Background & Aims
Several studies have reported that, despite objective indicators of surgical success, 20-25% of individuals who have undergone total knee arthroplasty (TKA) continue to report significant postsurgical pain and disability1,9. By week 6, most patients are off pain medications and have resumed their day-to-day routines. However, slow pain response during this period has been independently associate with clinically significant differences in pain outcomes at 6 months3,8. Prior work by this team and others have demonstrated that individuals reporting severe pain, anxiety, depression, pain catastrophizing, opioid intake, and chronic pain preoperatively are at increased risk of experiencing moderate to severe pain up to 6 months following total knee arthroplasty (TKA)5-7. The purpose of this study was to determine preoperative predictors of pain severity 6 weeks post TKA in a sample of older US Veterans experiencing severe knee pain prior to surgery.
Methods
A longitudinal, secondary analysis of a double-blind, two-arm, randomized controlled trial, evaluating the efficacy of an Acceptance and Commitment Therapy (ACT) intervention in veterans at risk for persistent post-surgical pain (PPSP) following total knee arthroplasty (TKA) was conducted to determine preoperative predictors of pain severity at 6 weeks post TKA. Preoperative demographics (age, race, etc.), medical history (comorbidities, BMI, PTSD, opioid use, etc.), psychological symptoms (anxiety, stress, depression), coping skills (pain catastrophizing, pain acceptance, etc.), and preoperative health status (function, sleep) were potential predictors. Pain severity at 6 weeks postoperatively was measured using the pain severity subscale of the Brief Pain Inventory (BPI). Predictor collinearity and bivariate correlations with pain intensity identified variables to include in linear regression analyses.
Results
A total of 294 Veterans (age 66.3 ? 9; male 87%; white 67%; Married 66%; BMI 33 ? 4.9) with severe pain (?7/10) prior to surgery, reported pain severity 6 weeks following TKA. Preoperative chronic pain (other than knee), rheumatoid arthritis, back pain, stress, anxiety, depression, pain catastrophizing, pain willingness and acceptance, dysfunction with activities of daily living and sleep disturbance/impairment were significantly correlated with 6-week pain severity. After controlling for the ACT intervention and occurrence of postoperative complications, rheumatoid arthritis and dysfunction with activities of daily living (ADL) were significant predictors (R2=0.18). When ADL dysfunction was removed from the model, pain willingness and sleep disturbance were significant predictors (R2=0.16).
Conclusions
This study provides insight into preoperative predictors of pain severity following physical therapy rehabilitation 6 weeks after TKA in a sample of mostly older, male Veterans with severe preoperative pain. Functional debilitation affecting activities of daily living, comorbidies, such as rheumatoid arthritis, an unwillingness to accept pain, and sleep disturbance have a significant influence on individuals’ perceptions of pain severity. These findings are consistent with prior literature showing preoperative pain and functional disability to be the only predictors of pain, severity 3 months following surgery2 and systematic reviews showing comorbidities, poor functional status, sleep difficulties, and psychological factors of depression, anxiety or catastrophic pain4,10
References
1.Ashoorion V, Sadeghirad B, Wang L, Noori A, et al. Predictors of persistent post-surgical pain following total knee arthroplasty: a systematic review and meta-analysis of observational studies, Pain Medicine, 24(4): 369-381.
2.Boekel RLM, Bronkhorst EM, Vloet L, Steegers MAM, Vissers KCP, (2021). Identification of preoperative predictors for acute postsurgical pain and for pain at three months after surgery: a prospective observational study. Scientific Reports, 11:16459. doi:10.1038/s41598-021-95963-y.
3.Buvanendran A, Della Valle CJ, Kroin JS, et al. (2019). Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: a prospective cohort study, Regional Anesthesia & Pain Medicine Published Online First: 15 February 2019. doi: 10.1136/rapm-2018-100036
4.Hernández C, Díaz-Heredia J, Berraquero ML, Crespo P, Loza E, Ruiz Ibán MÁ. (2015). Factores predictores prequirúrgicos de dolor posquirúrgico en pacientes sometidos a artroplastia de cadera o rodilla. Una revisión sistemática. Reumatol Clin.11:361–380.
5.Mimic A, Bantel C, Jovicic J, Mimic B, Kisic-Tepavcevic D, Durutovic O, Ladjevic. N. (2018). Psychological factors as predictors of early postoperative pain after open nephrectomy, Journal of Pain Research,11:, 955-966, DOI: 10.2147/JPR.S152282.
6.Rakel BA, Blodgett NP, Zimmerman MB, Logsden-Sackett N, Clark C, Noiseux N, Callaghan J, Herr K, Geasland K, Yang X, Sluka KA. (2012). Predictors of postoperative movement and resting pain following total knee replacement. Pain, 153: 2192–2203.
7.Schnabel A, Yahiaoui-Doktor M, Meissner W, Zahn PK, Pogatzki-Zahn EM. (2020). Predicting poor postoperative acute pain outcome in adults: an international, multicentre database analysis of risk factors in 50,005 patients. Pain Rep. Jul 27;5(4):e831. doi: 10.1097/PR9.0000000000000831. PMID: 32766467; PMCID: PMC7390596.
8.Singh J, Lemauy C, Nobel L, et al. (2019). Association of early postoperative pain trajectories with longer-term pain outcome after primary total knee arthroplasty. JAMA Netw Open. 2(11):e1915105. Doi:10.1001/jamanetworkopen.2019.15105.
9.Wlylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. (2018). Chronic pain after total knee arthroplasty, EFFORT Open Rev, 3:461-470. DOI: 10.1302/2058-5241.3.180004.
10.Yang MMH, Hartley RL, Laung AA, Ronksley P, Jette N, Casha S, Riva-Cambrin J. (2019). Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-anlysis, BMJ Open, 9:e025091. doi: 10.1136/bmjopen-2018-025091.
Presenting Author
Barbara Rakel
Poster Authors
Barbara Rakel
PhD, RN, FAAN
University of Iowa
Lead Author
M. Bridget Zimmerman
University of Iowa
Lead Author
Wen Liu
University of Iowa
Lead Author
Andrea Strayer
University of Iowa College of Nursing
Lead Author
Samantha Bjornson
University of Iowa
Lead Author
Lauren Garvin
University of Iowa
Lead Author
Katherine Hadlandsmyth
University of Iowa
Lead Author
Tracey Smith
Baylor College of Medicine
Lead Author
Lilian Dindo
Baylor College of Medicine
Lead Author
Topics
- Specific Pain Conditions/Pain in Specific Populations: Post-surgical/Post-traumatic Chronic Pain