The measurement of psychological constructs in people with osteoarthritis of the knee: a psychometric evaluation

Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is commonly performed for the treatment of knee osteoarthritis (KOA). Poor satisfaction continues to be seen after TKA. Whilst reasons for poor patient satisfaction are multifactorial, there is a strong correlation with persistent pain following TKA. Studies have shown an association between local and remote mechanical hypersensitivity, measured using pressure pain thresholds (PPTs), and severity of knee osteoarthritis and functional status. We aimed to determine if the pre-operative PPTs were associated with patient satisfaction following TKA.

Methods

A prospective longitudinal study of 77 individuals was undertaken. Regression modelling assessed the relationship between Patient Satisfaction using the Knee Society Score (satisfaction subscale) following TKA for KOA, and PPTs recorded pre-operatively locally and remote to the affected knee, while accounting for potentially confounding patient demographic and psychosocial factors.

Results

Lower PPTs (indicating increased mechanical hypersensitivity) locally and remote to the operative knee were modestly associated with lower patient satisfaction in the short-term (six weeks) following TKA (β 0.25-0.28, adjR2 = 0.14-0.15), independent of demographic or psychosocial influences. However, this relationship progressively diminished in the intermediate and long-term post TKA.

Conclusion

While pre-operative PPT measures may provide some foresight to patient satisfaction post TKA in the short term, these measures appear to provide little insight to patient satisfaction in the intermediate and longer term.

The cross-cultural adaptation and psychometric evaluation of a learned helplessness scale for maintenance hemodialysis patients in China (LHS-MHD-C)

Learned helplessness (LH) is an important concept in nursing. This study aimed to adapt and translate the Arthritis Helplessness Index scale into a Chinese version of an LH scale for maintenance hemodialysis patients in China (LHS-MHD-C), and to validate its psychometric properties. Data collected included LHS-MHD-C, as well as the Hospital Depression Scale (HADS-D), and the Beck Hopelessness Scale (BHS) for assessing LHS-MHD-C's criterion validity (predictive and concurrent, respectively). The expert consultation and the pilot study demonstrated semantic and conceptual equivalence and content validity (except for Item 3, the item content validity ranged from 0.82 to 1, and the scale content validity was 0.95). An exploratory factor analysis (n = 146) eliminated three items and accepted 11 items for the two factors, explaining 63.87% of the total variance. A CFA (n = 218) showed that the two-factors structure was consistent with the LH theory. The LHS-MHD-C can distinguish between maintenance hemodialysis (MHD) patients of different ages, education, working status, monthly income, and MHD duration. The scale had good concurrent validity with the BHS (r = .78, p < 0.01). Using the HADS-D as a criterion, the LHS-MHD-C showed a sensitivity of 86.2% and a specificity of 96.8%. A total score of 36.5 may be the best cut-off value for predicting MHD patients' depression. The scale showed good reliabilities (Cronbach's α value of .759, test-retest reliability of 0.772, and split-half reliability of 0.774). This study found that the LHS-MHD-C is a reliable and valid scale for assessing Chinese MHD patients' helplessness.

Medio-dorsal thalamic dysconnectivity in chronic knee pain: A possible mechanism for negative affect and pain comorbidity

The reciprocal interaction between pain and negative affect is acknowledged but pain-related alterations in brain circuits involved in this interaction, such as the mediodorsal thalamus (MDThal), still require a better understanding. We sought to investigate the relationship between MDThal circuitry, negative affect and pain severity in chronic musculoskeletal pain. For these analyses, participants with chronic knee pain (CKP, n = 74) and without (n = 36) completed magnetic resonance imaging scans and questionnaires. Seed-based MDThal functional connectivity (FC) was compared between groups. Within CKP group, we assessed the interdependence of MDThal FC with negative affect. Finally, post hoc moderation analysis explored whether burden of pain influences affect-related MDThal FC. The CKP group showed altered MDThal FC to hippocampus, ventromedial prefrontal cortex and subgenual anterior cingulate. Furthermore, in CKP group, MDThal connectivity correlated significantly with negative affect in several brain regions, most notably the medial prefrontal cortex, and this association was stronger with increasing pain burden and absent in pain-free controls. In conclusion, we demonstrate mediodorsal thalamo-cortical dysconnectivity in chronic pain with areas linked to mood disorders and associations of MDThal FC with negative affect. Moreover, burden of pain seems to enhance affect sensitivity of MDThal FC. These findings suggest mediodorsal thalamic network changes as possible drivers of the detrimental interplay between chronic pain and negative affect.

Further exploring the relationship between pressure pain thresholds and function in knee osteoarthritis

BACKGROUND

Studies in Knee Osteoarthritis (KOA) have shown lowered Pressure Pain Threshold (PPT) values compared to healthy controls potentially signifying mechanical hypersensitivity, although the relevance of these findings to knee function remains unclear.

OBJECTIVE

This study further explores the relationship between PPT measures and knee function (self-reported, physical) in individuals undergoing total knee arthroplasty for advanced KOA.

DESIGN

Cross-sectional observational study.

METHODS

PPT's were recorded both local to the affected knee and at a remote site (deltoid) in 79 individuals with advanced KOA. Participants also completed self-report (Knee Society Score - functional sub-score) and physical (6-min walk test distance)) measures of knee function, as well as measures of pain-related psychological distress. Hierarchical linear regression models evaluated the relationship between the measures of function (self-report and physical measures modelled separately), PPT measures (local and remote), while accounting for demographic and psychological distress measures.

RESULTS

Higher knee PPT scores were independently associated with higher self-reported knee function (β 0.33, p < 0.02) and higher 6-min walk test distance (β 0.41, p < 0.01), although pain self-efficacy (β 0.33, p < 0.01) was also a significant variable in both models. Nearly identical findings were evident for PPT's measured at the deltoid. Overall PPT's could only explain a modest portion of variance (adjusted R² = 0.15 to 0.17) in the functional measures.

CONCLUSIONS

PPT measures may be limited in their capacity to distinguish the impact of peripheral and central pain mechanisms on knee function in individuals undergoing total knee arthroplasty for advanced KOA.

End-range Maitland mobilization decreasing pain sensitivity in knee osteoarthritis: randomized, controlled clinical trial

BACKGROUND

Pressure pain threshold (PPT) is a widely applied method for measuring the magnitude of increased peripheral and central pain sensitivity causing hyperalgesia in knee osteoarthritis (OA). Although manual therapy techniques effects positively PPT, the effect of end-range Maitland mobilization has not been evaluated in knee OA.

AIM

The aim of this study was to investigate the effect of end-range Maitland mobilization compared to sham manual therapy technique on PPT and function-related measures.

DESIGN

The design of the study was of a randomized, controlled clinical trial.

SETTING

Outpatient setting.

POPULATION

Forty women with moderate-to-severe knee OA.

METHODS

Twenty patients (N.=20) were randomly assigned to Maitland group (MG) and twenty patients (N.=20) to control group (CG). Patients in MG received single end-range Maitland mobilization while patients in CG received sham manual therapy technique. Assessment was performed at baseline, 30 minutes and after 1-week period. Outcome measures were PPT locally at knee and distant at ipsilateral extensor carpi radialis longus muscle, general pain during the previous week using the Visual Analogue Scale (VAS), Timed Up and Go Test (TUG) time associated with pain measured with Numerating Pain Rating Scale (NPRS) and strength of passive resistance of knee at onset of pain.

RESULTS

Despite all outcome measures improved significantly postintervention, no changes were detected after 1-week period compared to postintervention in MG. No change of outcome measures was found also postintervention and after 1-week period compared to postintervention in CG. All postintervention results showed significant improvement in between-group comparison in favor of MG. However, after 1-week period, only strength of passive resistance revealed significant difference in between-group comparison in favor of MG (P<0.001).

CONCLUSIONS

Although end-range Maitland mobilization has an immediate effect on decreasing peripheral and central pain sensitivity and improving function-related measures in knee OA, these changes may not cause clinically relevant effect based on data measured after 1-week period.

CLINICAL REHABILITATION IMPACT

Investigating the time-course of end-range Maitland mobilization for determining the optimal treatment frequency during rehabilitation is suggested in knee OA.

Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: a systematic review

A higher level of pain self-efficacy has been suggested as a predictor of a better outcome in patients with musculoskeletal disorders. The Pain Self-Efficacy Questionnaire (PSEQ) is one of the most frequently used patient-reported outcome measures for pain self-efficacy. The purpose of this study was to conduct a systematic review that would identify, appraise, and synthetize the psychometric properties of the PSEQ. Embase, MEDLINE, and CINAHL databases were searched for publications reporting on psychometric properties of the PSEQ in populations with musculoskeletal disorders. After applying selection criteria on identified citations, 28 studies (9853 participants) were included. The methodological quality as measured with the COSMIN risk of bias tool varied from adequate to very good for most measurement properties. The results showed a weighted mean intraclass correlation coefficient of 0.86 (range: 0.75-0.93) for test-retest reliability for the original 10-item PSEQ and the minimal detectable change at 95% confidence interval was 11.52 out of 60 points. Effect size and standardized response mean values were 0.53 and 0.63, respectively, whereas the minimal clinically important difference ranged from 5.5 to 8.5 in patients with chronic low back pain. Internal consistency (Cronbach alpha) ranged from 0.79 to 0.95. The results also showed that the PSEQ has low to moderate correlations with measures of quality of life, disability, pain, pain interference, anxiety, depression, and catastrophizing. Finally, the PSEQ has been adapted and validated in 14 languages. Overall, the results demonstrate that the PSEQ has excellent validity, reliability, and responsiveness. Further high-quality studies are needed to determine responsiveness in populations other than chronic low back pain.

Scale Shortening and Decrease in Measurement Precision: Analysis of the Pain Self-Efficacy Questionnaire and Its Short Forms in an Italian-Speaking Population With Neck Pain Disorders

OBJECTIVE

Short (2- and 4-item) forms of the Pain Self-Efficacy Questionnaire (PSEQ) have been proposed, but their measurement precision at the individual level is unclear.The purpose of this study was to analyze the Rasch psychometric characteristics of PSEQ and its 3 short forms (one 4-item and two 2-item versions) in an Italian-speaking population with neck pain (NP) disorders and compare their measurement precision at the individual level through calculation of the test information function (TIF).

METHODS

Secondary analysis of data from a prospective single-group observational study was conducted. In 161 consecutive participants (mean age = 45 years [SD = 14]; 104 women) with NP disorders, a Rasch analysis was performed on each version of the PSEQ (full scale plus 3 short forms), and the TIF was calculated to examine the degree of measurement precision in estimating person ability over the whole measured construct (pain self-efficacy).

RESULTS

In all versions of the PSEQ, the rating scale fulfilled the category functioning criteria, and all items showed an adequate fit to the Rasch model. The TIF showed a bell-shaped distribution of information, with an acceptable measurement precision (standard error <0.5) for persons with a wide range of ability; conversely, measurement precision was unacceptably low in each short form (particularly the two 2-item versions).

CONCLUSIONS

The results confirm and expand reports on the sound psychometric characteristics of PSEQ, showing for the first time, to our knowledge, its conditional precision in estimating pain self-efficacy measures in Italian individuals with NP disorders. The study cautions against use of the 3 PSEQ short forms for individual-level clinical decision-making.

IMPACT

Short scales are popular in rehabilitation settings largely because they can save assessment time and related costs. The psychometric characteristics of the 10-item PSEQ were confirmed and deepened, including its precision in estimating individual pain self-efficacy at different levels of this latent variable. On the other hand, low measurement precision of the 3 PSEQ short forms cautions against their use for individual judgments.

Associations of the modified STarT back tool and Hospital Anxiety and Depression Scale (HADS) with gait speed and knee pain in knee osteoarthritis: a retrospective cohort study

OBJECTIVE

The association of the modified STarT Back Tool (mSBT) psychosocial measure with gait speed and knee pain in knee osteoarthritis is not well defined. This study aimed to, in patients with knee osteoarthritis, (i) examine the convergent validity of mSBT with the Hospital Anxiety and Depression Scale (HADS) and (ii) compare the predictive validity of mSBT and HADS with gait speed and knee pain.

METHODS

We performed a retrospective cohort analysis of mSBT, HADS, gait speed, and knee pain outcomes data collected from 119 patients who received outpatient physical therapy. Of these patients who were evaluated at their first (baseline) physical therapy visit, 55 had available data at the Week-16 follow-up visit.

RESULTS

mSBT and HADS showed moderately strong pairwise correlations (Spearman correlation > 0.57; p < 0.001). After adjusting for age, sex, body weight, and knee impairment variables in multivariable linear mixed-effects analyses, mSBT was associated with gait speed (p < 0.001) and knee pain intensity (p < 0.001) and it had comparable strength of association as HADS. In within-patient regression analyses, change in mSBT was associated with changes in gait speed (p = 0.04) and knee pain (p = 0.01) over 16 weeks.

CONCLUSION

The mSBT had convergent validity with HADS and it showed predictive validity with gait speed and knee pain in knee osteoarthritis. Although broader validation is required, the 5-item mSBT psychosocial measure may be applied as part of routine clinical care to assess psychological distress in patients with knee osteoarthritis. IMPLICATIONS FOR REHABILITATION The 5-item psychosocial subscale of the modified STarT Back tool (mSBT) showed good convergent validity with the 14-item Hospital Anxiety and Depression Scale in patients with knee osteoarthritis. The mSBT psychosocial subscale showed predictive validity, at both cross-sectional and longitudinal levels, with gait speed and knee pain in patients with knee osteoarthritis. The mSBT can potentially be used in the busy clinical setting to assess psychological distress in patients with knee osteoarthritis.

Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial

INTRODUCTION

Cognitive-behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes.

METHODS

The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects.

RESULTS

In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of -9 (95% CI -1 to -14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI -18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of -6 (-10 to -2, p=0.02).

CONCLUSIONS

Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT01772329, registration date 21 January 2013).

Measuring Anxiety in Patients With Early-Stage Parkinson's Disease: Rasch Analysis of the State-Trait Anxiety Inventory

The State-Trait Anxiety Inventory (STAI), composed of two 20-item subscales (STAI-state and STAI-trait), has been increasingly used to assess anxiety symptoms in patients with Parkinson's disease (PD). However, the clinimetric attributes of the STAI under the statistical framework of the item-response theory (IRT) have not been fully elucidated within this population to date. We performed an IRT-based Rasch analysis of the STAI outcomes of patients with de novo PD from the Parkinson's Progression Markers Initiative database. The unidimensionality, Rasch model fit, scale targeting, separation reliability, differential item functioning, and response category utility of the STAI were statistically evaluated. A total of 326 (209 males, 117 females) patients without cognitive dysfunction were enrolled in our study. The original versions of the STAI-state and STAI-trait had acceptable separation reliability but lacked appropriate response category functioning, exhibited scale off-targeting, and several items demonstrated poor fit to the Rasch model. The response categories were reduced from four to three, and the rescored three-point TASI-trait demonstrated a marked improvement in clinimetric properties without a significant impact on unidimensionality and separation reliability. The rescored three-point version of the STAI-state required the additional removal of four misfitting items in order to improve the Rasch model fit. To our knowledge, this is the first study to assess the measurement properties based on the IRT of the STAI in patients with PD. Our Rasch analysis identified the components requiring possible amendments in order to improve the clinimetric attributes of the STAI.

Ability to Cope with Pain Puts Migraine Surgery Patients in Perspective

BACKGROUND

Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients' pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome.

METHODS

Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison.

RESULTS

All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome.

CONCLUSIONS

The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.