Effects of bariatric surgery on joint pain: a review of emerging evidence

Differences in Psychological Health and Weight Loss after Bariatric Metabolic Surgery between Patients with and without Pain Syndromes

PURPOSE

Chronic pain and obesity often co-occur, negatively affecting one another and psychological wellbeing. Pain and psychological wellbeing improve after bariatric metabolic surgery (BMS), however, it is unknown whether psychological wellbeing improves differently after weight loss between patients with and without chronic pain. We investigated whether weight loss is associated with greater psychological wellbeing and functioning change after BMS, comparing patients with and without preoperative pain syndromes.

METHODS

Depression, health-related quality of life, self-esteem, self-efficacy to exercise and controlling eating behaviours, physical activity, and food cravings were measured before and 24 months after BMS among 276 patients with obesity. The presence of preoperative chronic pain syndromes was examined as a moderator for the relationship between 24-month weight loss and changes in psychological outcomes.

RESULTS

Chronic pain syndromes were present among 46% of patients. Weight loss was associated with greater improvement in health-related quality of life, self-efficacy to exercise and controlling eating behaviours, self-esteem and greater amelioration in food cravings. Pain syndromes only moderated negatively the relationship between the postoperative weight loss and change in self-efficacy to control eating behaviours (b = -0.49, CI [-0.88,-0.12]).

CONCLUSION

Patients with and without chronic pain showed similar improvements in weight and psychological wellbeing and behaviours after BMS. The relationship between weight loss and the improvement of self-efficacy to control eating behaviours was weaker among patients with chronic pain syndrome. Further work, measuring pain severity over time, is needed to shed light on the mechanism underlying pain and postoperative change in psychological wellbeing and weight loss.

Surgical Interventions for the Management of Obesity-Related Joint Pain: A Narrative Review

Obesity-related joint pain is a common and debilitating condition that significantly impacts the quality of life, primarily due to the excess weight straining the joints. This results in inflammation and degeneration, which can cause pain, stiffness, and difficulty moving. We aimed to comprehensively review the literature discussing surgical interventions for obesity-related joint pain. We searched across databases (PubMed, Scopus, and Cochrane Library) to identify studies published between 2000 and 2023 that assessed surgical interventions for obesity-related joint pain. This review highlights the complex interplay of mechanical, inflammatory, and metabolic factors contributing to joint pain in obese individuals, highlighting both surgical and non-surgical interventions. Non-surgical interventions include weight loss, exercise, physical therapy, and medications. Surgical interventions include bariatric surgery and joint replacement surgery. Bariatric surgery significantly reduces body weight and improves the quality of life outcomes; however, multiple studies have found no improvement or worsening of joint pain post-surgery. Total joint arthroplasty has demonstrated good improvement in pain and function outcomes based on recent meta-analyses, although risks of complications are higher in obese patients. The treatment choice for obesity-related joint pain depends on the individual patient's circumstances. Non-surgical interventions are usually the first line of treatment. However, if these interventions are not effective, surgical interventions may be an option.

The effectiveness of weight loss programs for low back pain: a systematic review

BACKGROUND

Low back pain has been associated with obesity or with being overweight. However, there are no high-quality systematic reviews that have been conducted on the effect of all types of weight loss programs focused on individuals with low back pain. Therefore, the present systematic review aims to evaluate the effectiveness of weight loss programs in reducing back pain and disability or increasing quality of life for individuals experiencing low back pain.

MATERIALS AND METHODS

Searches for relevant studies were conducted on CINAHL, Web of Science, Ovid Medline, Ovid Embase and AMED. Studies were included if they were randomized controlled trials, non-randomized studies of intervention or quasi-experimental designs evaluating a weight loss program for persons with low back pain aimed at decreasing back pain and disability. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool was used to evaluate individual studies and GRADE was used to summarize the quality of the evidence. The review was prospectively registered; PROSPERO#: CRD42020196099.

RESULTS

Eleven studies (n = 689 participants) including one randomized controlled trial, two non-randomized studies of intervention and eight single-arm studies were included (seven of which evaluated bariatric surgery). There was low-quality evidence that a lifestyle intervention was no better than waitlist for improving back pain and very low-quality evidence from single-arm studies that back pain improved from baseline after bariatric surgery. Most studies included were of poor quality, primarily due to selection bias, uncontrolled confounders, and lack of blinding, limiting the quality of evidence.

CONCLUSION

There is very low-quality evidence that weight loss programs may improve back pain, disability, and quality of life in patients with LBP, although adherence and maintenance are potential barriers to implementation.

A Meta-analysis of the Impact of Bariatric Surgery on Back Pain

BACKGROUND

The functional aspects of obesity are increasingly recognised as a significant clinical and public health concern. Whilst there is substantial evidence for the beneficial impact of bariatric surgery on metabolic and cardiovascular disease, there is less understanding of the quantitative effect of bariatric surgery on back pain. The aim of this meta-analysis was to assess the impact of bariatric surgery on back pain in reported studies.

METHODS

Medline, Embase, conference proceedings and reference lists were searched for studies assessing quantitative back pain scores both before and after bariatric surgery. The primary outcome was visual analogue score for back pain pre- and post-bariatric surgery. Secondary outcomes were change in BMI, SF-36 quality of life scores and Oswestry Disability Index (ODI) scores. Weighted mean differences (MD) were calculated for continuous outcomes.

RESULTS

Seven studies were included in the analysis of 246 patients undergoing bariatric surgery. Mean study follow-up was between 3 and 24 months. There was a statistically significant reduction in visual analogue score for back pain following bariatric surgery (MD - 3.01; 95% CI - 4.19 to - 1.89; p < 0.001). Bariatric surgery also resulted in statistically significant improvements in BMI, SF-36 score and ODI score.

CONCLUSIONS

Bariatric surgery produces significant and quantifiable reductions in back pain. This may be commuted through reductions in axial load or improved quality of life, but further studies will improve understanding and aid preoperative counselling.

Perioperative Outcomes of Primary Bariatric Surgery in North-Western Europe: a Pooled Multinational Registry Analysis

Introduction

The global prevalence of obesity has increased in recent decades, and bariatric surgery has become a part of the treatment algorithm of obesity. National high-quality registries enable large-scale evaluations of the use and outcome of bariatric surgery and may allow for improved knowledge. The main objective was to evaluate the rate and type of complications after primary bariatric surgery in three North-Western European countries using nationwide registries.

Materials and Methods

Data from three registries for bariatric surgery were used (January 2015–December 2016). All registries have nationwide coverage with data on patient characteristics, obesity-related diseases, surgical technique, complications, grading of complications, reinterventions, readmissions, and mortality. Eligibility criteria for bariatric surgery were similar and included body mass index of ≥ 40.0 or ≥ 35.0 kg/m², with one or more obesity-associated diseases.

Results

A total of 35,858 procedures (32,177 primary) were registered. The most common procedure was gastric bypass in the Netherlands (78.9%) and Sweden (67.0%), and sleeve gastrectomy in Norway (58.2%). A total of 904 (2.8%) patients developed major complications after primary surgery and 12 patients (0.04%) died within 30 days. Total number of complications between the registries were comparable (p = 0.939). However, significant differences were seen for Clavien-Dindo Classification grades IIIb and IV (p < 0.001). Pooled readmission rates were 4.3% (n = 1386).

Discussion

Bariatric surgery is safely performed in the three evaluated countries. Standardization of registries and consensus of variables are essential for international comparison and may contribute to improved quality of treatment across nations.

Predictors of Risk and Success of Obesity Surgery

BACKGROUND

Obesity surgery has proven successful for weight loss and the resolution of comorbidities. There is, however, little evidence on its success and the risk of complications when considering age of onset of obesity (AOO), years of obesity (YOO), preoperative body mass index (BMI), Edmonton obesity staging system (EOSS) score, and age as possible predictors of weight loss, the resolution of comorbidities, and the risk of complications.

METHODS

Patients who underwent Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) from a prospective database were analyzed. Multiple regression analyses were used to predict comorbidities and their resolution, percentage excess weight loss (%EWL) and total weight loss (%TWL) 12 months after surgery, and the risk of complications using the predictors AOO, YOO, age, EOSS, and BMI.

RESULTS

180 patients aged 46.8 ± 11.1 years with a preoperative BMI 49.5 ± 7.5 were included. The number of preoperative comorbidities was higher with older age (β = 0.054; p = 0.023) and a greater BMI (β = 0.040; p = 0.036) but was not related to AOO and YOO. Patients with AOO as a child or adolescent were more likely to have an EOSS score of ≥2. Greater preoperative BMI was negatively associated with %EWL (β = -1.236; p < 0.001) and older age was negatively associated with %TWL (β = -0.344; p = 0.020). Postoperative complications were positively associated with EOSS score (odds ratio [OR] 1.147; p = 0.042) and BMI (OR 1.010; p = 0.020), but not with age. AOO and YOO were not related to postoperative outcome.

CONCLUSION

Greater BMI was associated with a lower %EWL and age was associated with a low %TWL. YOO and AOO did not influence outcome. Age, BMI, and EOSS score were the most important predictors for risk and success after obesity surgery. Surgery should be performed early enough for optimal outcomes.

Consequences of bariatric surgery on outcomes in rheumatic diseases

Obesity is associated with numerous comorbidities including some rheumatic conditions. Through adipose-derived inflammation, obesity has been shown to induce increased initiation, progression, and worse responses on outcomes of rheumatic diseases. Bariatric surgery is being increasingly used thanks to its positive effects on major comorbidities such as type 2 diabetes mellitus and hypertension. Consequently, surgically induced weight and adipose tissue losses might play a role in the course of rheumatic conditions. The present narrative literature review aims to provide rheumatologists with an update on both the positive and negative effects of bariatric surgery on the rheumatic outcomes reported in the literature. Current evidence seems to show improved outcomes in obese populations with rheumatic disorders after bariatric surgery. However, rigorous prospective controlled studies with long follow-up are needed. Bariatric procedures have deleterious effects on bone and are associated with an increased risk of fractures.

Weight loss changed gait kinematics in individuals with obesity and knee pain

BACKGROUND

Obesity is a mechanical risk factor for osteoarthritis. In individuals with obesity, knee joint pain is prevalent. Weight loss reduces joint loads, and therefore potentially delays disease progression; however, how the knee joint responds to weight loss in individuals with obesity and knee pain is not clear.

RESEARCH QUESTION

To assess the effect of weight loss on knee joint kinematics during gait in individuals with obesity and knee pain.

METHODS

We recruited individuals with obesity (BMI ≥ 35) and knee pain who were participating in a weight loss program which included bariatric surgery or medical management. At baseline and 1 year follow-up, participants walked on a treadmill, and their knee joint kinematics were assessed using a dual-fluoroscopic imaging system and subject-specific magnetic resonance imaging knee joint models. Gait changes were represented by change in range of tibiofemoral motion, i.e., excursions in flexion-extension, adduction-abduction, internal-external rotation, anterior-posterior translation, medial-lateral translation, and superior-inferior translation during gait.

RESULTS

Twelve individuals with obesity and knee pain completed the gait analysis at baseline and 1 year follow-up. Participants lost on average 10.4% (standard deviation: 17.2%) of their baseline body weight. Reduction in body weight was associated with increased range of flexion-extension (r = -0.75, p < 0.01) and decreased range of adduction-abduction (r = 0.60, p = 0.04) during gait. The reduction in body weight was also associated with self-reported pain decrease (r = 0.62, p = 0.04); however, the change in pain was not significantly associated with kinematic changes.

SIGNIFICANCE

Weight loss was associated with improved gait kinematics in the sagittal and frontal planes. The change in gait pattern in individuals with obesity and knee pain was not associated with the change in pain given a reduction in body weight.

Functional impairment in obesity: a focus on knee and back pain

SUMMARY Cross-sectional and longitudinal evidence strongly indicate that obesity is related to physical impairment and joint pain, particularly in the lumbar spine, sacroiliac and knee joints. What is most disturbing is that obese children under 15 years are now reporting joint pain and cannot perform functional tasks as well as their nonobese counterparts. As the prevalence of obesity rises, so do the rates of musculoskeletal disease and physical dysfunction. Functional tasks that involve supporting or transferring body weight are typically painful and difficult to perform. Of most concern is that some of these tasks are simply impossible depending on the severity of obesity. As a consequence, the individual's quality of life suffers. A BMI of 35 kg/m(2) is emerging as the threshold at which functional impairment rates rise dramatically. To restore functional independence and optimize functional gains over the long term, a combination of treatments for the obese patient with joint pain may be effective. The initial use of physical therapy, pain medications or joint viscosupplementation, coupled with diet, exercise, or bariatric surgery are options for weight loss and reduction of pain symptoms. Irrespective of age, weight loss can reduce or eliminate joint pain. As body weight is reduced, so should the reliance on medication with a concomitant improvement in functional mobility.

Kinesiophobia and fear-avoidance beliefs in overweight older adults with chronic low-back pain: relationship to walking endurance--part II

OBJECTIVE

This study determined whether kinesiophobia levels were different among older adults with chronic low back pain (LBP) and varying body mass index and whether kinesiophobia predicted perceived disability or walking endurance.

DESIGN

This study was a secondary analysis from a larger interventional study. Older adults with obesity with LBP (N = 55; 60-85 yrs) were participants in this study. Data were stratified on the basis of body mass index: overweight (25-29.9 kg/m), obese (30-34.9 kg/m), and severely obese (35 kg/m). The participants completed a battery of surveys (the modified Tampa Scale of Kinesiophobia [TSK-11], the Fear-Avoidance Beliefs Questionnaire, the Pain Catastrophizing Scale, and the perceived disability measures of the Oswestry Disability Index and the Roland Morris Disability Questionnaire). Walking endurance time was captured using a symptom-limited graded walking treadmill test. The peak LBP ratings were captured during the walk test.

RESULTS

Walking endurance times did not differ by body mass index group, but the peak LBP ratings were higher in the moderately and severely obese groups compared with the overweight group (3.0 and 3.1 vs. 2.1 points; P < 0.05). There was no difference in the kinesiophobia scores (the TSK-11, the Pain Catastrophizing Scale, and the Fear-Avoidance Beliefs Questionnaire work and activity subscores) or the perceived disability scores (the Oswestry Disability Index and the Roland Morris Disability Questionnaire). However, adjusted regression analyses revealed that the TSK-11 scores contributed 10%-21% of the variance of the models pain with walking and perceived disability caused by back pain. Kinesiophobia was not a significant contributor to the variance of the regression model for walking endurance.

CONCLUSIONS

In the older population with obesity with LBP, the TSK-11 might be a quick and simple measure to identify patients at risk for poor self-perception of functional ability. The TSK and the Oswestry Disability Index may be quick useful measures to assess initial perceptions before rehabilitation. Kinesiophobia may be a good therapeutic target to address to help affected older adults with obesity fully engage in therapies for LBP.

Obesity and weight loss in the treatment and prevention of osteoarthritis

Obesity is associated with an increasing prevalence of musculoskeletal complaints and pain. Obesity is a major risk factor for osteoarthritis (OA), and pain can manifest in load-bearing and nonload-bearing joints. The lumbar spine and the knee are 2 primary sites for pain onset in the obese patient. Irrespective of the weight loss method, reduction of body fat can lower the mechanical and inflammatory stressors that contribute to OA. Single or combined methods of weight loss including exercise, dietary modification, medications, and bariatric surgery are associated with lower joint pain and increased physical function. Methods of weight loss or maintenance in early years may reduce the life exposure of joints to the obesity induced stressors on load bearing joints.

Health claims assessment in the field of joint and cartilage: a consensus viewpoint of the Group for the Respect of Ethics and Excellence in Science

INTRODUCTION

In 2006, the European Parliament and Council issued a regulation (No. 1924/2006) for the nutrition and health claims made on foods, including food supplements. According to the regulation, the use of nutrition and health claims shall only be permitted if the substance in respect of which the claim is made has been shown to have a beneficial nutritional or physiological effect. In the field of joint and cartilage health, there is no clear scientific-based definition of the nature of such a beneficial nutritional or physiological effect. The objective of this paper is to scientifically define the possible content of health claims related to joint and cartilage health and to provide scientific guidelines for the design of clinical studies which need to be adopted to substantiate such health claims.

METHODS

Literature review up to September 2011 followed by a consensus expert discussion organized by the Group for the Respect of Ethics and Excellence in Science (GREES).

RESULTS

In line with the general principles of the PASSCLAIM and the Codex recommendations, the GREES identified four acceptable health claims related to joint and cartilage health based on the effects on discomfort, joint and cartilage structural integrity or risk factors for joint and cartilage diseases. The GREES considers that randomized controlled trials on a relevant outcome is the best design to assess health claims. Moreover, animal studies could also be of interest to substantiate some health claims, to assess the clinical relevance of endpoints used in human studies or to extrapolate data obtained in patients to the target (apparently) healthy population.

CONCLUSION

According to the methodology and biomarkers used in the study and whether or not additional animal studies are provided to support the claim, various health claims can be acceptable in the field of joint and cartilage health.

Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery

BACKGROUND

Joint pain is a common musculoskeletal complaint of morbidly obese patients that can result in gait abnormalities, perceived mobility limitations, and declining quality of life (QOL). It is not yet known whether weight loss 3 months after bariatric surgery can induce favorable changes in joint pain, gait, perceived mobility, and QOL. Our objectives were to examine whether participants who had undergone bariatric surgery (n = 25; laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding) demonstrate improvements in joint pain, gait (speed, stride/step length, width of base of support, toe angles, single/double support, swing and stance time, functional ambulatory profile), mobility, and QOL by 3 months compared with nonsurgical controls (n = 20). The setting was an orthopedics laboratory at a university hospital in the United States.

METHODS

The present study was a prospective, comparative study. Numeric pain scales (indicating the presence and severity of pain), mobility-related surveys, and the Medical Outcomes Study short-form 36-item questionnaire (SF-36) were completed, and gait and walking speed were assessed at baseline and at month 3.

RESULTS

The bariatric group lost an average of 21.6 ± 7.7 kg. Significant differences existed between the 2 groups at month 3 in step length, heel to heel base of support, and the percentage of time spent in single and double support during the gait cycle (all P <.05). The severity of low back pain and knee pain decreased by 54% and 34%, respectively, with no changes in the control group (P = .05). The walking speed increased by 15% in the bariatric group (108-123 cm/s; P <.05) but not in the control group. Compared with the control group, fewer bariatric patients perceived limitations with walking and stair climbing by month 3. The bariatric group had a 4.8-cm increase in step length, 2.6% increase in single support time during the gait cycle, and 2.5-cm reduction in the base of support (all P <.05). The SF-36 physical component scores increased 11.8 points in the bariatric group compared with the control group, which showed no improvement by month 3 (P <.0001).

CONCLUSIONS

Improvements in some, but not all, gait parameters, walking speed, and QOL and of perceived functional limitations occur by 3 months after a bariatric procedure.

Impact of bariatric surgery on comorbidities

Published data show that bariatric surgery not only leads to significant and sustained weight loss but also resolves or improves multiple comorbidities associated with morbid obesity. Evidence suggests that the earlier the intervention the better the resolution of comorbidities. Patients with metabolic syndrome and comorbidities associated with morbid obesity should be promptly referred for consideration for bariatric surgery earlier in the disease process.