Cognitive behavioral therapy had positive, initial effect on TKA pain catastrophizing
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TAMPA, Fla. — Compared with usual orthopedic care, cognitive behavioral therapy after 1 month decreased pain catastrophizing in patients undergoing total knee arthroplasty, according to results presented here.
However, by 3 months after the cognitive behavioral therapy (CBT) intervention, patients’ pain catastrophizing scores (PCS) were not significantly different than at the 1-month mark, research conducted at the University of Illinois at Chicago showed.
Benjamin Mero, BS, a second-year medical student, presented the findings at the Orthopaedic Research Society Annual Meeting.
Mero and colleagues performed a systematic review and analyzed randomized controlled studies to investigate treatments for pain catastrophizing in the TKA setting.
“Our research demonstrates that CBT is an effective short-term treatment for pain catastrophizing in patients undergoing total knee arthroplasty in the perioperative period,” he said.
Researchers sought to examine the effect of CBT in patients undergoing TKA because conclusions on the effectiveness of pain catastrophizing treatments are mixed in the literature. Furthermore, the sample sizes in studies that did evaluate CBT for patients undergoing TKA are small, Mero said.
For the meta-analysis, researchers queried PubMed, Medline and Cochrane Library databases for randomized controlled trials that involved CBT in patients undergoing TKA. Among 284 results, they identified seven trials (658 patients) conducted from Jan. 1, 2011, to July 31, 2021, that met the inclusion qualifications of having such search terms as ‘pain,’ ‘pain catastrophizing’ and ‘TKA.’ After they excluded a trial that the abstract said had “a quasi-experimental control group,” the six remaining trials all described the CBT method used and included pain catastrophizing scores (PCS) and functional scores.
“CBT in this context refers to the train-of-thought process related to pain, with sessions with a therapist,” Mero said.
Researchers then extracted demographics, PCS scores preoperatively and at 1 month and 3 months postoperatively, as well as secondary functional outcomes between 2 and 6 months postoperatively, which included Knee Society Score, Oxford Knee Score, knee range of motion and WOMAC scale scores. They also extracted a random effects model mean difference (MD) in PCS scores for the study population.
Results after 1 month of the CBT intervention showed the random effects model MD for PCS scores was -4.85, “showing improvement of PCS scores after CBT,” according to the abstract.
“At 1-month postop, our data show that CBT does appear to improve PCS scores with a mean difference of about 5 points compared to routine orthopedic care. At 3 months, the data show that there was no significant difference between CBT and routine orthopedic care. In the end, no differences were found between CBT and routine orthopedic care in functional outcomes at the 2- to 6-month postoperative interval,” Mero said.
Among the study limitations were the small number of studies included in the analysis and that these were all level-2 studies, he said.
Mero said, “Another limitation is a lack of studies that evaluated the effectiveness of CBT over a longer interval.”
Perspective
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We must remember the PCS is only a measure of a patient’s anxiety related to their anticipated and/or realized pain. It has been correlated with numerous patient-reported outcomes, but it is not a direct measure of those outcomes. We anticipate patients will experience the worst of their pain during the first month after TKA, but not have significant pain by 3 months. Therefore, the results favoring CBT to reduce PCS scores at 1-month demonstrate the intervention works during the time period we anticipate patients to have anxiety related to the worst postoperative pain. Because 3 months after TKA most patients don’t have significant pain, we wouldn’t expect to see a difference regarding a treatment for pain catastrophizing. At later time points, direct measures of functional outcomes, instead of PCS, would be more important to investigate whether CBT was able to improve long-term outcomes by improving the patient’s pain experience.
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Mero B, et al. Paper 72. Presented at: Orthopaedic Research Society Annual Meeting. Feb. 4-8, 2022; Tampa, Fla.
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