The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty

The influence of pain catastrophizing on pain and function after knee arthroplasty in knee osteoarthritis

Pain catastrophizing is an exaggerated focus on pain sensations. It may be an independent factor influencing pain and functional outcomes of knee arthroplasty. We aimed to evaluate the association between pre-operative pain catastrophizing with pain and function outcomes up to one year after knee arthroplasty. We used data from a cohort study of patients undergoing primary knee arthroplasty (either total or unicompartmental arthroplasty) for knee osteoarthritis. Pain catastrophizing was assessed pre-operatively using the Pain Catastrophizing scale (PCS). Other baseline variables included demographics, body mass index, radiographic severity, anxiety, depression, and knee pain and function assessed using the Western Ontario and McMaster University Index (WOMAC). Patients completed the WOMAC at 6- and 12-months after arthroplasty. WOMAC pain and function scores were converted to interval scale and the association of PCS and changes of WOMAC pain and function were evaluated in generalized linear regression models with adjustment with confounding variables. Of the 1136 patients who underwent arthroplasty (70% female, 84% Chinese, 92% total knee arthroplasty), 1102 and 1089 provided data at 6- and 12-months post-operatively. Mean (± SD) age of patients was 65.9 (± 7.0) years. PCS was associated with a change in WOMAC pain at both 6-months and 12-months (β = - 0.04, 95% confidence interval: - 0.06, - 0.02; P < 0.001) post-operatively after adjustment in multivariable models; as well as change in WOMAC function at 6-months and 12-months. In this large cohort study, pre-operative pain catastrophizing was associated with lower improvements in pain and function at 6-months and 12-months after arthroplasty.

Anxiety and depression prior to total knee arthroplasty are associated with worse pain and subjective function: A prospective comparative study

PURPOSE

The aim of this study was to investigate the influence of preoperative anxiety and depression on subjective function, pain and revision rates following total knee arthroplasty (TKA).

METHODS

A prospective comparative study was conducted, including 349 patients undergoing TKA surgery between January 2019 and April 2021. Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire preoperatively, and a set of Patient-Reported Outcome Measures (PROMs) preoperatively and at 6, 12 and 24 months postoperatively. Patients were categorized into anxiety and depression groups based on HADS scores. PROMs included the Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS) and NRS-Pain. Differences in PROM scores between the anxiety/depression group and, respectively, nonanxiety/nondepression group were assessed, as well as differences in minimal clinical important difference (MCID) and attainment of Patient Acceptable Symptom State (PASS). Lastly, revision rates were compared.

RESULTS

Anxiety and depression groups exhibited inferior subjective function preoperatively and postoperatively compared to nonanxiety and nondepression groups (all p < 0.05), experienced more pain preoperatively (p < 0.001) and also postoperatively for depression patients (all p < 0.05). Significantly fewer patients with anxiety and depression reached the PASS for KOOS-PS, OKS and NRS-Pain (all p < 0.05). There were no differences in the proportion of patients reaching the MCID for all PROMs (all p > 0.060), and revision rates did not differ between groups (both p > 0.96).

CONCLUSION

Preoperative anxiety and depression negatively influence subjective function and pain preoperatively and up to 2-year follow-up in patients undergoing TKA. Revision rates did not differ between groups, and there were no relevant differences in clinical improvement of subjective function and pain.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Cognitive Therapy, Mindfulness-Based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain: Predictors and Moderators of Treatment Response

Psychosocial interventions for people with chronic pain produce significant improvements in outcomes, but these effects on average are modest with much variability in the benefits conferred on individuals. To enhance the magnitude of treatment effects, characteristics of people that might predict the degree to which they respond more or less well could be identified. People with chronic low back pain (N = 521) participated in a randomized controlled trial which compared cognitive therapy, mindfulness-based stress reduction, behavior therapy and treatment as usual. Hypotheses regarding predictors and/or moderators were based on the Limit, Activate, and Enhance model; developed to predict and explain moderators/predictors of psychosocial pain treatments. Results were: 1) low levels of cognitive/behavioral function at pre-treatment predicted favorable pre- to post-treatment outcomes; 2) favorable expectations of benefit from treatment and sound working alliances predicted favorable pre- to post-treatment outcomes; 3) women benefited more than men. These effects emerged without regard to treatment condition. Of note, high levels of cognitive/behavioral function at pre-treatment predicted favorable outcomes only for people in the treatment as usual condition. Analyses identified a set of psychosocial variables that may act as treatment predictors across cognitive therapy, mindfulness-based stress reduction and behavior therapy, as hypothesized by the Limit, Activate, and Enhance model if these 3 treatments operate via similar mechanisms. Findings point toward people who may and who may not benefit fully from the 3 psychosocial treatments studied here, and so may guide future research on matching people to these kinds of psychosocial approaches or to other (eg, forced-based interventions) non-psychosocial approaches. TRIAL REGISTRATION: The ClinicalTrials.gov Identifier is NCT02133976. PERSPECTIVE: This article examines potential predictors/moderators of response to psychosocial treatments for chronic pain. Results could guide efforts to match people to the most effective treatment type or kind.

Risk factors of chronic postoperative pain after total knee arthroplasty: a systematic review

BACKGROUND

There is a lack of relevant studies to grade the evidence on the risk factors of chronic pain after total knee arthroplasty (TKA), and only quantitative methods are used for systematic evaluation. The review aimed to systematically identify risk factors of chronic postoperative pain following TKA and to evaluate the strength of the evidence underlying these correlations.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched from initiation to September 2023. Cohort studies, case-control studies, and cross-sectional studies involving patients undergoing total knee replacement were included. A semi-quantitative approach was used to grade the strength of the evidence-based on the number of investigations, the quality of the studies, and the consistency of the associations reported by the studies.

RESULTS

Thirty-two articles involving 18,792 patients were included in the final systematic review. Ten variables were found to be strongly associated with postoperative pain, including Age, body mass index (BMI), comorbidities condition, preoperative pain, chronic widespread pain, preoperative adverse health beliefs, preoperative sleep disorders, central sensitization, preoperative anxiety, and preoperative function. Sixteen factors were identified as inconclusive evidence.

CONCLUSIONS

This systematic review clarifies which risk factors could be involved in future research on TKA pain management for surgeons and patients. It highlights those factors that have been controversial or weakly correlated, emphasizing the need for further high-quality studies to validate them. Most crucially, it can furnish clinicians with vital information regarding high-risk patients and their clinical attributes, thereby aiding in the development of preventive strategies to mitigate postoperative pain following TKA.

TRIAL REGISTRATION

This systematic review has been registered on the PROSPERO platform (CRD42023444097).

The mind matters: Psychological factors influence subjective outcomes following unicompartmental knee arthroplasty-A prospective study

PURPOSE

This study aimed to investigate how psychological factors, including pain catastrophizing (PC), anxiety and depression affect preoperative and postoperative subjective outcomes in patients undergoing unicompartmental knee arthroplasty (UKA).

METHODS

A prospective comparative study was performed among 150 patients undergoing medial or lateral UKA for isolated unicompartmental osteoarthritis. Patients were categorized based on their preoperative PC and Hospital Anxiety and Depression Scale, stratifying them into groups with PC, anxiety or depression, and those without these psychological factors. Patient-reported outcomes, including the Knee Injury and Osteoarthritis Outcome Score-Physical function Short form (KOOS-PS), 5-level EQ5D Visual Analogue Scale (EQ5D-VAS), Forgotten Joint Score (FJS) and Numeric Rating Scale for pain (NRS-pain) were compared between groups preoperatively and at 6-, 12-, and 24-month follow-up.

RESULTS

At 24 months, PC patients had inferior outcomes in KOOS-PS (66.9 ± 16.5 vs. 77.6 ± 14.7, p = .008), EQ5D-VAS (63.5 ± 19.9 vs. 78.9 ± 20.1, p = .003) and FJS (73.7 ± 14.3 vs. 84.6 ± 13.8, p = .003). Anxiety was associated with inferior KOOS-PS (65.4 ± 15.2 vs. 78.2 ± 14.5, p = <.001), EQ5D-VAS (64.2 ± 23.2 vs. 79.3 ± 19.4, p = .002), FJS (75.7 ± 16.8 vs. 84.6 ± 13.4, p = .008) and NRS-pain (27.4 ± 24.6 vs. 13.7 ± 19.3, p = .023) at 24 months. Depression consistently resulted in inferior outcomes in KOOS-PS, EQ5D-VAS, FJS and NRS-pain across all follow-up assessments (p = <.05). Additionally, patients with anxiety and depression experienced longer length of hospital stay compared to those without these psychological factors (anxiety: 2.3 ± 2.3 vs. 0.8 ± 0.8 days, p = .006; depression: 2.3 ± 2.4 vs. 0.8 ± 0.8 days, p = .017).

CONCLUSIONS

Preoperative PC, anxiety and depression are associated with inferior subjective outcomes both prior to and following UKA. Among these factors, depression seemed to exert the most substantial adverse impact on outcomes following UKA. Patients with anxiety and depression had an extended duration of hospitalization lasting over twice as long as patients without these psychological factors. It seems that inferior outcomes primarily stem from the suboptimal preoperative condition rather than an inherent inability to benefit from UKA.

LEVEL OF EVIDENCE

Level II, prospective study.

Perioperative experiences of patients with high pain catastrophizing and knee arthroplasty after receiving or not preoperative physiotherapy: Qualitative study

BACKGROUND

Among the risk factors studied for persistent pain after total knee arthroplasty (TKA), pain catastrophizing stands out above the others. In this regard, preoperative interventions based on pain neuroscience education or multimodal physiotherapy have been shown to be effective in reducing pain catastrophizing.

OBJECTIVES

The present qualitative study aims to explore the perioperative experiences of high pain catastrophizing participants undergoing total knee arthroplasty surgery. Comparisons will be made between those who received, and those who did not receive a preoperative physiotherapy intervention.

METHODS

Based on the purposive sampling approach, participants from a randomized controlled trial were selected. In total, 14 persons participated in face-to-face semi-structured interviews.

RESULTS

Following a thematic analysis, the results were divided into two themes: 1) The preoperative experiences of patients with symptomatic knee arthroplasty, covering aspects related to health, functioning, cognition, and behaviour; and 2) The perioperative TKA rehabilitation process, illustrating differing experiences between individuals who received the preoperative physiotherapy interventions and those who did not.

CONCLUSIONS

While participants who received no preoperative physiotherapy intervention showed limited coping strategies during post-surgery rehabilitation and the same cognitions as before (hypervigilance, rumination, or avoidance of activities), those participants who received the preoperative physiotherapy showed abilities to cope with their pain, felt empowered and were involved in their rehabilitation.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study

OBJECTIVE

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA.

METHODS

A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1 week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6 months after surgery.

RESULTS

Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6 months after surgery in a univariate analysis. However, at 3 months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6 months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress.

CONCLUSION

The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA.

IMPACT

Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

Only Low Patients' Expectations Are Prognostic for Dissatisfaction With Performing Work-Related Knee-Straining Activities After Total Knee Arthroplasty: A Prospective Multicenter Cohort Study

OBJECTIVE

To investigate whether preoperative expectations regarding performing work-related knee-straining activities were associated with being dissatisfied 6 months after total knee arthroplasty (TKA) among working patients, and, to identify prognostic factors for being dissatisfied with performing these work-related knee-straining activities.

DESIGN

Multicenter prospective cohort study.

SETTING

Orthopedic surgery departments of 7 hospitals in the Netherlands.

PARTICIPANTS

A consecutive sample of 175 working patients who were on the waiting list for TKA (median age 59 years, 53% women) and intended to return to work (N=175).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Dissatisfaction with performing work-related knee-straining activities 6 months postoperative was measured using the Work Osteoarthritis or joint-Replacement Questionnaire (score range 0-100). The clinically relevant cut-off points for being satisfied and dissatisfied were ≥71 and ≤50, respectively.

RESULTS

Thirty-three patients (19%) were dissatisfied with performing work-related knee-straining activities 6 months after TKA. Patients who expected to be dissatisfied preoperative had a 5.1 times higher odds (95% CI 1.7-15.5) of being dissatisfied 6 months postoperatively compared with patients who expected to be satisfied preoperative. Regression analyses revealed that only patients' expectations were prognostic for being dissatisfied 6 months postoperatively rather than age, pain level, or having a knee-straining job.

CONCLUSIONS

Two in 10 working patients are dissatisfied with performing work-related knee-straining activities 6 months after TKA. Only preoperative patients' expectations appeared prognostic. Therefore, we should better prepare working patients with low expectations by managing their preoperative expectations and improving their performance of work-related knee-straining activities in rehabilitation.

Prognostic factors of knee pain and function 12 months after total knee arthroplasty: A prospective cohort study of 798 patients

BACKGROUND

Approximately 20% of patients undergoing total knee arthroplasty (TKA) do not experience long-term improvements. Our aim was to identify prognostic factors of knee pain and function 12 months after TKA.

METHODS

In a prospective cohort study, 1026 patients underwent primary TKA between 2018 and 2020. Main outcome was measured by the Oxford Knee Score (OKS) categorized in five categories (0-9, 10-19, 20-29, 30-39 and 40-48). Potential prognostic factors obtained at baseline included sex, age, baseline OKS, pain catastrophizing scale, EuroQol 5 dimensions, previous surgery, BMI, ASA classification, opioid consumption, living and employment conditions as well as educational level. Ordinal logistic regression analysis was used to identify prognostic factors of OKS.

RESULTS

A total of 915 patients completed follow up (89%), and patients with complete data were included (n = 798). Patients with a baseline OKS between 10-19 and 20-29 had 2.5 (CI 1.6;4.0) and 1.6 (CI 1.1;2.4) higher odds, respectively, of no improvement or deterioration to a lower post-operative OKS category, compared with patients with a baseline score between 30 and 39. Female patients had 1.5 (CI 1.1;2.0) and patients receiving social benefits compared with retired patients had 2.0 (CI 1.1;3.5) higher odds of no improvement or deterioration to a lower OKS category.

CONCLUSION

Baseline level of pain and function, sex and employment status were significant prognostic factors of OKS 12 months after TKA. Overall, the regression analysis only explained 4% of the outcome, indicating that it is difficult to predict 12-month TKA outcome prior to surgery.

Preoperative and Postoperative Kinesiophobia Influences Postoperative Outcome Measures Following Anterior Cruciate Ligament Reconstruction: A Prospective Study

The anterior cruciate ligament (ACL) is the most injured ligament of the knee, and the treatment of choice is usually ACL reconstruction. Kinesiophobia refers to an irrational and paralyzing fear of movement caused by the feeling of being prone to injury or reinjury. The aim of the present study is to evaluate the relationship between preoperative and postoperative kinesiophobia with postoperative outcomes of ACL-R evaluated through SF-36, ACL-RSI, KOOS, and OKS scores. Included patients all underwent ACL reconstruction. The preoperative TSK-13 questionnaire and six-month postoperative TSK-13, ACL-RSI, SF-36, KOOS, and OKS questionnaires were assessed in included patients. Normal distribution was assessed using the Shapiro-Wilk test. The study included 50 patients who filled out the questionnaires at the 6-month postoperative follow-up. Correlations between preoperative TSK-13 and postoperative outcome measures revealed a low-moderate negative correlation between preoperative TSK-13 and SF-36 PCS at 6-month follow-up. Correlations between postoperative TSK-13 and postoperative outcome measures revealed a high negative correlation between preoperative TSK-13 and ACL-RSI, KOOS Symptoms, KOOS Pain, KOOS ADL, and OKS at 6-month follow-up. Preoperative and postoperative kinesiophobia were found to influence postoperative ACL-R outcomes negatively, more specifically an increase in kinesiophobia showed a statistically significant correlation with worse postoperative SF-36 PCS scores in patients.

Effect of Psychosocial Interventions for Individuals Who Underwent Arthroscopy in Femoroacetabular Impingement: A Randomized Controlled Trial

PURPOSE

The purpose of this protocol was to discover the connection between patients with non-surgical pain or other discomfort and their psychosocial status. Cognitive behavior therapy will be used, which we verified will determine the effect and feasibility of postoperative rehabilitation processes.

MATERIALS AND METHODS

This study will include 200 patients ranging from 18 to 60 years old who have underwent or will undergo FAI arthroscopy in the West China Hospital Sports Medicine Center from 2023 to 2026. A standardized prospective single-center parallel-group randomized controlled trial will be used for these participants. The participants will be divided into intervention (telephone versus face-to-face versus music versus floatation) and control groups. The follow-up periods will be measured pre-operatively, as well as postoperatively at 1, 3, and 6 months. The primary outcomes will include the modified Harris Hip Score (mHHS) and the Visual Analogic Score (VAS), and the secondary outcomes will include the range of motion (ROM), the Huaxi Emotional-distress Index (HEI), and the depression, anxiety, and stress scale (DASS-21 scale). Furthermore, the Patient Health Questionnaire-9 (PHQ-9) and a Short-Form 12 (SF-12) questionnaire will also be evaluated.

DISCUSSION

This study will evaluate the clinical and cost-effectiveness of different types of psychosocial-therapy-based rehabilitation methods designed to improve the quality of life of FAI patients with persistent symptoms.

A single-center, open-label, randomized, parallel-group trial to pilot the effectiveness of a peer coach behavioral intervention versus an active control in reducing anxiety and depression in patients scheduled for total knee replacement

BACKGROUND

Moving Well is a behavioral intervention for patients with knee osteoarthritis (KOA) scheduled for a total knee replacement (TKR). The objective of this intervention is to help patients with KOA mentally and physically prepare for and recover from TKR.

METHODS

This is an open-label pilot randomized clinical trial that will test the feasibility and effectiveness of the Moving Well intervention compared to an attention control group, Staying Well, to reduce symptoms of anxiety and depression in patients with KOA undergoing TKR. The Moving Well intervention is guided by Social Cognitive Theory. During this 12-week intervention, participants will receive 7 weekly calls before surgery and 5 weekly calls after surgery from a peer coach. During these calls, participants will be coached to use principles of cognitive behavioral therapy (CBT), stress reduction techniques, and will be assigned an online exercise program, and self-monitoring activities to complete on their own time throughout the program. Staying Well participants will receive weekly calls of similar duration from research staff to discuss a variety of health topics unrelated to TKR, CBT, or exercise. The primary outcome is the difference in levels of anxiety and/or depression between participants in the Moving Well and Staying Well groups 6 months after TKR.

DISCUSSION

This study will pilot test the feasibility and effectiveness of Moving Well, a peer coach intervention, alongside principles of CBT and home exercise, to help patients with KOA mentally and physically prepare for and recover from TKR.

TRIAL REGISTRATION

Clinicaltrials.gov. NCT05217420; Registered: January 31, 2022.

Recovery expectations can be assessed with single-item measures: findings of a systematic review and meta-analysis on the role of recovery expectations on return-to-work outcomes after musculoskeletal pain conditions

ABSTRACT

The objective of this systematic review is to quantify the association between recovery expectations and return-to-work outcomes in adults with musculoskeletal pain conditions. In addition, this review has the second objective to compare the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Relevant articles were selected from Embase, PsycINFO, PubMed, Cochrane, and manual searches. Studies that assessed recovery expectations as predictors of return-to-work outcomes in adults with musculoskeletal pain conditions were eligible. Data were extracted on study characteristics, recovery expectations, return-to-work outcomes, and the quantitative association between recovery expectations and return-to-work outcomes. Risk of bias was assessed using the Effective Public Health Practice Project. Odds ratios were pooled to examine the effects of recovery expectations on return-to-work outcomes. Chi-square analyses compared the predictive utility of single-item and multi-item recovery expectation scales on return-to-work outcomes. Thirty studies on a total of 28,741 individuals with musculoskeletal pain conditions were included in this review. The odds of being work disabled at follow-up were twice as high in individuals with low recovery expectations (OR = 2.06 [95% CI 1.20-2.92] P < 0.001). Analyses also revealed no significant differences in the predictive value of validated and nonvalidated single-item measures of recovery expectations on work disability (χ 2 = 1.68, P = 0.19). There is strong evidence that recovery expectations are associated with return-to-work outcomes. The results suggest that single-item measures of recovery expectations can validly be used to predict return-to-work outcomes in individuals with musculoskeletal pain conditions.

Preoperative Pain Catastrophizing Prior to Total Knee Arthroplasty is Associated With Worse Preoperative Symptoms and More Clinical Improvement: A Prospective Comparative Study

BACKGROUND

Total knee arthroplasty (TKA) is a reliable procedure for end-stage osteoarthritis with excellent long-term survivorship, but approximately 15% of patients are not satisfied. Pain catastrophizing (PC) has been proposed as a potential cause but current evidence is limited to smaller studies with short-term follow-up. Our goal was to assess outcomes following TKA in a large cohort with and without PC.

METHODS

A prospective comparative study was performed with patients undergoing unilateral primary TKA between 2019 and 2021 with 2-year follow-up. All patients completed a PC Scale questionnaire preoperatively and a score of minimum 30 was considered PC. Outcomes consisted of Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS), Oxford Knee Score (OKS), numeric rating scale Pain, and aseptic revisions. Ultimately, 301 patients were included (mean age 69 years [range, 30-92 years], with 60.8% women). Forty four patients (14.6%) had PC.

RESULTS

Preoperatively, PC patients had inferior KOOS-PS, inferior OKS, and more pain than non-PC patients (all P < .001). PC patients had more improvement from preoperatively to 6 months postoperatively for KOOS-PS, OKS, and pain (all P < .05) and to 12 months for KOOS-PS and OKS (both P < .005). Similarly, PC patients had more improvement from preoperative to 24 months for OKS (P = .003). At 24 months, however, PC patients reported more pain than non-PC patients. There was no difference in revision rates (P = .192).

CONCLUSION

Patients who had PC reported worse function and pain preoperatively but had more improvement to 6 months and 12 months postoperatively. At 24 months, similar subjective function was noted, although PC patients reported more pain.

Effects of Occupational Therapy Practice on Patient Outcomes after High Tibial Osteotomy: A Non-randomized Study in Japan

We examined the effectiveness of occupational therapy intervention combined with standard rehabilitation in patients undergoing high tibial osteotomy (HTO). Overall, 115 patients with HTO for knee osteoarthritis were examined. An intervention group (n = 50), who received occupational therapy and standard rehabilitation, was compared to a control group (n = 65), who underwent standard rehabilitation only (n = 65). Compared with the control group, the intervention group had significantly lower Hospital Anxiety and Depression Scale depression and anxiety scores (both p < 0.05), with between-group differences showing large- and medium-effect sizes, respectively (d = 1.06 and 0.61). Results suggest occupational therapy with rehabilitation during hospitalization improves depression and anxiety rates in patients post-HTO.

Does reverse shoulder arthroplasty improve emotional status and quality of life in patients with rotator cuff insufficiency? Prospective sequential follow-up study

BACKGROUND

The purpose of this study was to investigate sequential changes of emotional status and quality of life after reverse shoulder arthroplasty (RSA) for rotator cuff insufficiency and to determine the predictors that can affect postoperative clinical outcomes. This study was conducted to prove the hypothesis that RSA would improve emotional status and quality of life.

METHODS

Fifty patients undergoing RSA for rotator cuff insufficiency were prospectively included. Evaluation using the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value, Hospital Anxiety and Depression Scale (HADS), and Abbreviated scale of World Health Organization Quality of Life (WHOQOL-BREF) was performed before surgery and at 1.5, 3, 6, and 12 months after surgery.

RESULTS

The mean visual analog scale pain score, HADS-depression score, and HADS-anxiety score showed a significant decrease from 6.6, 13.3, and 13.9 before surgery to 1.5, 3.9, and 3.7 after 12 months after surgery, respectively (all P < .001). The mean ASES score, WHOQOL-BREF score, and subjective shoulder value showed a significant improvement from 28.5, 32.3, and 23.6% to 81.3, 79.1, and 78.4%, respectively (all P < .001). All outcome measurements showed a significant improvement from 6 weeks after RSA. In multivariate analysis, age was an independent predictor of the final ASES score and WHOQOL-BREF score (P = .037 and .004, respectively).

CONCLUSION

This study showed a sequential improvement of emotional status and quality of life as well as functional recovery with pain relief from 6 weeks after RSA in patients with rotator cuff insufficiency. Especially, younger patients had better postoperative functional ability and quality of life. These findings suggest that RSA for rotator cuff insufficiency provides a rapid improvement of emotional status and quality of life.

Pain catastrophizing and pre-operative psychological state are predictive of chronic pain after joint arthroplasty of the hip, knee or shoulder: results of a prospective, comparative study at one year follow-up

PURPOSE

To assess the relationship between pre-operative psychological state, postoperative pain and function one year after total shoulder, hip or knee arthroplasty.

METHODS

Patients undergoing shoulder, hip or knee arthroplasty between March 2014 and November 2015 were included. Pain catastrophizing score (PCS) was determined preoperatively, at six months and at one year follow-up. Joint pain at rest was quantified using a Visual Analogue Scale (0‒100). Depressive symptoms were measured using the Beck Depression Inventory or Geriatric Depression Score, situational anxiety and dispositional anxiety were measured using the State-Trait Inventory and joint function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index for the hip and knee and Oxford Shoulder Score for the shoulder.

RESULTS

A total of 266 patients were included (65% female; mean (± SD) age: 71.8 ± 10.3 years; mean body mass index: 27.5 ± 5.0 kg/m²). Pre-operative PCS was significantly correlated with pain > 30/100 at one year and with functional scores, for all joints. Multivariate analysis identified the following variables as risk factors for pain intensity > 30/100 at one year: pre-operative PCS > 20/52 (OR = 3.5 ± 1.1 [95% CI: 1.9‒6.6]; p = 0.0001), trait-anxiety score ≥ 46 (OR = 2.4 ± 0.9 [95% CI: 1.1‒5.2]; p = 0.03), pre-operative pain ≥ 60/100 (OR = 3.2 ± 1 [95% CI: 1.8‒6.1]; p = 0.0001) and pain for at least 3 years (OR = 1.8 ± 0.6 [95% CI: 1‒3.4]; p = 0.04).

CONCLUSION

Pre-operative pain catastrophizing and trait-anxiety are risk factors for post-operative pain after shoulder, hip and knee arthroplasty.

TRIAL REGISTRATION NUMBER

www.

CLINICALTRIALS

gov NCT02361359.

The Influence of Expectancies on Pain and Function Over Time After Total Knee Arthroplasty

OBJECTIVE

Expectancies have a well-documented influence on the experience of pain, responses to treatment, and postsurgical outcomes. In individuals with osteoarthritis, several studies have shown that expectations predict increased pain and disability after total knee replacement surgery. Despite the growing recognition of the importance of expectancies in clinical settings, few studies have examined the influence of expectancies throughout postsurgical recovery trajectories. The objective of the present study was to examine the role of presurgical expectancies on pain and function at 6-week, 6-month, and 1-year follow-ups after total knee arthroplasty.

DESIGN AND PARTICIPANTS

Data were collected from patients scheduled for total knee arthroplasty 1 week before surgery and then at 6 weeks, 6 months, and 1 year after surgery. Correlational and multivariable regression analyses examined the influence of expectancies on patients' perceptions of pain reduction and functional improvement at each time point. Analyses controlled for age, sex, body mass index, presurgical pain intensity and function, pain catastrophizing, anxiety, and depression.

RESULTS

Results revealed that expectancies significantly predicted pain reduction and functional improvement at 1-year follow-up. However, expectancies did not predict outcomes at the 6-week and 6-month follow-ups. Catastrophizing and depressive symptoms emerged as short-term predictors of postsurgical functional limitations at 6-week and 6-month follow-ups, respectively.

CONCLUSIONS

The results suggest that targeting high levels of catastrophizing and depressive symptoms could optimize short-term recovery after total knee arthroplasty. However, the results demonstrate that targeting presurgical negative expectancies could prevent prolonged recovery trajectories, characterized by pain and loss of function up to 1 year after total knee arthroplasty.

Long-Term Postoperative Pain Prediction Using Higher-Order Singular Value Decomposition of Intraoperative Physiological Responses: Prospective Cohort Study

BACKGROUND

Long-term postoperative pain (POP) and patient responses to pain relief medications are not yet fully understood. Although recent studies have developed an index for the nociception level of patients under general anesthesia based on multiple physiological parameters, it remains unclear whether these parameters correlate with long-term POP outcomes.

OBJECTIVE

This study aims to extract unbiased and interpretable descriptions of how the dynamics of physiological parameters change over time and across patients in response to surgical procedures and intraoperative medications using a multivariate-temporal analysis. We demonstrated that there is an association (correlation) between the main features of intraoperative physiological responses and long-term POP, which has a predictive value, even without claiming causality.

METHODS

We proposed a complex higher-order singular value decomposition method to accurately decompose patients' physiological responses into multivariate structures evolving over time. We used intraoperative vital signs of 175 patients from a mixed surgical cohort to extract three interconnected, low-dimensional, complex-valued descriptions of patients' physiological responses: multivariate factors, reflecting subphysiological parameters; temporal factors, reflecting common intrasurgery temporal dynamics; and patients' factors, describing interpatient changes in physiological responses.

RESULTS

Adoption of the complex higher-order singular value decomposition method allowed us to clarify the dynamic correlation structure included in the intraoperative physiological responses. Instantaneous phases of the complex-valued physiological responses of 242 patients within the subspace of principal descriptors enabled us to discriminate between mild and not-mild (moderate-severe) levels of pain at postoperative days 30 and 90. Following rotation of physiological responses before projection to align with the common multivariate-temporal dynamic, the method achieved an area under curve for postoperative day 30 and 90 outcomes of 0.81 and 0.89 for thoracic surgery, 0.87 and 0.83 for orthopedic surgery, 0.87 and 0.88 for urological surgery, 0.86 and 1 for colorectal surgery, 1 and 1 for transplant surgery, and 0.83 and 0.92 for pancreatic surgery, respectively.

CONCLUSIONS

By categorizing patients into different surgical groups, we identified significant surgery-related principal descriptors. Each of them potentially encodes different surgical stimulation. The dynamics of patients' physiological responses to these surgical events were linked to long-term POP development.

Effectiveness of a rectal cancer education video on patient expectations

AIM

Discrepancy between patient expectations and outcomes can negatively affect patient satisfaction and quality of life. We aimed to assess patient expectations of bowel, urinary, and sexual function after rectal cancer treatments, and whether a preoperative education video changed expectations.

METHODS

A total of 45 patients were assessed between January 2018 and January 2021 in a tertiary care hospital in Vancouver, Canada. Patients included were rectal cancer patients who had neoadjuvant chemoradiation and were listed for low anterior resection but had not yet had surgery. Following surgical consultation but before surgery, a questionnaire assessing expectations of lifestyle after treatments was administered. Patients then watched an educational video and repeated the questionnaire to assess for changes in expectations.

RESULTS

Patient scores indicated expectation that control of bowel movements, urination, and sexual function would sometimes be problematic, but had a range from occasionally problematic to good function. Significant change after the video was seen in the expectation of needing medications for bowel control, and 44%-69% of individual patient answers changed from prevideo to post-video, depending on the question. The education video was scored as helpful or very helpful by 82% of patients.

CONCLUSIONS

Patients have varying expectations of problematic control of bowel, urinary, and sexual function following rectal cancer treatments. A pretreatment education video resulted in a trend toward changed expectations for functional outcomes in most patients. Further educational modalities for patients may provide more uniform expectations of function and increase patient satisfaction after rectal cancer treatments.

Factors Correlated With Physical Function 1 Year After Total Knee Arthroplasty in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

IMPORTANCE

More than 1 in 5 patients do not experience improved physical function after total knee arthroplasty (TKA). Identification of factors associated with physical function may be warranted to improve outcomes in these patients.

OBJECTIVE

To identify preoperative and intraoperative factors associated with physical function at 12 months after TKA in a systematic review and meta-analysis.

DATA SOURCES

Data from January 2000 to October 2021 were searched in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Physiotherapy Evidence Database (PEDro). No language restrictions were applied.

STUDY SELECTION

Prospective observational studies or randomized clinical trials on factors associated with physical function after TKA in adult patients with osteoarthritis were selected. A prespecified peer-reviewed protocol was followed.

DATA EXTRACTION AND SYNTHESIS

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently screened titles and abstracts and judged risk of bias using Quality in Prognosis Studies (QUIPS). Multivariate random-effects meta-analyses were performed to estimate mean correlations between factors and physical function with 95% CIs. Sensitivity analyses were conducted for each QUIPS domain. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

MAIN OUTCOMES AND MEASURES

The primary outcome was physical function 12 months after TKA. Secondary outcomes were physical function 3 and 6 months after TKA. All estimates are mean correlations between factors and postoperative function. Positive correlations correspond to better function.

RESULTS

Among 12 052 articles, 20 studies (including 11 317 patients and 37 factors) were analyzed. Mean correlation with higher BMI was estimated to be -0.15 (95% CI, -0.24 to -0.05; P = .33; moderate-certainty evidence), while mean correlation with better physical function was estimated to be 0.14 (95% CI, 0.02 to 0.26; P = .03; low-certainty evidence) and mean correlation with more severe osteoarthritis was estimated to be 0.10 (95% CI, 0.01 to 0.19; P = .17; high-certainty evidence). In sensitivity analyses, mean correlation with better physical function was estimated to be 0.20 (95% CI, 0.04 to 0.36; P = .02), and so perhaps a larger coefficient than in the main analysis, while mean correlations were estimated to be similar for other factors (BMI: -0.17; 95% CI, -0.28 to -0.06; P < .001; osteoarthritis severity: 0.10; 95% CI, -0.01 to 0.20; P = .05).

CONCLUSIONS AND RELEVANCE

This study found that higher presurgical BMI was correlated with worse physical function (with moderate certainty) and that better physical function (low certainty) and osteoarthritis severity (high certainty) were correlated with better physical function after TKA. These findings suggest that these factors should be included when testing predictive models of TKA outcomes.

Pain catastrophizing and associated factors in preoperative total knee arthroplasty in Lanzhou, China: a cross-sectional study

Background

Pain catastrophizing in preoperative total knee arthroplasty (TKA) patients is associated with several poorly characterised factors in the literature. This study investigated the current state and associated factors of preoperative pain catastrophizing in patients undergoing TKA.

Methods

This descriptive cross-sectional study was conducted at the orthopedics ward of two tertiary hospitals in Lanzhou, China. Pain catastrophizing was measured using the Chinese versions of the Pain Catastrophizing Scale, Short Form-36 (physical function domain), Numerical Rating Scale, Oxford Knee Score, Hospital Anxiety and Depression Scale, and Life Orientation Test-Revised.

Results

The study included 360 participants. Preoperative TKA pain catastrophizing in all patients was high, with a mean score of 24.92 (SD: 12.38). The stepwise multiple linear regression analysis revealed anxiety (β = 0.548, P < 0.01), education level (β =  − 0.179, P < 0.01), physical function (β =  − 0.156, P < 0.01), and pain intensity during activity (β = 0.105, P = 0.015) as associated factors for pain catastrophizing, possibly explaining 51.2% of the total variation (F = 95.149, P < 0.01).

Conclusion

Anxiety was the most relevant factor for pain catastrophizing in patients with preoperative TKA. Lower education levels, poor physical function, and stronger pain intensity during the activity were also associated with pain catastrophizing.

Do patients’ pre-treatment expectations about acupuncture effectiveness predict treatment outcome in patients with chronic low back pain? A secondary analysis of data from a randomised controlled clinical trial

Objective

This secondary analysis of a randomised controlled patient-blinded trial comparing effectiveness and side effect briefings in patients with chronic low back pain (CLBP) investigated the association between patients’ pre-treatment expectations about minimal acupuncture treatment and pain intensity as outcome during and after the end of the treatment.

Methods

Chronic low back pain patients with a pain intensity of at least 4 on a numeric rating scale from 0 to 10 received eight sessions of minimal acupuncture treatment over 4 weeks. The primary outcome was change in pain intensity rated on a Numerical Rating Scale (NRS 0–10) from inclusion visit to treatment session 4 and to the end of the treatment. Patients’ expectations about the effectiveness of acupuncture were assessed using the Expectation for Treatment Scale (ETS) before randomization. Linear regression was applied to investigate whether patients’ pre-treatment expectations predicted changes in pain intensity during and after treatment.

Results

A total of 142 CLBP patients (40.1 ± 12.5 years; 65.5% female) were included in our analysis. Patients’ pre-treatment expectations about acupuncture treatment were associated with changes in pain intensity after four sessions of minimal acupuncture treatment (b = -0.264, p = 0.002), but not after the end of the treatment. This association was found in females and males.

Conclusions

Our results imply that higher pre-treatment expectations only lead to larger reductions in pain intensity in the initial phase of a treatment, with a similar magnitude for both females and males. As the treatment progresses in the second half of the treatment, adapted expectations or other non-specific effects might play a more important role in predicting treatment outcome.

Effect of Early Electroacupuncture Combined with Enhanced Recovery after Surgery (ERAS) on Pain Perception and Dysfunction in Patients after Total Knee Arthroplasty (TKA)

Objective

A retrospective case-control study was performed to observe the effect and clinical significance of early electroacupuncture combined with enhanced recovery after surgery (ERAS) on pain perception and dysfunction after total knee arthroplasty (TKA).

Methods

About 100 patients who diagnosed with TKA from February 2019 to April 2021 were enrolled in our hospital. The patients were arbitrarily assigned into control group and study group. The former group was cured with electroacupuncture in the early stage, and the latter group was intervened on the basis of early electroacupuncture combined with the concept of ERAS. The curative effect, the time of getting out of bed for the first time after operation, the time of postoperative rehabilitation, postoperative rehabilitation cost, pain score and knee joint function score, range of motion (ROM) of knee joint, low shear of whole blood viscosity, plasma viscosity, fibrinogen level, and postoperative complications were compared.

Results

There exhibited no statistical difference in clinical data. In terms of the treatment effects, there were 27 cases of markedly effective, 22 cases of effective, and 1 case of ineffective in the study group, and the total effective rate was 98.00%; in the control group, 15 cases were markedly effective, 28 cases were effective, and 13 cases were ineffective, and the total effective rate was 86.00%. Compared to the control group, the total effective rate of the study group was higher (P < 0.05). And the first time to get out of bed and the postoperative rehabilitation time in the study group were lower. Compared to the control group (10113.42 ± 524.83) yuan, the postoperative rehabilitation cost in the study group (12401.71 ± 530.77) yuan was higher. In terms of the scores of VAS and HSS, there exhibited no remarkable difference before treatment (P > 0.05). After treatment, the VAS score lessened and the HSS score augmented the study group VAS score (1.76 ± 0.28); the score in the control group was lower compared to the control group (3.45 ± 0.36), and HSS scoring (83.48 ± 11.23) points higher compared to the control group (65.82 ± 10.44) points (P < 0.05). The ROM of knee joint augmented successively at the 1st, 2nd, 4th, and 8th week after treatment comparison between groups, the ROM of the knee joint in the study group at the 1st, 2nd, 4th, and 8th week was (49.47 ± 3.60)°, (64.38 ± 5.32)°, (86.93 ± 6.72)°, and (104.20 ± 9.11)°, is higher compared to the control group (46.53 ± 3.41)°, (61.52 ± 5.20)°, (78.42 ± 6.45)°, and (98.77 ± 8.67)° (P < 0.05). One day after operation, there exhibited no remarkable difference in whole blood viscosity low shear, plasma viscosity, and fibrinogen level (P > 0.05). However, there exhibited no remarkable difference in plasma viscosity and fibrinogen level at 1 day and 7 days after operation (P > 0.05). Seven days after operation, the whole blood viscosity, plasma viscosity, and fibrinogen in the study group were lower (P < 0.05). The probability of postoperative complications was compared. In the study group, there were 2 cases of limb swelling and pain, 1 case of joint stiffness, and no swelling and pain complicated with deep venous thrombosis, and the total incidence was 6.00%. In the control group, there were 5 cases of limb swelling and pain, 3 cases of joint stiffness, and 3 cases of swelling and pain complicated with deep venous thrombosis, with a total incidence of 22.00%. The incidence of adverse reactions in the study group was lower (χ 2 = 5.317 P < 0.05).

Conclusion

Early electroacupuncture combined with ERAS is of positive significance to the patients after TKA, which can reduce the pain, enhance the function of the knee joint, and promote the ROM of the knee joint, and can effectively shorten the first time out of bed and postoperative rehabilitation time and reduce whole blood viscosity low shear, plasma viscosity, and fibrinogen level, but the overall rehabilitation cost is high, and clinical application should be combined with the actual situation of patients.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial

BACKGROUND

We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic.

METHODS

Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention.

RESULTS

Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4).

CONCLUSION

A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic.

LEVEL OF EVIDENCE

1.

The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty

➤

There is a growing body of evidence implicating psychosocial factors, including anxiety, depression, kinesiophobia, central sensitization, and pain catastrophizing, as negative prognostic factors following total knee arthroplasty (TKA).

➤

Symptoms of anxiety and depression likely represent risk factors for negative outcomes in patients undergoing TKA. However, few studies have assessed the impact of preoperative interventions for these conditions on postoperative outcomes.

➤

The Tampa Scale of Kinesiophobia and the Central Sensitization Inventory have demonstrated value in the diagnosis of kinesiophobia and central sensitization. Higher preoperative indices of kinesiophobia and central sensitization predict worse patient-reported outcomes postoperatively.

➤

Although evidence is limited, cognitive-behavioral therapy for kinesiophobia and duloxetine for central sensitization may help to diminish the negative impact of these preoperative comorbidities. It is important to note, however, that outside the realm of TKA, cognitive-behavioral therapy has been recognized as a more effective treatment for central sensitization than medical treatment.

➤

Awareness of these issues will allow surgeons to better prepare patients regarding postoperative expectations in the setting of a comorbid psychosocial risk factor. Further research into the role of preoperative assessment and possible treatment of these conditions in patients undergoing TKA is warranted.

Combining goal setting and achievement with occupational therapy to improve pain, psychological factors and physical activity in patients after high tibial osteotomy: A non-randomized controlled study

Background

Psychological factors contribute to chronic pain and may lead to physical inactivity and poor functional outcomes.

Purpose

We conducted a non-randomized controlled study to evaluate the effectiveness of goal setting and achievement following occupational therapy (OT) intervention to improve pain, psychological factors, and physical activity among patients after high tibial osteotomy (HTO).

Method

We analyzed the data of 31 patients who underwent HTO, allocated into OT intervention and control groups. Goal achievement was encouraged through OT in the intervention groups; the control groups did not receive OT intervention. Outcome measures included the Canadian Occupational Performance Measure (COPM) score (before and after the OT intervention), walking pain, pain catastrophizing, anxiety, depression, pain self-efficacy, and physical activity level.

Results

OT significantly improved the COPM score, depression, and physical activity. At the final assessment, the depression score was lower while the step count and physical activity time were significantly higher in the intervention group than in the control group (p < 0.05).

Conclusion

Embedding goal setting and achievement as part of an OT intervention improved the outcomes after HTO.

Artificial neural network prediction of same-day discharge following primary total knee arthroplasty based on preoperative and intraoperative variables

AIMS

This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).

METHODS

Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.

RESULTS

The predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis.

CONCLUSION

Both ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols. Cite this article: Bone Joint J 2021;103-B(8):1358-1366.

Resilience and pain catastrophizing among patients with total knee arthroplasty: a cohort study to examine psychological constructs as predictors of post-operative outcomes

Background

Patients’ psychological health may influence recovery and functional outcomes after total knee arthroplasty (TKA). Pain catastrophizing, known to be associated with poor function following TKA, encompasses rumination, magnification, and helplessness that patients feel toward their pain. Resilience, however, is an individual's ability to adapt to adversity and may be an important psychological construct that supersedes the relationship between pain catastrophizing and recovery. In this study we sought to identify whether pre-operative resilience is predictive of 3-month postoperative outcomes after adjusting for pain catastrophizing and other covariates.

Methods

Patients undergoing TKA between January 2019 and November 2019 were included in this longitudinal cohort study. Demographics and questionnaires [Brief Resilience Scale (BRS), Pain Catastrophizing Scale (PCS), Knee injury and Osteoarthritis Outcome Score, Junior (KOOS, JR.) and Patient-Reported Outcomes Measurement Information System Physical and Mental Health (PROMIS PH and MH, respectively)] were collected preoperatively and 3 months postoperatively. Multivariable regression was used to test associations of preoperative BRS with postoperative outcomes, adjusting for PCS and other patient-level sociodemographic and clinical characteristics.

Results

The study cohort included 117 patients with a median age of 67.0 years (Q1–Q3: 59.0–72.0). Fifty-three percent of patients were women and 70.1% were white. Unadjusted analyses identified an association between resilience and post-operative outcomes and the relationship persisted for physical function after adjusting for PCS and other covariates; in multivariable linear regression analyses, higher baseline resilience was positively associated with better postoperative knee function (β = 0.24, p = 0.019) and better general physical health (β = 0.24, p = 0.013) but not general mental health (β = 0.04, p = 0.738).

Conclusions

Our prospective cohort study suggests that resilience predicts postoperative knee function and general physical health in patients undergoing TKA. Exploring interventions that address preoperative mental health and resilience more specifically may improve self-reported physical function outcomes of patients undergoing TKA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01772-2.

Perioperative predictability of unsatisfactory functional outcomes 6 months after hip arthroplasty

Background

Aiming at an early identification of patients with an unsatisfactory outcome after hip arthroplasty we investigated the pre-, intra- and early postoperative predictability.

Methods

Using logistic regression models at nine different time points we calculated the area under the curve of the receiver operating characteristic (ROC-AUC) to compare the predictability of an unsatisfactory outcome.

Results

The predictability of unsatisfactory outcomes increased significantly from a ROC-AUC (95% CI) of 0.73 (0.62-0.84) in the preoperative setting to 0.85 (0.77-0.94) on day 2 after surgery.

Conclusion

Most of the patients with unsatisfactory outcomes can be identified during the first days after surgery.

The virtue of optimistic realism - expectation fulfillment predicts patient-rated global effectiveness of total hip arthroplasty

BACKGROUND

Emerging evidence highlights the importance of preoperative expectations in predicting patient-reported outcomes of orthopedic surgeries. To date, it is still a matter of controversy whether patient satisfaction can be maximized by promoting either optimistic or realistic outcome expectations before surgery. Adjusting overly optimistic outcome expectancies in favor of a more realistic outlook on the limitations of total hip arthroplasty could reduce the risk of disappointment and lead to greater satisfaction with surgery outcomes. Our prospective cohort study was aimed at comparing the relative predictive influence of baseline expectations, expectation fulfillment and symptomatic improvement on the global effectiveness of total hip arthroplasty.

METHODS

Ninety patients (49 female, 41 male; mean age: 63 ± 12.87 years) fulfilled inclusion criteria and completed a comprehensive preoperative assessment comprising sociodemographic, clinical, functional and psychological phenotypes. Moreover, the strengths of preoperative expectations for improvements in eight pain-related and functional domains were recorded on a 5-point Likert-scale. At 12 months after surgery, patients were asked to rate perceived improvements in each of these domains as well as the global effectiveness of the total hip replacement on a 5-point Likert-scale. To evaluate the relative impact of preoperative expectations, symptom improvement and the fulfillment of expectations on the global effectiveness of surgery, a sequential multiple regression analysis was performed.

RESULTS

Compared with the actual improvement at 12-months follow-up, prior expectations had been overly optimistic in about 28% of patients for hip pain, in about 45% for walking ability and around 60% for back pain, independence in everyday life, physical exercise, general function social interactions and mental well-being. An optimistic hip pain expectation, walking ability at baseline and the fulfillment of expectations for walking ability, general function and independence in everyday life were found to independently predict global effectiveness ratings.

CONCLUSIONS

Positive expectation about pain and the fulfillment of expectations concerning functional domains predicted higher global effectiveness ratings. In line with many authors investigating the relationship between the fulfillment of expectations and satisfaction with medical interventions, we suggest that professionals should explicitly address their patients' expectations during the preoperative education and consultation.

Postoperative Psychosocial Factors in Health Functioning and Health-Related Quality of Life After Knee Arthroplasty: A 6-Month Follow up Prospective Observational Study

OBJECTIVE

Knee arthroplasty (KA) is an effective and cost-effective treatment for end-stage knee osteoarthritis. Despite high surgical success rates, as many as 25% of patients report compromised postoperative functioning, persistent pain, and reduced quality of life. The purpose of this study was to assess the predictive value of psychological factors in health functioning and quality of life, during a 6-month period after KA.

DESIGN

A prospective observational study.

SETTING

Surgery at two hospitals and follow-up was carried out through the domiciliary rehabilitation service.

SUBJECTS

In total, 89 patients (age 70.27 ± 7.99 years) met the inclusion criteria.

METHOD

A test battery composed of Health functioning associated with osteoarthritis (WOMAC), Health-related quality of life (EQ-5D-5L), Anxiety and Depression (HADS), Pain attitudes (SOPA-B), Pain catastrophizing (PCS), and Fear of Movement (TSK-11) was assessed at 1 week, and 1, 3, and 6 months after surgery. A mixed effects linear model was used to estimate the effect of time and covariates. An exploratory factor analysis was used to identify the number of dimensions underlying the group of psychological measurements.

RESULTS

In WOMAC model, anxiety level (F = 120.8), PCS (F = 103.9), depression level (F = 93.6) and pain score (F = 72.8) were the most influential variables. Regarding EQ-5D-5L model, anxiety level (F = 98.5), PCS (F = 79.8), depression level (F = 78.3) and pain score (F = 45) were the most influential variables. Pain score and the psychosocial variables of PCS, TSK, HADS-A, HADS-D, SOPA-B Emotion, SOPA-B Harm and SOPA-B Disability loaded in one single dimension.

CONCLUSIONS

Postoperative acute pain and psychosocial factors of pain catastrophizing, anxiety, depression, and pain attitudes might influence health functioning and quality of life during KA rehabilitation. Such factors could be gathered into one single dimension defined as pain-related psychologic distress.

Effect of Preoperative Modifiable Psychological and Behavioural Factors on Early Outcome Following Total Knee Arthroplasty in an Indian Population

BACKGROUND

Non-surgical factors have been found to have significant impact on outcome following Total Knee Arthroplasty (TKA). The study was conducted to know the independent effect of each of the four interacting psychological factors: anxiety, depression, pain catastrophizing and kinesiophobia on early outcome following TKA in an Indian population.

MATERIALS AND METHODS

104 consecutive patients undergoing TKA were included in the study and followed up at 6 weeks, 6 months and one year. Preoperatively, Hospital Anxiety and Depression Scale was used to diagnose and quantify anxiety and depression, pain catastrophizing and kinesiophobia were assessed using Pain Catastrophizing Scale and Tampa Scale for Kinesiophobia, respectively. Outcome was assessed on the basis of Knee Society Score and Knee Injury and Osteoarthritis Outcome Score. Regression analysis was done to know independent effect of each factor on outcome scores.

RESULTS

Nine (8.7%) patients were found to have undiagnosed psychopathology. The patients with psychopathologies were found to have significantly worse knee outcome scores on follow-up, although the rate of improvement in knee symptoms and function was not significantly different from those without psychopathology. The degree of Anxiety correlated with worse knee pain and stiffness up to 6 months while it correlated with poor knee function for a longer duration. The degree of depression and pain catastrophizing correlated with worse knee pain, stiffness and function at all visits while kinesiophobia didn't show correlation independent other factors.

CONCLUSION

Psychopathology was found to be associated poor knee outcome scores with degree of preoperative depression and pain catastrophizing as significant independent predictors as poor outcome, whereas the effect of degree of anxiety on knee pain and stiffness was found to wane over time. Kinesiophobia didn't show any independent correlation.

SUPPLEMENTARY INFORMATION

The online version of this article (10.1007/s43465-020-00325-x) contains supplementary material, which is available to authorized users.

Psychological and psychosocial predictors of chronic postsurgical pain: a systematic review and meta-analysis

Knowledge about psychological and psychosocial predictors of chronic postsurgical pain is important to identify patients at risk for poor outcomes. The objective of this systematic review with meta-analysis was to assess the effect of such predictors. A comprehensive search of the available literature on this topic was performed using the electronic databases PubMed, Scopus, Embase, and PsycInfo. Estimates of the effect of each predictor were extracted, and both a narrative synthesis and a quantitative synthesis of these estimates were performed. Multiple imputation was used to take into account the effect of nonsignificant estimates in case they were not reported by original studies. From a sample of 8322 records, 83 articles were included in the narrative synthesis and 41 studies were used to perform the meta-analyses. The narrative synthesis showed that evidence about the effect of psychological predictors is heterogeneous, with few expected predictors, such as optimism, state anxiety and psychological distress, consistently associated with chronic postsurgical pain. By contrast, the meta-analyses showed that state anxiety, trait anxiety, mental health, depression, catastrophizing and, to a lesser extent, kinesiophobia and self-efficacy have a weak but significant association with chronic postsurgical pain. In conclusion, this study showed that psychological predictors have a significant association with chronic postsurgical pain and that state anxiety is the most explicative one.

High kinesiophobia and pain catastrophizing in people with articular cartilage defects in the knee and associations with knee function

PURPOSE

The purpose of this study was to evaluate the extent to which individuals with knee articular cartilage defects (ACDs) have kinesiophobia and pain catastrophizing, and how these psychological factors relate to self-reported knee outcomes.

METHODS

Thirty-five individuals seeking surgical consultation for an ACD in the knee confirmed with 3.0T MRI and 18 controls without history of knee injury participated in the study. Kinesiophobia was measured with the Tampa Scale of Kinesiophobia (TSK), and scored using the modified 11-item (TSK-11) methods. Pain catastrophizing was measured with the Pain Catastrophizing Scale (PCS). Data were analyzed using descriptive statistics, independent t-tests, chi-squared tests and Spearman's correlation coefficients, as appropriate (α = 0.05).

RESULTS

Participants with ACDs reported higher TSK-11 scores (median 27 [IQR 25-29]) and higher PCS scores (median 10 [IQR 4-18]) than controls (median TSK-11 16 [IQR 14-17], p < 0.001; median PCS 0 [IQR 0-9], p < 0.001). Within those with knee ACDs, higher TSK-11 scores were associated with worse knee pain, function on activities of daily living, sports/recreation, and knee-related quality of life scores (rho = -0.38 to -0.61). Higher pain catastrophizing was associated with worse function with activities of daily living and knee-related quality of life (rho = -0.37 to -0.40).

CONCLUSIONS

Kinesiophobia and pain catastrophizing in people with knee ACDs were higher than controls. Higher kinesiophobia and pain catastrophizing were associated with worse function and quality of life. Further study of the impact of these psychological factors on outcomes and prognosis in people with knee ACDs is warranted.

The effects of patients' expectations on surgery outcome in total hip and knee arthroplasty: a prognostic factor meta-analysis

Patients' expectations are among the most frequently studied psychological prognostic factors in total knee and hip arthroplasty (TKA/THA). So far, however, evidence on the effect of patients' preoperative expectations on surgery outcome is inconclusive. Heterogeneity of expectation constructs and the use of psychometrically not evaluated measurement instruments have constituted major obstacles for the integration of the current literature. Using a theory-based model of expectation constructs , this meta-analysis set out to disentangle the conflicting results in the current literature. Systematic literature searches yielded k = 46 studies (N = 10,465) that reported associations of preoperative expectations with postoperative pain, functioning and disability, and satisfaction. Random effects meta-analysis revealed a robust small association (r = .16; 95% CI .13, .19) between patients' positive preoperative expectations and better postoperative outcomes. This effect did not differ between THA and TKA, different outcome categories and different follow-up periods. Studies using psychometrically evaluated expectation measures reported significantly higher effects (r = .19; 95% CI .16, .22). Whether this effect varies among different expectation constructs remains unclear. High-quality studies using validated, multidimensional expectation measures are needed to further understand the role of different expectation constructs in THA and TKA surgery.

Preoperative risk factors associated with chronic pain profiles following total knee arthroplasty

Background

One in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person‐centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles.

Methods

On the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified.

Results

Patients in the “lower average” and “lower worst” pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the “higher average” and “higher worst” pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes.

Conclusions

These risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients’ outcomes after TKA.

Significance statement

The present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.

The effects of kinesiophobia on outcome following total knee replacement: a systematic review

INTRODUCTION

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR.

MATERIALS AND METHODS

A primary search of electronic databases, grey literature, and trial registries was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Outcome measures were grouped into short (< 6 months), medium (6-12 months), and long term (> 12 months). Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials.

RESULTS

All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p < 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at 2 weeks [65.98 (SD = 14.51) versus 47.35 (SD = 14.48) p = 0.000], 4 weeks [88.20 (SD = 15.11) versus 57.65 (SD = 14.80) p = 0.000], and 6 months [105.33 (SD = 12.34) versus 85.53 (SD = 14.77) p = 0.000] post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme [TSK - 14.30 (SD = 0.80) versus - 2.10 (SD = 0.80) p < 0.001], an outpatient cognitive behavioural therapy (CBT) programme [TSK 27.76 (SD = 4.56) versus 36.54 (SD = 3.58)], and video-based psychological treatment [TSK 24 (SD = 5) versus 29 (SD = 5) p < 0.01].

CONCLUSIONS

Kinesiophobia negatively affects functional outcomes up until 1 year post-operatively, while active ROM is reduced up to 6 months post-procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

Is kinesiophobia a predictor of early functional performance after total hip replacement? A prospective prognostic cohort study

BACKGROUND

Considerable attention has been paid to the role of kinesiophobia with respect to knee prosthesis but it has not yet been studied as a prognostic factor of short-term functional performance following total hip replacement. The main purpose of the present study is to examine the possible predictors of early functional performance of patients undergoing total primary hip arthroplasty, including demographics as age, sex and body mass index, preoperative functional ability, type of anaesthesia, level of haemoglobin, pain and level of kinesiophobia before surgery. Secondly, we want to describe the main characteristics of the population with the highest levels of kinesiophobia.

METHODS

A prospective, prognostic cohort study was carried out. Patients undergoing primary hip replacement were recruited consecutively. The main outcome is the early functional performance achieved by patients after surgery and measured using the Iowa Level of Assistance (ILOA) scale on the fifth postoperative day. Preoperative kinesiophobia was measured by the Tampa Scale and the preoperative functional ability by the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The multivariate analysis was performed by the General Linear Model. The analysis of the population with high levels of kinesiophobia was conducted by identifying a cut-off of 40 compared to the Tampa Scale.

RESULTS

Statistical analysis was performed on 269 patients. The average ILOA score recorded was 19.5 (DS 8.3). The levels of kinesiophobia, showed an average score of 35.1 (7.8) and it was not associated with early functional performance. The independent predictive factors include age, sex and body mass index. Kinesiophobia high levels were recorded in 30% of the population and this population had a higher level of pre-operative WOMAC score.

CONCLUSIONS

Early functional performance after hip replacement surgery was not correlated with the level of kinesiophobia. Three significant factors that describe a population most at risk of not achieving optimal functional performance are increased age, being female and increase in body mass index. In the preoperative phase, high levels of kinesiophobia were associated with more impaired preoperative functional ability.

TRIAL REGISTRATION

Current Controlled Trials NCT02786121 , May 2016. Retrospectively registered.

Investigating the True Effect of Psychological Variables Measured Prior to Arthroplastic Surgery on Postsurgical Outcomes: A P-Curve Analysis

Patients' presurgical psychological profiles have been posited to predict pain and function following arthroplastic surgery of the hip and knee. Nevertheless, findings are conflicting, and this may be rooted in biased reporting that makes the determination of evidential value difficult. This ambiguity may have negative consequences for researchers and governmental agencies, as these rely on findings to accurately reflect reality. P-Curve analyses were used to establish the presence of evidential value and selective reporting in a sample of studies examining the effect of presurgical psychological predictors on outcomes following knee and hip arthroplastic surgery. A systematic search of the literature revealed 26 relevant studies. The examined sets of studies indicate that there is evidential value for the effect of depression on pain intensity and function, anxiety on pain intensity and function, pain catastrophizing on pain intensity, as well as the combined effects of all psychological predictors on pain intensity and function. The presence of evidential value was inconclusive for the effect of optimism on pain intensity. There were no signs that any results were influenced by biased reporting. The results highlight the importance of patients' psychological profiles in predicting surgical outcomes, which represent a promising avenue for future treatment approaches. PERSPECTIVE: The effects of P-hacking are difficult to detect and might be at the root of conflicting findings pertaining to the predictive properties of presurgical psychological variables on postsurgical outcomes. P-Curve analysis allows the determination of evidential value underlying these relationships and detection of P-hacking to ensure that findings are not the result of selective reporting.

Patient-Reported Outcome Measures (Pain, Function, and Quality of Life) After Aseptic Revision Total Knee Arthroplasty

BACKGROUND

Despite the growing frequency of revision total knee arthroplasty (rTKA), there is limited information regarding patient-reported outcome measures (PROMs) after that procedure. Therefore, the purpose of this study was to determine (1) PROM improvements in pain, function, quality of life (QOL), and global health and (2) predictors of PROMs for patients undergoing aseptic rTKA as determined using a multilevel model with patients nested within surgeons.

METHODS

A prospective cohort of 246 patients who underwent aseptic rTKA from January 2016 to December 2017 and had baseline and 1-year postoperative PROMs were analyzed. The most common surgical indications were aseptic loosening (n = 109), instability (n = 73), and implant failure (n = 64). The PROMs included in this study were the Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain, -Physical Function Short Form (PS), and -Quality of Life (QOL) as well as the Veterans Rand-12 (VR-12) Physical Component Summary (PCS) and Mental Component Summary (MCS). Multivariable linear regression models with patients nested within surgeons were constructed for predicting change in PROMs from baseline to 1 year.

RESULTS

The mean 1-year postoperative improvements in the KOOS-Pain and PS PROMs were 30.3 and 19.15 points, respectively, for the overall rTKA series. Improvement in the KOOS-Pain was associated with older age, baseline arthrofibrosis, lower baseline pain, and non-Medicare/Medicaid insurance and worsening of the scores was associated with multiple prior surgical procedures and instability. Improvement in the KOOS-PS was associated with baseline arthrofibrosis and female sex and worsening was associated with limited baseline function, an instability diagnosis, multiple prior surgical procedures, and increased hospital length of stay (LOS). Overall, the mean KOOS-QOL improved by 29.7 points. Although the mean VR-12 PCS improved, 54.9% of the patients saw no clinical improvement. Additionally, only 31.3% of the patients reported improvements in the VR-12 MCS. A multilevel mixed-effects model with patients/operations nested within surgeons demonstrated that the differences in the surgeons' results were minimal and explained only ∼1.86%, ∼1.12%, and ∼1.65% of the KOOS-Pain, KOOS-PS, and KOOS-QOL variance that was not explained by other predictors, respectively.

CONCLUSIONS

Overall, patients undergoing aseptic rTKA had improvements in pain, function, and QOL PROMs at 1 year. Although overall QOL improved, other global-health PROMs remained unchanged. The associations highlighted in this study can help guide the preoperative clinical decision-making process by setting expectations before aseptic rTKA.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biopsychosocial Characteristics of Patients With Chronic Pain Expecting Different Levels of Pain Relief in the Context of Multidisciplinary Treatments

OBJECTIVES

Evidence suggests that patients' expectations predict chronic pain treatment outcomes. Although patients vary in terms of expected pain relief, little is known about individual factors related to such variations. This study aims to investigate how patients with various levels of pain relief expectations differ on the basis of biopsychosocial baseline characteristics in the context of multidisciplinary chronic pain treatment.

MATERIALS AND METHODS

Data from 3110 individuals with chronic pain attending one of 3 multidisciplinary pain treatment centers were considered. Participants completed a self-reported measure of pain relief expectations and provided information pertaining to biological, psychological, and social variables.

RESULTS

A backward stepwise regression helped identify biopsychosocial variables that significantly predicted expected pain relief. Subsequent analyses suggest that patients reporting low, moderate, high, and very high expectations of pain relief differed significantly in terms of pain duration and depressive symptoms. Significant between-group differences were also found with regard to overall physical health, age, sex, and ethnicity.

DISCUSSION

Identifying characteristics related to different levels of pain relief expectations is a fundamental step in generating a more comprehensive understanding of how expectations can be of use in the successful management of chronic pain conditions.

Assessment of postoperative health functioning after knee arthroplasty in relation to pain catastrophizing: a 6-month follow-up cohort study

BACKGROUND

Knee arthroplasty (KA) is a typically successful surgical procedure commonly performed to alleviate painin participants with end-stage knee osteoarthritis. Despite its beneficial effects, a significant proportion of individuals with KA continue experiencing persistent pain and functional limitations. The purpose of this study was to assess the postoperative outcomes after KA in relation to postoperative pain catastrophizing.

METHODS

Participants were recruited at a domiciliary physiotherapy service, using a prospective, observational, hypothesis-generating cohort design. Participants were divided into two groups based on their Pain Catastrophizing Scale (PCS) total score (50th percentile), which resulted in high and low PCS groups. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, quality of life, walking speed, physical performance, range of motion, and pain were measured. Outcome measures were collected at baseline (1 week postoperatively) and at follow-up (1, 3, and 6 months postoperatively).

RESULTS

A total of 60 participants (21 total KA and 39 unicompartmental KA) were recruited. Individuals with a higher degree of pain catastrophizing showed significantly higher WOMAC total scores at every follow-up, indicating poorer health functioning (p < 0.01). Similarly, the high PCS group showed higher WOMAC pain, stiffness and disability subscale scores (p < 0.05), poorer quality of life (p < 0.01), and poorer physical performance (p < 0.05) at every follow-up. In addition, the high PCS group achieved a slower walking speed at baseline and at 3 months follow-up (p < 0.05), and a higher degree of pain at rest, on walking and on knee flexion at every follow-up (p < 0.01, p < 0.05 and p < 0.05, respectively) except for walking pain at 3 months follow-up. No significant differences were observed between groups in range of motion, except for active knee extension at the 6-month follow-up (p < 0.05). Effect size was large at 1 month follow-up in WOMAC total score (r = 0.578) and pain intensity during knee flexion (r = 0.529). Longitudinal analyses revealed different improvement trends during the rehabilitation process between groups, with a lack of significant improvements in the high PCS group between the 3- and 6-month follow-up in WOMAC total score, WOMAC pain, WOMAC disability, quality of life, physical performance, active knee extension and resting pain (p > 0.05).

CONCLUSION

The results of the present study suggest that participants with high postoperative pain catastrophizing might have poorer outcomes during the rehabilitation process after KA. Future work should seek to clarify if this relationship is causal.

Stability of Measures of Pain Catastrophizing and Widespread Pain Following Total Knee Replacement

OBJECTIVE

Pain catastrophizing and widespread pain are predictors of pain chronicity/severity. Gaps remain in our understanding of the extent to which each is a stable (trait) or dynamic (state) variable. We undertook this study to assess the stability of each variable from before to after total knee replacement (TKR) and whether changes are explained by pain improvements.

METHODS

We used data from a prospective study of TKR recipients ages ≥40 years. Questionnaires included body pain diagrams assessing widespread pain, the Pain Catastrophizing Scale (PCS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. We divided subjects into widespread pain groups (0 versus 1-2 versus ≥3 pain regions) and into low and high PCS score groups (<16 versus ≥16). We assessed changes in group membership from pre-TKR to 12 months post-TKR, then compared these changes between subjects with most and least WOMAC pain improvement.

RESULTS

A total of 176 subjects completed scales at both time points; 64% were female, the mean age was 66 years, and baseline median WOMAC pain score was 40. In all, 71% of subjects in the high PCS score group improved to join the low PCS score group at follow-up. While 73 subjects (41%) changed widespread pain group, they were similarly likely to worsen and to improve. We found a statistically significant positive association of improvement in WOMAC pain score with improvement in PCS score (r = 0.31), but not widespread pain (r = -0.004).

CONCLUSION

The PCS score reflects state-like aspects of catastrophizing that diminish along with pain. In contrast, widespread pain scores worsened and improved equally often, regardless of knee pain relief. The findings urge caution in interpreting PCS score and widespread pain as trait measures in musculoskeletal research.

Influence of Peripartum Expectations, Mode of Delivery, and Perineal Injury on Women's Postpartum Sexuality

BACKGROUND

Sexual health has been identified as an important factor for postpartum quality of life. Although pregnancy-related changes in anatomy and metabolism return to their prepregnancy state, female sexual function may not be at the level it was before birth because of physical and psychological changes.

AIM

The goal of our study was to explore the influence of the mode of delivery, perineal injury, and peripartum expectations on postpartum sexual function.

METHODS

Between 2013 and 2018, 522 women were enrolled in this prospective investigation. At time of recruitment during the peripartum hospitalization, patients completed a standardized questionnaire addressing expectations concerning postpartum sexuality with focus on expected influence of the mode of delivery. Sexual function was evaluated using the Female Sexual Function Index (FSFI) and Sexual Activity Questionnaire (SAQ) at time of recruitment to evaluate baseline sexual function (4 weeks before pregnancy). Follow-up assessments were conducted at 3, 6, and 12 months postpartum.

OUTCOMES

Peripartum expectations, influence of the mode of delivery, and perineal injury were analyzed for their impact on women's sexual function within 12 months postpartum by repetitive FSFI and SAQ assessments.

RESULTS

A total of 522 women with 263 spontaneous vaginal deliveries, 41 operative vaginal deliveries, and 218 cesarean sections were analyzed. Although the data demonstrate a significant postpartum decline in sexual function at 3 and 6 months postpartum, sexual functioning converges to baseline prepregnancy values 12 months postpartum. This observation was independent of the mode of delivery and perineal injuries with no significant between-group differences at any of the analyzed time points. Apart from breastfeeding, for which negative anticipations resulted in impaired sexuality, women's expectations (pertaining to quantity and quality of female orgasm, partner's sexuality, fear of altered sexuality, frequency of intercourse, the mode of delivery) do not influence female sexual function at 12 months postpartum.

CLINICAL IMPLICATIONS

Deciphering the potential influence of patient expectations as well as pregnancy- and childbirth-related aspects on female postpartum sexuality will help in the effort to improve women's postpartum sexual health.

STRENGTHS & LIMITATIONS

As a strength of this study, postpartum sexuality was independently assessed with 2 different scoring systems (FSFI and SAQ). Limitations include that our follow-up is incomplete and amounts to about 2-thirds of patients who were initially recruited.

CONCLUSION

The mode of delivery and perineal trauma do not influence women's postpartum sexual function. With the exception of breastfeeding, peripartum expectations do not result in altered sexual functioning at 12 months postpartum. Spaich S, Link G, Alvarez SO, et al. Influence of Peripartum Expectations, Mode of Delivery, and Perineal Injury on Women's Postpartum Sexuality. J Sex Med 2020;17:1312-1325.

Psychosocial predictors of outcomes up to one year following total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) aims to relieve pain and improve physical functioning of the knee, however, some patients continue to experience pain and impaired function following TKA which cannot be explained by surgical and implant factors. Psychological factors may influence the outcomes of TKA. The aim of this prospective study was to examine the psychosocial factors that predicted pain, stiffness and physical functioning up to one year following TKA.

METHODS

One hundred and two patients completed pre-operative and one-year questionnaires which assessed a wide range of psychosocial and sociodemographic factors prior to surgery. The Oxford Knee Score (OKS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain, Stiffness and Physical Functioning subscales were used as outcome measures. Pearson correlation analysis and multiple linear regression were conducted to examine relationships between predictor and outcome variables.

RESULTS

Regression analysis showed that regarding variance in WOMAC outcome measures post TKA, our model predicted 31% for physical functioning, 25% for pain and 29% for stiffness at one year. Regarding variance in OKS post TKA, the model predicted 36% at one year. Greater levels of depressive symptoms and neuroticism and worse pre-operative scores significantly predicted poorer outcomes.

CONCLUSIONS

The findings indicate that pre-operative psychosocial factors are important in understanding outcomes of TKA. Psychosocial factors could be considered during pre-operative assessment. Further research conducted on psychological interventions is needed within this population to determine whether early and one-year outcomes can be improved.