significant differences at T1 (cold pain threshold hand mean in degree Celsius for the hand: 11.12 [T0], 15.12 [T1]; and blunt pressure pain mean in kilograms for the lower back right: 2.87 [T0], 3.56 [T1]). They were capable of enduring higher blunt pressure, but on the other hand cold pain tolerance had decreased (P=0.045 and P=0.019, respectively).

Conclusions

In conclusion, we were able to demonstrate significant differences of QST results among the three groups and we detected early changes following multidisciplinary pain therapy, which will be discussed.

[Clinical studies on multimodal pain therapy : Standardized measurement of therapy outcomes with a core outcome set]

Decision making in evidence-based medicine is based on general data on therapy outcomes as well as the effectiveness and safety in specific patient populations. Typically, findings concerning therapy outcomes from different studies are aggregated for a final conclusion. In this context a comparison of results is hampered by studies in which therapy outcomes are heterogeneously measured. Such methodological challenges exist for almost all areas of medical treatment, as well as for multimodal pain therapy (MMPT). Through establishing core outcome sets (COS) the required standardization of measurement of therapy outcomes in clinical research can be achieved. A COS is an evidence-based and consented minimum set consisting of outcome domains (i.e. partial aspects of the medical condition to be investigated, which have to be measured in order to give the best possible demonstration of therapy outcome of an intervention) accomplished by valid, reliable and sensitive measurement instruments which should be applied in each clinical trial. No such COS has so far been found for MMPT. The aim of this article is to give an overview about currently recommended methodological approaches to develop a COS accompanied by a brief introduction about existing COS initiatives focusing on chronic pain. The existing COS recommendations are discussed and conclusions are drawn on whether existing recommendations could also be applied for MMPT. Finally, the impact of healthcare research in Germany on a standardized assessment of therapy outcome in MMPT is outlined.

Medial rather than lateral knee instability correlates with inferior patient satisfaction and knee function after total knee arthroplasty

BACKGROUND

It is commonly thought that balanced medial and lateral tibiofemoral joint gaps are essential, but the effect of joint laxity on clinical outcome after total knee arthroplasty (TKA) is unclear. It was hypothesised that medial joint laxity correlates with inferior patient satisfaction and knee function, although lateral joint laxity is allowed to a certain degree in TKA.

METHODS

This study included 50 knees that underwent primary TKA. Knee laxity was measured with postoperative stress radiographs in flexion and extension, and patient satisfaction and knee function were evaluated by the 2011 Knee Society Knee Scoring System.

RESULTS

In a comparison of medially tight and medially loose knees in flexion, the scores for satisfaction, symptoms, standard activity, and advanced activity were significantly better in medially tight than in medially loose knees (satisfaction: 29.8, 22.2; symptoms: 20.3, 15.9; standard activities: 24.2, 19.1; and advanced activities: 15.3, 8.7, in the tight and loose knees, respectively). Neither lateral joint laxity during knee flexion nor medial joint laxity during knee extension was associated with a poor postoperative clinical outcome, whereas lateral joint laxity and the standard activity score in extension had a moderate positive correlation.

CONCLUSIONS

Knees with medial joint laxity during flexion resulted in an inferior postoperative outcome, and lateral joint laxity did not influence patient satisfaction or function. Care should be taken to maintain medial joint stability during the TKA procedure.

Predictors of multidimensional functional outcomes after total knee arthroplasty

Multiple assessments are used clinically after total knee arthroplasty (TKA) including self-report, performance tasks, and physical activity levels. It is unclear if these different functional assessments are interchangeable or if they measure different constructs. The objective of this study was to characterize different functional measures before and after TKA. We characterized function before and after TKA using perceived function (KOOS ADL), physical performance (gait speed), and daily activity (steps/day via accelerometry); compared function in people undergoing TKA to age-matched healthy controls; and examined characteristics of those undergoing TKA for potential predictors of postoperative function. Prior to TKA, all three functional assessments were significantly lower for participants than those of healthy controls and each measure remained lower for participants than for controls postoperatively. All three functional assessments developed differently over time postoperatively. Each functional outcome had a unique set of predictors. Perceived function was predicted primarily by anxiety and depression, physical performance was most strongly predicted by age, and daily activity was chiefly predicted by BMI. Pressure pain threshold was a common predictor across all models. Functional limitations exist preoperatively and persist postoperatively across different measures in people undergoing TKA when compared to those measures in healthy controls. Functional outcomes after TKA are different depending on the functional measure utilized, implying that different constructs underlie each measure. Multiple functional measures should be assessed to provide a more comprehensive assessment of function after TKA. Further work should assess the impact of interventions designed to treat modifiable predictors of postoperative TKA function. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2790-2798, 2017.

Risk of Opioid Abuse and Biopsychosocial Characteristics Associated With This Risk Among Chronic Pain Patients Attending a Multidisciplinary Pain Treatment Facility

OBJECTIVES

The objectives of this study were to (1) determine the proportion of patients referred to a multidisciplinary pain treatment facility at risk of opioid abuse, (2) examine biopsychosocial factors associated with this risk, and (3) compare patient outcomes 6 months later across risk of opioid abuse and type of treatment (opioids vs. no opioids).

METHODS

Participants were 3040 patients (mean age=53.3±14.7 y; female=56%) enrolled in the Quebec Pain Registry between July 2012 and May 2014. Patients answered self-report and nurse-administered questionnaires (pain and psychosocial constructs, Opioid Risk Tool, pain medication, etc.) before initiating treatment at the multidisciplinary pain treatment facility and 6 months later. Data were analyzed using the Pearson χ tests, multivariable binary logistic regression, and multivariate general linear model.

RESULTS

Results showed that 81%, 13%, and 6% of patients were at low, moderate, and severe risk of opioid abuse, respectively. Civil status, pain duration, mental health-related quality of life, and cigarette smoking were significantly associated with risk of opioid abuse (P<0.001). There was a significant interaction between risk of opioid abuse and type of treatment in predicting 6-month pain outcomes and quality of life.

DISCUSSION

Almost 20% of patients had a moderate/severe risk of opioid abuse; whether these patients were taking opioids or not for their pain, they had worse outcomes at follow-up. These results point to the importance of assessing risk of opioid abuse in chronic pain patients and to consider how this risk may impact on their clinical evolution.

Causes of Aseptic Persistent Pain after Total Knee Arthroplasty

Background

Persistent pain after total knee arthroplasty (TKA) is dissatisfying to the patient and frustrating to the surgeon. The purpose of this study is to evaluate the aseptic causes and clinical course of intractable pain following TKA.

Methods

Of the total 2,534 cases of primary TKA reviewed, 178 cases were classified as having aseptic persistent pain that was not resolved within 1 year after surgery. Except for the cases with periprosthetic fracture (56 knees), 122 cases of aseptic painful TKA were divided into two groups: intra-articular group (83 knees) and extra-articular group (39 knees).

Results

In the intra-articular group, the main reasons for pain were aseptic loosening (n = 40), polyethylene wear (n = 16), instability (n = 10), recurrent hemarthrosis (n = 5), patellar maltracking (n = 4), tendon ruptures (n = 4), and stiffness (n = 2). In the extraarticular group, 10 knees (25.6%) were found to have nerve entrapment in the spine, 6 knees (15.4%) were found to have hip osteoarthritis or femoral head avascular necrosis. The reasons for persistent knee pain in the remaining 23 knees (59.0%) still remain elusive.

Conclusions

Persistent pain after TKA originated from pathology of extra-articular origin in a considerable number of cases in this study. Therefore, it is important to perform thorough preoperative evaluations to reduce pain resulting from extra-articular causes. Furthermore, meticulous surgical procedures and optimal alignment are required to reduce pain of intra-articular origin related to implant wear, instability, and patellar maltracking.

Noise Generation With Good Range of Motion but Without Femorotibial Instability Has Small Effect on Patient Satisfaction After Total Knee Arthroplasty

BACKGROUND

There are several causes of patient dissatisfaction after total knee arthroplasty (TKA). This study hypothesized that noise occurring in the knee would worsen patient satisfaction after TKA.

METHODS

We mailed a newly developed questionnaire to 103 consecutive participants who were followed for one year, resulting in data from 61 knees in 60 patients (47 women and 13 men, mean age 73 years) who underwent cruciate-substituting TKA. We evaluated postoperative range of motion, knee instability, and the 2011 Knee Society Score in terms of noise generation after TKA.

RESULTS

Over half of the patients noticed postoperative noise that occurred during the mid range of knee motion, but noise was not associated with feelings of instability. Postoperative range of motion differed significantly between the group with noise (122.8 ± 12.0°) and that without noise (106.3 ± 23.3°). The patellar tilt angle was also significantly larger in the group with noise (7.4 ± 5.5°) than that without noise (3.3 ± 2.6°). However, collateral ligament laxity had no significant effect on noise, and the 2011 Knee Society Score did not differ significantly different between the noise and no-noise groups.

CONCLUSION

Our hypothesis was refuted, and these findings suggest patient satisfaction after TKA is influenced more by good knee function than by noise generation.

Interventions for the prediction and management of chronic postsurgical pain after total knee replacement: systematic review of randomised controlled trials

OBJECTIVES

Total knee replacement can be a successful operation for pain relief. However, 10-34% of patients experience chronic postsurgical pain. Our aim was to synthesise evidence on the effectiveness of applying predictive models to guide preventive treatment, and for interventions in the management of chronic pain after total knee replacement.

SETTING

We conducted a systematic review of randomised controlled trials using appropriate search strategies in the Cochrane Library, MEDLINE and EMBASE from inception to October 2014. No language restrictions were applied.

PARTICIPANTS

Adult patients receiving total knee replacement.

INTERVENTIONS

Predictive models to guide treatment for prevention of chronic pain. Interventions for management of chronic pain.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reporting of specific outcomes was not an eligibility criterion but we sought outcomes relating to pain severity.

RESULTS

No studies evaluated the effectiveness of predictive models in guiding treatment and improving outcomes after total knee replacement. One study evaluated an intervention for the management of chronic pain. The trial evaluated the use of a botulinum toxin A injection with antinociceptive and anticholinergic activity in 49 patients with chronic postsurgical pain after knee replacement. A single injection provided meaningful pain relief for about 40 days and the authors acknowledged the need for a large trial with repeated injections. No trials of multidisciplinary interventions or individualised treatments were identified.

CONCLUSIONS

Our systematic review highlights a lack of evidence about the effectiveness of prediction and management strategies for chronic postsurgical pain after total knee replacement. As a large number of people are affected by chronic pain after total knee replacement, development of an evidence base about care for these patients should be a research priority.

Pain threshold correlates with functional scores in osteoarthritis patients

BACKGROUND AND PURPOSE

Pain sensitization may be one of the reasons for persistent pain after technically successful joint replacement. We analyzed how pain sensitization, as measured by quantitative sensory testing, relates preoperatively to joint function in patients with osteoarthritis (OA) scheduled for joint replacement.

PATIENTS AND METHODS

We included 50 patients with knee OA and 49 with hip OA who were scheduled for joint replacement, and 15 control participants. Hip/knee scores, thermal and pressure detection, and pain thresholds were examined.

RESULTS

Median pressure pain thresholds were lower in patients than in control subjects: 4.0 (range: 0-10) vs. 7.8 (4-10) (p = 0.003) for the affected knee; 4.5 (2-10) vs. 6.8 (4-10) (p = 0.03) for the affected hip. Lower pressure pain threshold values were found at the affected joint in 26 of the 50 patients with knee OA and in 17 of the 49 patients with hip OA. The American Knee Society score 1 and 2, the Oxford knee score, and functional questionnaire of Hannover for osteoarthritis score correlated with the pressure pain thresholds in patients with knee OA. Also, Harris hip score and the functional questionnaire of Hannover for osteoarthritis score correlated with the cold detection threshold in patients with hip OA.

INTERPRETATION

Quantitative sensory testing appeared to identify patients with sensory changes indicative of mechanisms of central sensitization. These patients may require additional pain treatment in order to profit fully from surgery. There were correlations between the clinical scores and the level of sensitization.

Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial

BACKGROUND

The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA.

QUESTIONS/PURPOSES

We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)?

METHODS

A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared.

RESULTS

Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p<0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p<0.001).

CONCLUSIONS

The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty.

LEVEL OF EVIDENCE

Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.