Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Several studies have identified clinical, psychosocial, patient characteristic, and perioperative variables that are associated with persistent postsurgical pain; however, the relative effect of these variables has yet to be quantified. The aim of the study was to provide a systematic review and meta-analysis of predictor variables associated with persistent pain after total knee arthroplasty (TKA).

METHODS

Included studies were required to measure predictor variables prior to or at the time of surgery, include a pain outcome measure at least 3 months post-TKA, and include a statistical analysis of the effect of the predictor variable(s) on the outcome measure. Counts were undertaken of the number of times each predictor was analysed and the number of times it was found to have a significant relationship with persistent pain. Separate meta-analyses were performed to determine the effect size of each predictor on persistent pain. Outcomes from studies implementing uni- and multivariable statistical models were analysed separately.

RESULTS

Thirty-two studies involving almost 30 000 patients were included in the review. Preoperative pain was the predictor that most commonly demonstrated a significant relationship with persistent pain across uni- and multivariable analyses. In the meta-analyses of data from univariate models, the largest effect sizes were found for: other pain sites, catastrophizing, and depression. For data from multivariate models, significant effects were evident for: catastrophizing, preoperative pain, mental health, and comorbidities.

CONCLUSIONS

Catastrophizing, mental health, preoperative knee pain, and pain at other sites are the strongest independent predictors of persistent pain after TKA.

Cortical contributions to the stretch reflex response in biceps brachii

Long-latency components of the stretch reflex may aid in organizing multi-joint movements and posture. The aims of this study were to investigate if the M2 response in biceps brachii is mediated through a trans-cortical pathway. Ipsi-lateral and contra-lateral transcranial magnetic stimulation, combined with a variety of ramp-and-hold perturbations in which the subject was instructed to either intervene or not resist were applied to biceps brachii. The biceps M2 response modulates with task and can be facilitated through contra-lateral TMS. This is consistent with the existence of a trans-cortical pathway. Attempts to inhibit this pathway, possibly affecting the long-latency stretch reflex have not yet produced consistent results.

A method to monitor corticomotor excitability during passive rhythmic movement of the upper limb

A procedure is outlined in which the excitability of the corticomotor pathway is examined during rhythmic, passive upper limb movement. Using a custom built apparatus and software, wrist flexion-extension movements of a programmable frequency, amplitude and duration are induced while transcranial magnetic stimuli are delivered to the contralateral cortex over the area representing the flexor carpi radialis muscle. Stimuli are timed to occur during different phases of the movement cycle in order to examine the influence of ascending sensory input on the excitability of the corticospinal pathway. The protocol enables modulations in evoked responses to be analysed during movement of different frequencies and amplitudes, and permits alterations in cortical excitability to be examined by using paired pulse paradigms. The technique may also be utilised to examine hemispheric and segmental transfer if a stationary target limb is probed while the contralateral limb is passively moved. The protocol has potential use in examining corticomotor excitability in subjects with deficits in sensory and/or motor function, such as patients with Parkinson's disease or individuals recovering from stroke.

Phasic modulation of corticomotor excitability during passive movement of the upper limb: effects of movement frequency and muscle specificity

Modulations in the excitability of spinal reflex pathways during passive rhythmic movements of the lower limb have been demonstrated by a number of previous studies [4]. Less emphasis has been placed on the role of supraspinal pathways during passive movement, and on tasks involving the upper limb. In the present study, transcranial magnetic stimulation (TMS) was delivered to subjects while undergoing passive flexion-extension movements of the contralateral wrist. Motor evoked potentials (MEPs) of flexor carpi radialis (FCR) and abductor pollicus brevis (APB) muscles were recorded. Stimuli were delivered in eight phases of the movement cycle during three different frequencies of movement. Evidence of marked modulations in pathway excitability was found in the MEP amplitudes of the FCR muscle, with responses inhibited and facilitated from static values in the extension and flexion phases, respectively. The results indicated that at higher frequencies of movement there was greater modulation in pathway excitability. Paired-pulse TMS (sub-threshold conditioning) at short interstimulus intervals revealed modulations in the extent of inhibition in MEP amplitude at high movement frequencies. In the APB muscle, there was some evidence of phasic modulations of response amplitude, although the effects were less marked than those observed in FCR. It is speculated that these modulatory effects are mediated via Ia afferent pathways and arise as a consequence of the induced forearm muscle shortening and lengthening. Although the level at which this input influences the corticomotoneuronal pathway is difficult to discern, a contribution from cortical regions is suggested.

Stride length regulation in Parkinson's disease: the use of extrinsic, visual cues

It has been well documented that marked improvements in the hypokinetic gait pattern of Parkinson's disease patients are possible with the use of appropriate visual cues. This project served to evaluate Parkinson's disease gait performance as well as residual processing capacity while using fixed or gait-regulated visual cues. Three-dimensional kinematic, kinetic and electromyographic gait analysis was carried out on 14 patients and 14 matched controls in baseline conditions and with two types of visual cues: taped step length (SL) markers and an individualized subject-mounted light device (SMLD). A probe reaction time paradigm was invoked to assess residual processing capacity. Ratings of perceived task load were also made using the NASA-Task Load Index. Stride length and gait velocity were reduced in patients in baseline conditions. Both of these parameters increased to control levels with the use of visual cues. These alterations were generally accompanied by modifications of lower limb kinematics and kinetics towards control subjects. Perceived task load was higher in all conditions and was further elevated by the use of the SMLD for both groups. Patients produced larger overall reaction times, although reaction time was not different between baseline and SL marker conditions. Reaction time was increased in both groups when using the SMLD. The overarching finding is that stride length can be regulated in Parkinson's disease using stationary visual cues without increased central processing capacity or perceived effort. This may occur via utilization of visual feedback, reducing the patients' reliance on kinaesthetic feedback for the regulation of movement amplitude.

The subdominant hand increases in the efficacy of voluntary alterations in bimanual coordination

Subjects performed a bimanual circle-tracing task in time with an auditory metronome while restricted to moving with either proximal or distal musculature of the upper limb. Patterns were made in symmetric or asymmetric directions with respect to the midline. Symmetric patterns were more stable than asymmetric patterns. In response to a visual stimulus, subjects reversed the direction of one limb. Unwanted disruptions (momentary or lasting reversals) in the limb contralateral to the reversing limb were observed in 48% of trials. Incidence of disruption was equivalent between postures, but occurred more frequently when the dominant hand reversed direction. This result is consistent with anisotropy in coupling between hands and reveals a unifying constraint between spontaneous and intentional dynamics in bimanual coordination.

Dispelling myths about verification of sea-launched cruise missiles

It is widely believed that an arms control limit on nuclear-armed sea-launched cruise missiles would be nearly impossible to verify. Among the reasons usually given are: these weapons are small, built in nondistinctive industrial facilities, deployed on a variety of ships and submarines, and difficult to distinguish from their conventionally armed counterparts. In this article, it is argued that the covert production and deployment of nuclear-armed sealaunched cruise missiles would not be so straightforward. A specific arms control proposal is described, namely a total ban on nuclear-armed sea-launched cruise missiles. This proposal is used to illustrate how an effective verification scheme might be constructed.

Treatment of delayed union and nonunion with an implanted direct current stimulator

A multicentered research program on direct electrical current for stimulation of bone healing was performed by 30 Australian orthopedic surgeons. The program was designed to test an implanted device named direct current bone growth stimulation (DCBGS). The DCBGS achieved union in 72 of 84 (86%) cases of ununited fractures of long bones. These results are comparable to those obtained with other devices. The time to achieve sound union however, appears to be significantly less than by conventional bone grafting techniques. The procedure is safe and simple, with a short hospital stay and low rate of complications. Certain technical details have been stressed. The presence of previous infection is not a contraindication to this procedure. The procedure has advantages over Phemister or Charnley bone graft operations in that it produces less pain, generally avoids the need for a cancellous bone graft and allows an anterior approach to the shaft of the tibia when this might otherwise not be possible. The results for the various techniques of applying electric stimulation to bone are generally comparable although the clinical indications favoring one technique over another have yet to be determined. Electric stimulation used as described is an effective method of treatment for ununited fractures of long bones.

Treatment of congenital pseudarthrosis of the tibia with direct current stimulation

Congenital pseudarthrosis of the tibia presents surgeons with one of the most challenging of all orthopedic problems. The results of various forms of surgical treatment are rarely successful. This is a preliminary report on an implanted direct current bone growth stimulator (DCBGS) for treatment of congential pseudarthrosis of the tibia. The implanted stimulator achieved encouraging results in 6 patients when it was used in conjunction with cancellous bone grafting and efficient immobilization of the tibia. The leg requires long-term protection of the fracture site until skeletal maturity is complete.