Pain Coping Skills Training for Patients With Elevated Pain Catastrophizing Who Are Scheduled for Knee Arthroplasty: A Quasi-Experimental Study

doi:10.1016/j.apmr.2011.01.003

Archives of Physical Medicine and Rehabilitation

Volume 92, Issue 6, June 2011, Pages 859-865

Presented to the Osteoarthritis Research Society, September 23–26, 2010, Brussels, Belgium.

https://doi.org/10.1016/j.apmr.2011.01.003 Get rights and content

Abstract

Riddle DL, Keefe FJ, Nay WT, McKee D, Attarian DE, Jensen MP. Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study.

Objectives

To (1) describe a behavioral intervention designed for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty, and (2) use a quasi-experimental design to evaluate the potential efficacy of the intervention on pain severity, catastrophizing cognitions, and disability.

Design

Quasi-experimental nonequivalent control group design with a 2-month follow-up.

Setting

Two university-based orthopedic surgery departments.

Participants

Adults (N=63) scheduled for knee replacement surgery who reported elevated levels of pain catastrophizing. Patients were recruited from 2 clinics and were assessed prior to surgery and 2 months after surgery.

Interventions

A group of 18 patients received a psychologist-directed pain coping skills training intervention comprising 8 sessions. The other group, a historical cohort of 45 patients, received usual care.

Main Outcome Measures

Western Ontario and McMaster Universities Arthritis Index Pain and Disability scores, as well as scores on the Pain Catastrophizing Scale.

Results

Two months after surgery, the patients who received pain coping skills training reported significantly greater reductions in pain severity and catastrophizing, and greater improvements in function as compared to the usual care cohort.

Conclusions

Pain catastrophizing is known to increase risk of poor outcome after knee arthroplasty. The findings provide preliminary evidence that the treatment may be highly efficacious for reducing pain, catastrophizing, and disability, in patients reporting elevated catastrophizing prior to knee arthroplasty. A randomized controlled trial is warranted to confirm these effects.

Section snippets

Design

This quasi-experimental (ie, nonrandomized) study compared treatment outcome between 2 independent cohorts, 1 that received the pain coping skills training and 1 that received usual care.

Pain coping skills training cohort

Participants in the pain coping skills group were consecutively recruited between April and September 2009 from 2 sites: (1) Virginia Commonwealth University Medical Center, Richmond, Virginia or (2) Duke University Medical Center, Durham, North Carolina. The patients had already consented to have knee

Results

A total of 45 patients from the usual care cohort and 18 patients from the pain coping skills cohort were included in the study (table 3). Of the 18 patients recruited for pain coping skills training, 15 completed the training. For the 3 remaining patients, 2 canceled their surgery and 1 dropped out of the study after the first training session.

Patients in the pain coping skills group demonstrated a mean improvement ± SD in WOMAC Pain scores of 6.9±4.7 points, while patients in the usual care

Discussion

We found that improvement in self-reported function and function-related pain after pain coping skills training was substantial relative to the usual care group. The mean improvements in WOMAC Disability scores were 14.3 points greater for the pain coping skills group than the usual care group. For the WOMAC Pain scale, the mean difference between groups was 4.2 points. These mean differences are substantially larger than the minimal clinically important difference of approximately 10% of the

Conclusions

Despite the limitations in the design of our study, we found what appears to be very promising effects of pain coping skills training for knee arthroplasty patients with elevated pain catastrophizing. Mean differences in WOMAC Pain, WOMAC Function, and PCS scores between the treatment groups far exceeded clinically important differences. The findings indicate that a definitive trial of pain coping skills training for the subset of knee arthroplasty patients with elevated pain catastrophizing is

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Citation Excerpt :
In a randomized controlled trial of 100 patients, Cai et al [31] showed that 4 tailored sessions focusing on relaxation techniques, education about kinesiophobia, and functional rehabilitation delivered by a physiotherapist and a psychologist had significant improvement in pain catastrophizing behavior, kinesiophobia, pain and knee function at 6 months postoperative as compared to a control group. This was similar to Riddle et al [32] who demonstrated, in a case controlled study of 63 patients, that patients who received pain coping skills training by a psychologist over a series of 8 sessions had greater improvements in function, reductions in pain severity, and catastrophizing. However, in a subsequent randomized controlled trial by the same author, they could not demonstrate a difference in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score at 12 months in patients who received pain coping skills training via telephone as compared to arthritis education or standard care in patients who exhibit pain catastrophizing behavior [33].
The relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.
A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.
We recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).
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: Supported by the National Institute of Arthritis, Musculoskeletal and Skin Diseases (grant no. 1R34AR056727-01).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints will not be available from the author.

: Published online April 29, 2011 at www.archives-pmr.org.

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Original articlePain Coping Skills Training for Patients With Elevated Pain Catastrophizing Who Are Scheduled for Knee Arthroplasty: A Quasi-Experimental Study

Abstract

Objectives

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Design

Pain coping skills training cohort

Results

Discussion

Conclusions

Pain

J Pain

J Pain

Pain

Behavior Therapy

Med Clin North Am

Osteoarthritis Cartilage

Pain

Pain

Behavior Therapy

Pain Manag Nurs

Pain

Pain

Pain

Gen Hosp Psychiatry

J Pain

J Pain

Pain

NIH Consensus Statement on total knee replacement December 8-10, 2003

J Bone Joint Surg Am

The John Insall Award: patient expectations affect satisfaction with total knee arthroplasty

Clin Orthop Relat Res

Predicting total knee replacement pain: a prospective, observational study

Clin Orthop Relat Res

Health-related quality of life after knee replacement

J Bone Joint Surg Am

Pain in the assessment of total knee replacement

J Bone Joint Surg Br

Health-related quality of life in total hip and total knee arthroplastyA qualitative and systematic review of the literature

J Bone Joint Surg Am

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

Pain Res Manag

Prospective relation between catastrophizing and residual pain following knee arthroplasty: two-year follow-up

Pain Res Manag

Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty

Clin Orthop Relat Res

Demographic and psychosocial predictors of acute perioperative pain for total knee arthroplasty

Pain Res Manag

Theoretical perspectives on the relation between catastrophizing and pain

Clin J Pain

Quasi-experimentation: design & analysis issues for field settings

Original article
Pain Coping Skills Training for Patients With Elevated Pain Catastrophizing Who Are Scheduled for Knee Arthroplasty: A Quasi-Experimental Study