Psychological factors associated with short-term recovery from total knee replacement

Control beliefs as mediators between education and quality of life in patients with breast, prostate, colorectal, and lung cancer: a large register based study

OBJECTIVE

Control beliefs have been found to influence adaption to a cancer diagnosis. This study explored interrelationships among education, control beliefs, and health-related quality of life (HRQoL) in patients with breast, prostate, colorectal, and lung cancer and tested weather control beliefs act as mediators.

METHODS

Six hundred and five patients with breast (n = 205), prostate (n = 205), colorectal (n = 124), and lung (n = 71) cancer from two German cancer registries answered standardized questionnaires. Response rate was 54%. HRQoL was assessed with the EORTC QLQ-C30 core questionnaire and control beliefs (internal, external, and fatalistic) were evaluated using the IPC-questionnaire. Education was measured on a scale ranging from 1 to 8. Data were analyzed using multiple mediation models.

RESULTS

There was a positive correlation between education and HRQoL. Internal beliefs were positive and external beliefs were negative correlated with HRQoL. Internal control beliefs mediated the relationship between education and global health-related quality of life (.299, CI .122, .531), physical functioning (.272, CI .110, .486), emotional functioning (.325, CI .120, .578), and pain (-.288, CI - .558, - .094). External and fatalistic control beliefs did not act as mediators.

CONCLUSION

Patients with low education feel they have less control over their cancer disease and consequently a poorer health-related quality of life.

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.

The Effect of Duloxetine on Mechanistic Pain Profiles, Cognitive Factors, and Clinical Pain in Patients with Painful Knee Osteoarthritis - A Randomized, Double-Blind, Placebo-Controlled, Crossover Study

BACKGROUND

Duloxetine is indicated in the management of pain in osteoarthritis. Evidence suggests that duloxetine modulate central pain mechanisms and cognitive factors, and these factors are assumed contributing to the analgesic effect. This proof-of-mechanism, randomized, placebo-controlled, crossover, double-blinded trial evaluated the effect of duloxetine on quantitative sensory testing (QST), cognitive factors, and clinical pain in patients with osteoarthritis and to predict the analgesic effect.

METHODS

Twenty-five patients completed this cross-over study with either 18-weeks duloxetine (maximum 60 mg/daily) followed by placebo or vice-versa. Pressure pain thresholds, temporal summation of pain, and conditioned pain modulation were assessed using cuff algometry. The Hospital Anxiety and Depression Scale and the Pain Catastrophizing Scale evaluated cognitive factors. Clinical pain was assessed using Brief Pain Inventory and Western Ontario and McMaster Universities Osteoarthritis Index. Linear regression models were used to predict the analgesic effect of duloxetine.

RESULTS

Depending on the clinical pain outcome, 40-68% of patients were classified as responders to duloxetine. Linear regression models predicted the analgesic effect (predictive value of 45-75% depending on clinical pain outcome parameter) using a combination of pre-treatment QST parameters, cognitive factors, and clinical pain. No significant changes were found for QST, cognitive factors, or clinical pain on a group level when comparing duloxetine to placebo.

CONCLUSION

A combination of pre-treatment QST, cognitive factors, and clinical pain was able to predict the analgesic response of duloxetine. However, in this relatively small study, duloxetine did not selectively modulate QST, cognitive factors, or clinical pain intensity when compared with placebo.

Patient beliefs about who and what influences their hip and knee osteoarthritis symptoms and progression

BACKGROUND

Osteoarthritis management aims to reduce pain and improve function. Many factors affect whether patients follow recommended strategies. Locus of control refers to individual beliefs around who and what influences health. Locus of control is related to the treatment strategies patients prefer. Currently, no studies explore locus of control in non-surgical management of osteoarthritis.

OBJECTIVES

To explore patients' beliefs about the influences on their osteoarthritis symptoms and disease progression.

METHODS

Semi-structured interviews were conducted with individuals experiencing self-reported hip and/or knee osteoarthritis who had at least one joint that had not undergone replacement surgery. We used a qualitative description approach and the Braun and Clarke method for thematic analysis. Participants' locus of control classifications-internal, chance, doctors, or other people-were based on the Multidimensional Health Locus of Control (MHLC) Scales Form C score.

RESULTS

Locus of control was discussed in relation to aetiology, progression, and symptoms. Participants' opinions varied on whether their osteoarthritis progression could be influenced. 46% of participants attributed control to other people. Most participants believed that a previous injury had caused their osteoarthritis and that both themselves and others had some influence over their osteoarthritis symptoms, regardless of their locus of control classification.

CONCLUSION

This research highlights the need for education about: the aetiology of osteoarthritis, the link between management and progression, and patient management of osteoarthritis. Further research is required to discern why expected patterns were not observed between participants' beliefs and locus of control classifications.

Pain Catastrophizing, Self-reported Disability, and Temporal Summation of Pain Predict Self-reported Pain in Low Back Pain Patients 12 Weeks After General Practitioner Consultation: A Prospective Cohort Study

OBJECTIVES

Patients with low back pain (LBP) often demonstrate pain sensitization, high degree of pain catastrophizing, and psychological distress. This study investigated whether pain sensitization mechanisms, the Pain Catastrophizing Scale (PCS), and Start Back Screening Tool were associated with pain in recurrent LBP patients 12 weeks after consulting their general practitioner (GP).

MATERIALS AND METHODS

In 45 LBP patients, pressure pain thresholds, temporal summation of pain (TSP), conditioned pain modulation (CPM), the Roland Morris Disability Questionnaire (RMDQ), and the PCS were assessed before consultation. Patients were classified into low to medium or high risk of poor prognosis on the basis of the Start Back Screening Tool. Worst pain within the last 24 hours was assessed on a visual analogue scale (VAS) at inclusion and 12 weeks after GP consultation.

RESULTS

VAS scores were reduced after 12 weeks in the low-to-medium (N=30, P<0.05), but not the high-risk group (N=15, P=0.40). RMDQ was reduced after 12 weeks (P<0.001), but with no difference between the groups. PCS was reduced in the low-to-medium and the high-risk group (P<0.05). TSP was significantly higher at follow-up in the high-risk group compared with the low-to-medium-risk group (P<0.05). A linear regression model explained 54.9% of the variance in VAS scores at follow-up utilizing baseline assessments of TSP, RMDQ, and PCS.

DISCUSSION

This study indicate that patients with LBP and high self-reported disability, high pain catastrophizing, and facilitated TSP assessed when consulting the GP might predictive poor pain progression 12 weeks after the consultation.

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.

Psychosocial Determinants of Total Knee Arthroplasty Outcomes Two Years After Surgery

OBJECTIVE

To evaluate the association of preoperative psychosocial and demographic factors with total knee arthroplasty (TKA) outcomes and satisfaction in patients with osteoarthritis (OA) of the knee at 24 months after surgery.

METHODS

A prospective cohort study of patients undergoing TKA was conducted. Outcome measures included: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form 36 (SF-36) scores at baseline and 24 months after surgery, and patient satisfaction with TKA at 24 months. Linear regression models were performed to evaluate the association of preoperative psychosocial determinants (ie, Medical Outcome Study Social Support Scale; Depression, Anxiety, and Stress Scale; Brief COPE inventory, The Life Orientation Test-Revised; Multidimensional Health Locus of Control; and Arthritis Self-Efficacy Scale) on outcomes.

RESULTS

We included 178 patients. Increasing WOMAC pain scores at 24 months were associated with increasing age and body mass index (BMI); low tangible social support and low optimism were associated with higher levels of pain (R2 = 0.15). A decrease in WOMAC function scores was also associated with older age and higher BMI; low tangible support, increased stress, and low optimism were also associated with worse function (R2 = 0.22). When evaluating quality of life, lower SF-36 physical functioning scores at 24 months were associated with age, high BMI, and comorbidity (R2 = 0.34). Lower SF-36 mental functioning scores were associated with depression and low optimism (R2 = 0.38). Having a dysfunctional style of coping was associated with lower satisfaction with surgery after 24 months (adjusted R2 = 0.12).

CONCLUSION

Psychosocial factors, such as tangible support, depression, dysfunctional coping, and optimism, were associated with pain, function, and satisfaction 2 years after TKA. Perioperative programs identifying and addressing psychosocial problems may result in improvements in pain and function after TKA.

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.

Improving Patient Outcomes Following Total Knee Arthroplasty: Identifying Rehabilitation Pathways Based on Modifiable Psychological Risk and Resilience Factors

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centered outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively remediated patients' real-world "quality of life" experiences. We propose a novel precision medicine approach to improving patient-centered TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centered TKA outcomes. Of particular importance to the model's predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centered outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarized, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilization of multivariate prediction models to inform individually tailored interventions targeting a range of health conditions.

The Association Between Anxiety, Depression, and Locus of Control With Patient Outcomes Following Total Knee Arthroplasty

BACKGROUND

We aimed to determine how preoperative anxiety, depression, and locus of control (LoC) might predict patient outcomes following total knee arthroplasty (TKA).

METHODS

Patients undergoing TKA were prospectively recruited over an 18-month period. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess TKA outcomes. The Short Form-12, Hospital Anxiety and Depression Score, and LoC surveys were completed by the patients to assess their psychosocial state. These scores were collected preoperatively and at 6 weeks, 18 weeks, and 1 year postoperation.

RESULTS

The final cohort consisted of 136 patients. Greater preoperative depression (P = .004) and anxiety (P = .001) scores were correlated with worse total WOMAC score at 6 weeks and 18 weeks postoperatively, respectively. A poorer preoperative Short Form-12 mental score was also correlated with a worse total WOMAC score at 6 weeks postoperatively (P = .007). Greater tendency toward an internal LoC preoperatively was correlated with better WOMAC pain (P < .001) and function (P = .003) scores at 18 weeks postoperatively. However, there was no correlation between preoperative external LoC and postoperative WOMAC score. There was also no correlation between any of the preoperative psychosocial measures and WOMAC score at 1 year postoperatively.

CONCLUSION

We identified a group of patients whose psychosocial markers predicted them to have worse outcomes in the short to medium term even though they normalized to satisfactory outcomes at 1 year postoperatively. Identifying this group could allow for targeted intervention with an adjustment of expectations and thus more effective recovery.

Resolving design issues in developing a nutrition app: A case study using formative research

Mobile phone apps have become ubiquitous in health, but they often fail to demonstrate effectiveness in achieving behavior outcomes among intended users. A failure to conduct formative research on app content or functions may contribute to some of this shortfall. We describe simple research procedures we followed when building a nutrition app for low-income household cooks. Our studies improved the placement and design of key screen controls, helped select and guide an illustrator who created graphic support for textual content, and tested whether adding secondary users to the primary audience would attract additional app use. Whether because of these preliminary tests, or for other reasons, our app has generated heavy use by its intended market and has demonstrated desired effects on client behavior. We offer our experiences in formative evaluation as potential tools for other app developers to adapt to their circumstances.

Systematic review: Predicting adverse psychological outcomes after hand trauma

STUDY DESIGN

Systematic review.

INTRODUCTION AND PURPOSE OF THE STUDY

After traumatic hand injury, extensive physical and psychological adaptation is required following surgical reconstruction. Recovery from injury can understandably be emotionally challenging, which may result in impaired quality of life and delayed physical recovery. However, the evidence base for identifying high-risk patients is limited.

METHODS

A PROSPERO-registered literature search of MEDLINE (1946-present), EMBASE (1980-present), PsychInfo, and CINAHL electronic databases identified 5156 results for studies reporting psychological outcomes after acute hand trauma. Subsequent review and selection by 2 independent reviewers identified 19 studies for inclusion. These were poor quality level 2 prognostic studies, cross sectional or cohort in design, and varied widely in methodology, sample sizes, diagnostic methods, and cutoff values used to identify psychological symptoms. Data regarding symptoms, predisposing factors, and questionnaires used to identify them were extracted and analyzed.

RESULTS

Patients with amputations or a tendency to catastrophize suffered highest pain ratings. Persisting symptom presence at 3 months was the best predictor of chronicity. Many different questionnaires were used for symptom detection, but none had been specifically validated in a hand trauma population of patients. Few studies assessed the ability of selection tools to predict patients at high risk of developing adverse psychological outcomes.

DISCUSSION AND CONCLUSION

Despite a limited evidence base, screening at 3 months may detect post-traumatic stress disorder, anxiety, depression, and chronic pain, potentially allowing for early intervention and improved treatment outcomes.

LEVEL OF EVIDENCE

Level 4.

Multifactorial analysis of dissatisfaction after primary total knee replacement

BACKGROUND

The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to compare the psychological characteristics of dissatisfied patients to matched, satisfied controls.

METHODS

Unilateral TKR patients were evaluated to identify those dissatisfied with their TKR. Dissatisfied and satisfied patients were matched in terms of age, gender, follow-up duration and body mass index (BMI). Psychological evaluation was performed using the Pain Catastrophizing Scale (PCS), Depression, Anxiety and Stress Scale (DASS) and the Multidimensional Health Locus of Control (MHLC) scale. The preoperative grade of osteoarthritis, prevalence of comorbidities, and postoperative functional outcomes, were also compared.

RESULTS

A cohort comprised 301 patients (response rate 71%), with 24 patients (eight percent) dissatisfied at a mean follow-up of 37months (range eight to 74months). Persistent pain was the most common reason for dissatisfaction (n=10). Dissatisfied patients reported a significantly higher mean PCS score (P=0.03), higher depression component of the DASS (P=0.02) and lower internal locus of control (P=0.02). The dissatisfied group exhibited reduced improvement (P<0.05) in the Oxford Knee Score (OKS) and range of motion (ROM), as well as a lower preoperative grade of osteoarthritis compared to satisfied patients.

CONCLUSIONS

Dissatisfied patients exhibit an altered psychological profile to matched satisfied controls. In addition, they have lesser improvements in the OKS and ROM. Thus, both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors may help in planning focused interventions to address dissatisfaction.

Evaluation of the acceptability of a sphygmomanometer device in knee extension training following surgical procedures of the knee

BACKGROUND

The postoperative treatment after a standard surgical intervention such as knee arthroplasty, proximal tibial osteotomy or supracondylar osteotomy, can have an important impact on the overall treatment outcome. In most cases, outcomes are positively effected by patients receiving physiotherapy and occupational therapy. Basic movements and range of motion need to be learnt. Self-responsible behaviour, which is similar to exercise programs in sports, needs to be supported. However, in most cases the transfer of training techniques into successful and desired postoperative care is not simple. A training technique needs to be developed which is self-explanatory, effective, encouraging for and accessible to the patient.

OBJECTIVES

The purpose of this study was to describe and evaluate an easy and effective technique to support regular physiotherapy in early postoperative rehabilitation using a sphygmomanometer device. Measurements were undertaken relating to handling, training results and motivation.

DESIGN

This was a descriptive study.

METHODS

Forty one patients were instructed to undertake extension exercises of the knee in the early postoperative phase. A sphygmomanometer cuff was rolled out and placed just below the popliteal fossa, and inflated to 20 mmHg. In this position the patients were prompted to push the knee down with the maximum available power. The quadriceps muscle of the leg is activated when patients extend the knee using two thirds of their maximum power, and then followed by one third of their maximum power. This exercise sequence was carried out three times for 5 seconds. The results were documented by using a patient questionnaire.

RESULTS

Thirteen patients indicated that they felt highly motivated while undertaking the training program. One patient reported poor motivation due to inconvenient handling (preparing the cuff by closing the valve screw or calculating the target value) and six patients reported that the method of handwritten recording of training sessions needed to be improved. There were no technical problems. The training results were rated as being predominantly good. Due to the variation in individual ability in extending the knee, comparison of the overall values obtained could not be done.

CONCLUSION

The use of a sphygmomanometer device is cheap and feasible technique in postoperative independent knee extension training.

Preoperative Predictors of Pain Catastrophizing, Anxiety, and Depression in Patients Undergoing Total Joint Arthroplasty

BACKGROUND

The relationship between pain catastrophizing and emotional disorders including anxiety and depression in osteoarthritic patients undergoing total joint arthroplasty (TJA) is an emerging area of study. The purpose of this study was to examine the association of these factors with preoperative patient characteristics.

METHODS

A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Preoperative measures included visual analog pain scale (VAS), Harris Hip and Knee Society scores, Oxford Score, and Kellgren-Lawrence grade. Logistic and quantile regression were used to assess the relationship between preoperative characteristics and PCS or HADS, adjusting for covariate effects.

RESULTS

We recruited 463 TJA patients. VAS pain (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and Oxford (OR 1.13; 95% CI 1.07-1.20) were significant predictors for PCS and its subdomains excluding rumination. Oxford was the only significant predictor for abnormal HADS-A (OR 1.10; 95% CI 1.04-1.17). VAS pain (OR 1.27; 95% CI 1.02-1.52) and Oxford (OR 1.09; 95% CI 1.01-1.17) were significant predictors for abnormal HADS-D. The quantile regression showed similar patterns of association, with female gender, younger age, and higher ASA also associated with HADS-A.

CONCLUSION

The most important predictor of catastrophizing, anxiety and/or depression in TJA patients is preoperative pain and poor subjective function. At-risk patients include those with increased pain and generally good clinical function, as well as younger women with significant comorbidities. Such patients should be identified and targeted psychological therapy implemented preoperatively to optimize coping strategies and adaptive behavior to mitigate potential for inferior TJA outcomes including pain and patient dissatisfaction.

Descriptive analysis of the cost-effectiveness of depressed patients undergoing total knee arthroplasty: an economic decision analysis

BACKGROUND

Recent rising concern about the cost-effectiveness ratio of total knee arthroplasty (TKA) led us to evaluate this successful procedure from the economic perspective, thereby helping policy-makers to conduct medical resource allocation more effectively and efficiently. However, up to now no study has investigated the influence of patients' psychological factors on their evaluation of TKA's cost-effectiveness. Therefore, we decided to determine whether and how depression, which is a common negative psychological factor in the population undergoing TKA, affects their economic evaluation of the procedure.

METHODS

A total of 312 patients who had undergone TKA were graded into three groups based on the level of depression measured by the Center for Epidemiological Studies Depression Scale (CES-D) scores. Clinical effectiveness information was obtained using the WOMAC questionnaire; total costs related to TKA were acquired through interviews with patients and review of their medical records in the computing system.

RESULTS

Patients with high-level depression (3491.9$/QALYS; 95% CI, 3471.1-3491.9$/QALYS) had greater cost-effectiveness compared tothose with low-level (2447.1$/QALYS; 95% CI, 2427.9-2466.3$/QALYS) and middle-level (3027.2$/QALYS; 95% CI, 3011.0-3043.4$/QALYS) depression. We concluded there was a significant positive correlation between cost-effectiveness and the level of depression after TKA (r = 0.703, P = 0.014). Significant differences in the costs of hospital stay, medical treatment, rehabilitation, and outpatient care were detected among the three groups.

CONCLUSIONS

Our study might help policy-makers and clinicians identify which types of patients benefit most from TKA and then advise high-risk patients (high-level depression status in this study) about how to recovery better with limited resource allocation. Preoperative evaluation of patients' psychological state may decrease unnecessary economic burdens and suffering during the recovery period.

The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty

Neglect-like symptoms have been defined as a loss of perception of a limb, with pain and excessive effort necessary to move the limb. This phenomenon has been studied in patients with complex regional pain syndrome, but has not been assessed in patients who have undergone orthopedic procedures such as total knee arthroplasty. The authors of this study assessed neglect-like symptoms in a group of 90 patients three and six weeks after total knee arthroplasty.

BACKGROUND:

Persistent postoperative pain has a significant relationship with patient health and satisfaction.

OBJECTIVES:

To investigate the prevalence and association of neglect-like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain.

METHODS:

The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State-Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two-point discrimination in the thigh) and NLS were also investigated.

RESULTS:

At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS.

CONCLUSIONS:

These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.

The Influence of Mood on the Relation between Proactive Coping and Rehabilitation Outcomes

Cette étude a examiné un échantillon de 228 personnes âgées en réhabilitation après chirurgie pour remplacement d’une articulation; elle a porté sur la relation entre une adaptation proactive, l’humeur et les résultats psychologiques et fonctionnels. Faire face proactivement c’est une façon de réagir qui est axée sur les objectifs et nécessite qu’on affront les facteurs qui incitent le stress comme un défi plutôt qu’une menace. Selon notre hypothèse, les personnes âgées qui adoptent des stratégies proactives d’adaptation subiraient une amélioration du fonctionnement physique et psychologique apres la réadaptation et connaîtraient une humeur positive. Le modèle proposé a trouvé du support, par lequel une expérience de vigueur a été trouvé à la médiation de l’effet d’une adaptation proactive sur les résultats. Les implications théoriques et pratiques des résultats de recherche sont discutées dans le contexte des interventions qui encourageraient les personnes âgées à faire face proactivement.

Knee replacement

Knee-replacement surgery is frequently done and highly successful. It relieves pain and improves knee function in people with advanced arthritis of the joint. The most common indication for the procedure is osteoarthritis. We review the epidemiology of and risk factors for knee replacement. Because replacement is increasingly considered for patients younger than 55 years, improved decision making about whether a patient should undergo the procedure is needed. We discuss assessment of surgery outcomes based on data for revision surgery from national joint-replacement registries and on patient-reported outcome measures. Widespread surveillance of existing implants is urgently needed alongside the carefully monitored introduction of new implant designs. Developments for the future are improved delivery of care and training for surgeons and clinical teams. In an increasingly ageing society, the demand for knee-replacement surgery will probably rise further, and we predict future trends. We also emphasise the need for new strategies to treat early-stage osteoarthritis, which will ultimately reduce the demand for joint-replacement surgery.

The role of preoperative self-efficacy in predicting outcome after total knee replacement

OBJECTIVES

The aim of the present study was to determine if self-efficacy is a significant and independent preoperative predictor of patient-reported pain and function at one year after total knee replacement (TKR).

METHODS

Patients listed for a primary TKR because of osteoarthritis were recruited from preoperative assessment clinics at one regional orthopaedic centre. Before surgery, patients completed the Western Ontario and McMasters Osteoarthritis Index (WOMAC) Pain and Function Scale, Pain Self-Efficacy Scale, the Hospital Anxiety and Depression Scale, the Self-Administered Co-morbidity Questionnaire and questions about other painful joints. Patients then completed the WOMAC Pain and Function Scales at one year postoperatively. Regression analysis was performed to determine if self-efficacy was a significant predictor of outcome after TKR.

RESULTS

Overall, 251 patients were recruited into this study, and one-year questionnaire data were available for 220 patients. At one year postoperatively, 7% of patients reported severe pain in their replaced knee and 9% reported severe functional limitations. Self-efficacy was found to be a significant preoperative predictor of functional ability, but not pain, at one year postoperatively, after controlling for age, gender, depression, anxiety, number of medical co-morbidities, preoperative knee status and painful joints elsewhere. Significant predictors of postoperative pain were greater anxiety and higher pain severity. Other significant predictors of postoperative disability were greater anxiety, worse functional disability and a greater number of painful joints elsewhere.

CONCLUSIONS

The present study demonstrated that self-efficacy is a significant preoperative predictor of patient-reported functional ability at one year after TKR. Future research is needed to assess the impact of interventions for enhancing self-efficacy on patient-reported outcomes after TKR.

Fear of pain as a prognostic factor in chronic pain: conceptual models, assessment, and treatment implications

Chronic pain is a pervasive health care issue affecting over 50 million Americans and costing more than $100 billion dollars annually in lost productivity and health care costs. As a financially and emotionally taxing condition, the families and friends of people with chronic pain, as well as society at large, are affected. Current theory supports the role of biological, psychological, and environmental factors in the etiology, exacerbation, and maintenance of chronic pain. Recently, the specific role of pain-related fear in pain experience has received increasing attention. This article summarizes current understanding of the role of pain-related fear in the onset of acute pain incidents, the transition of acute pain to chronic, and the pain severity and disability of patients with ongoing chronic pain conditions. Treatments demonstrated to reduce pain-related fear are presented, evidence demonstrating their efficacy at reducing disability and pain severity are summarized, and recent criticisms of the fear-avoidance model and future directions are considered.

Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement

Several recent reports suggest that pain-related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long-term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.

Catastrophic thinking about pain as a predictor of length of hospital stay after total knee arthroplasty: a prospective study

This study prospectively investigates whether catastrophizing thinking is associated with length of hospital stay after total knee arthroplasty. Forty-three patients who underwent primary total knee arthroplasty were included in this study. Prior to their operation all patients were asked to complete the pain catastrophizing scale, and a Western Ontario McMaster Universities Osteoarthritis index. A multiple regression analysis identified pain catastrophizing thinking and age as predictors of hospital stay after total knee arthroplasty. Patients with a higher degree of pain catastrophizing prior to the total knee arthroplasty and those with a higher age have a significantly greater risk for a longer hospital stay. Therefore, the results of this study indicate that the pre-operative level of pain catastrophizing in patients determine, in combination with other variables, the length and inter-individual variation in hospital stay after total knee arthroplasty. Reducing catastrophizing thinking about pain through cognitive-behavioral techniques is likely to reduce levels of fear after total knee arthroplasty. As a result, pain and function immediately post-operative might improve, leading to a decrease in length of hospital stay. Although during the last decades the duration of hospital stay is significantly reduced, this study shows that this can be improved when taking into account the contribution of psychological factors such as pain catastrophizing.

Pain catastrophizing: a critical review

Pain catastrophizing is conceptualized as a negative cognitive-affective response to anticipated or actual pain and has been associated with a number of important pain-related outcomes. In the present review, we first focus our efforts on the conceptualization of pain catastrophizing, highlighting its conceptual history and potential problem areas. We then focus our discussion on a number of theoretical mechanisms of action: appraisal theory, attention bias/information processing, communal coping, CNS pain processing mechanisms, psychophysiological pathways and neural pathways. We then offer evidence to suggest that pain catastrophizing represents an important process factor in pain treatment. We conclude by offering what we believe represents an integrated heuristic model for use by researchers over the next 5 years; a model we believe will advance the field most expediently.

Total knee replacement: is it really an effective procedure for all?

Total knee replacement (TKR) is considered an effective intervention for the treatment of chronic knee pain and disability. Yet there is increasing evidence, based on research using patient-based outcome measures, that a significant proportion of patients experience chronic knee pain, functional disability, a poor quality of life and dissatisfaction after TKR. Although some poor outcomes after TKR are due to surgical technique and implant factors, much of the pain and disability after surgery is medically unexplained. A range of possible patient factors could contribute to a poor outcome after TKR. Socio-demographic factors that have been found to correlate with a poor outcome after TKR include female gender, older age and low socio-economical status. Medical factors that are highly predictive of pain and disability after TKR are a greater number of co-morbidities and a worse pre-operative status. A range of psychological factors could be predictive of a poor outcome after surgery including depression, low self-efficacy, poor pain coping strategies, somatization, low social support and patient expectations. It is also proposed that a biological explanation for continuing pain after TKR could involve central sensitisation, a dysfunction of pain modulation by the central nervous system. To improve patient selection for TKR, future research needs to focus on developing a pre-operative screening protocol to identify those patients at risk of medically unexplained pain and disability after TKR.

Somatic and psychologic predictors of long-term unfavorable outcome after surgical intervention

OBJECTIVE

To identify somatic and psychologic predictors of pain, functional limitations, global perceived recovery, and quality of life 6 months after surgical intervention.

SUMMARY BACKGROUND DATA

Recent studies have indicated that chronic pain after surgical intervention is more common than previously assumed. Several demographic and somatic predictors of long-term unfavorable outcome have been identified, but little is known about the contribution of psychologic risk factors.

METHODS

A prospective cohort study, including 625 patients undergoing elective surgery at the University Hospital Maastricht, The Netherlands, was conducted between February and August 2003. Psychologic questionnaires were completed preoperatively and acute postoperative pain was recorded until 4 days after the operation. Six months later, all patients received follow-up questionnaires to assess pain, functional limitations, global perceived recovery, and quality of life. Multivariable logistic regression analyses were used to estimate relative risk of poor outcome in terms of pain, functional limitations, and global recovery. Multivariable linear regression analysis was used to assess associations with quality of life at 6 months.

RESULTS

The most important somatic predictors of unfavorable outcome were duration of the operation and high levels of acute postoperative pain. Patients reporting high levels of pain 4 days after the operation and patients undergoing an operation of longer than 3 hours were at risk for increased pain, increased functional limitations, poor global recovery, and reported lower levels of quality of life 6 months after the operation. Psychologic variables that influenced long-term outcome were preoperative fear of surgery and optimism. Fear of the long-term consequences of the operation was associated with more pain, poor global recovery, and worse quality of life 6 months later, whereas optimism was associated with better recovery and higher quality of life.

CONCLUSIONS

This study was the first to identify the joint contribution of somatic and psychologic factors to chronic pain, functional limitations, and quality of life 6 months after surgical interventions. It replicates previous findings that intense acute postoperative pain is a risk factor for long-term adverse outcome and also identified additional risk factors, namely, long duration of the operation, ASA status, and preoperative fear of surgery.

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'

PURPOSE

An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres.

METHOD

In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N=200 patients per centre.

RESULTS

Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres.

CONCLUSIONS

The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.

Psychological aspects of persistent pain: current state of the science

This article provides an overview of current research on psychological aspects of persistent pain. It is divided into 3 sections. In section 1, recent studies are reviewed that provide evidence that psychological factors are related to adjustment to persistent pain. This section addresses research on factors associated with increased pain and poorer adjustment to pain (ie, pain catastrophizing, pain-related anxiety and fear of pain, and helplessness) and factors associated with decreased pain and improved adjustment to pain (ie, self-efficacy, pain coping strategies, readiness to change, and acceptance). In section 2, we review recent research on behavioral and psychosocial interventions for patients with persistent pain. Topics addressed include early intervention, tailoring treatment, telephone/Internet-based treatment, caregiver-assisted treatment, and exposure-based protocols. In section 3, we conclude with a general discussion that highlights steps needed to advance this area of research including developing more comprehensive and integrative conceptual models, increasing attention to the social context of pain, examining the link of psychological factors to pain-related brain activation patterns, and investigating the mechanisms underlying the efficacy of psychological treatments for pain.

PERSPECTIVE

This is one of several invited commentaries to appear in The Journal of Pain in recognition of The Decade of Pain Research. This article provides an overview of current research on psychological aspects of persistent pain, and highlights steps needed to advance this area of research.