The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty
These authors point out that psychosocial factors, including anxiety, depression, kinesiophobia, central sensitization, and pain catastrophizing, are recognized as negative prognostic factors for total knee arthroplasty (TKA) outcomes.
Depressive disorders are characterized by the "presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect function." Depression is a risk factor for adverse outcomes and objective complications after primary TKA, including mechanical failure and other implant-related complications, all-cause revisions, and medical complications. With respect to implant-related complications and revisions, it is possible that surgeons overinterpret or misinterpret examination and imaging findings in these patients because of their patient's increased pain intensity and activity intolerance, which may lead to an increased chance of reoperating on a patient who would have otherwise been treated more conservatively.
Anxiety is characterized by "excessive fear". Anxiety is a risk factor for increased pain and multiple medical complications.
Central sensitization (CS) is defined by “an increase in the intensity of a response when an identical stimulus is presented multiple times over an extended period of time.” CS has been correlated with increased postoperative pain intensity. Importantly, centrally sensitized patients tend to present with a significantly lower Kellgren-Lawrence grade of OA.
Kinesiophobia is "an excessive and/or irrational fear of movement regarding concern for painful injury" Kinesiophobia is associated with decreased activity, pain and decreased range of motion after TKA
Pain catastrophizing (PC) is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience.” Patients who exhibit higher preoperative levels of PC have more pain and reduced physical activity after TKA.
The authors summarized the strength of evidence in the chart shown below.
As indicated in the right hand column, they did not find strong evidence supporting the benefit of preoperative treatment on outcome for depression, anxiety, or pain catastrophizing. They found that cognitive-behavioral therapy for kinesiophobia and duloxetine for central sensitization
may help to diminish the negative impact of these preoperative comorbidities.
Comment: It seems likely that these relationships found for total knee arthroplasty would apply as well to shoulder arthroplasty.
This information is useful in selecting candidates that are most likely to benefit from arthroplasty and, for selected physiological factors, considering preoperative intervention.
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