The anticipation of postoperative pain associated with a large operation such as a total knee arthroplasty (TKA) scares many patients. Some worry to the point of “catastrophizing” pain prior to surgery. As orthopaedic surgeons, we try to assuage our patients’ fears through preoperative education and multimodal pain-management modalities after surgery, but there are still some patients in whom the fear of pain—and the pain itself that inevitably accompanies arthroplasty— negatively affect their outcome. Preparing such patients for surgery and helping them recover afterward despite this high anxiety are big challenges for the orthopaedic care team. Some data suggest that cognitive behavioral therapy (CBT) might help.
However, a multisite randomized trial by Riddle et al. published in the February 6, 2019 issue of JBJS did not find any differences in pain or function among patients with moderate to high preoperative pain catastrophizing scores who underwent a form of CBT focused on pain coping skills, when their outcomes were compared to those of similar patients in “usual care” or “arthritis education” arms of the study. Each group had similar WOMAC pain scores and pain catastrophizing scores to start, and all patients were found to have significant but very similar decreases in their pain scores at 2, 6, and 12 months postoperatively. Independent assessors determined that the quality of the intervention in the coping-skills and arthritis-education arms was high, suggesting that it was not poor-quality interventions that accounted for the consistent similarities among the 3 groups.
While there are many physiological and psychological factors contributing to an individual’s experience of pain, the results of this study ran surprisingly counter to prior evidence. The authors speculate that differences between the 3 groups may have been masked by the fact that all patients had such a large decrease in pain after the TKA. While that would appear to be good news, we know that there is a stubbornly large subset of patients (cited in this article as 20%) who undergo a technically and radiographically ”successful” knee arthroplasty only to have continued pain without an obvious cause. (See related OrthoBuzz Editor’s Choice post.)
These findings lead me to believe a statement that probably cannot be proven: there are some patients who will experience function-limiting pain no matter what surgery is performed, no matter which drugs are administered, and no matter what rehabilitative therapy is provided. Learning how to identify those patients and clearly communicating expectations to them pre- and postoperatively might help improve their satisfaction with their procedure.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Most studies investigating the psychosocial determinants of orthopaedic pain and disability have focused on the spine, hand, hip, and knee. But in the December 16, 2015 JBJS, Menendez et al. looked at psychosocial associations among 139 patients presenting with shoulder complaints. Similar to findings regarding those other anatomical areas, Menendez et al. found that patient variability in perceived symptom intensity and magnitude was more strongly related to psychological distress than to a specific shoulder diagnosis, which included rotator cuff tear, impingement, osteoarthritis, and frozen shoulder.
The authors measured patient pain and disability scores upon presentation using the Shoulder Pain and Disability Index (SPADI). They then analyzed the SPADI scores in relation to sociodemographic data and patient responses to three additional validated tests measuring depression, tendencies to catastrophize, and self-efficacy. They found that disabled and retired work status, higher BMI, catastrophic thinking, and lower self-efficacy (i.e., ineffective coping strategies) were associated with greater patient-reported symptom intensity and magnitude of disability.
Interestingly, BMI was the only biological influence on pain and disability scores. Also, retirement had a negative influence on pain and disability scores, which was somewhat surprising considering that retirement often has positive effects on well-being.
The authors conclude that future research focused on the effect of psychosocial factors on postoperative pain and response to treatment might “allow surgeons to identify patients who are at risk for a treatment-refractory course.” They further surmise that “interventions to decrease catastrophic thinking and to optimize self-efficacy…before shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability.”