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Impact of Psychological Distress on Pain and Function Following Knee Arthroplasty
Elizabeth A. Lingard, BPhty, MPhil, MPH1; Daniel L. Riddle, PT, PhD, FAPTA2
1 Department of Orthopaedics, Level 7, Room 134, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
2 Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298-0224. E-mail address: dlriddle@vcu.edu
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Stryker Howmedica (Mahwah, New Jersey, and Limerick, Ireland). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Stryker Howmedica) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Note: The authors acknowledge the work of the Kinemax Outcomes Group in collecting the data presented in this article. The Kinemax Outcomes Group consists of the following surgeons and their research assistants: William Gillespie, Colin Howie, Ian Annan, Alastair Gibson, and Judith Lane (Princess Margaret Rose Hospital, Edinburgh, Scotland); Ian Pinder, David Weir, Nigel Brewster, and Karen Bettinson (Freeman Hospital, Newcastle Upon Tyne, England); Maurice Needhoff and Roz Jackson (King's Mill Centre, Mansfield, England); Tim Wilton and Peter Howard (Derbyshire Royal Infirmary, Derby, England); Ian Forster, Paul Szyprt, Chris Moran, David Whitaker, Mike Bullock, and Zena Hinchcliffe (Queen's Medical Centre, Nottingham, England); Ian Learmonth, John Newman, Chris Ackroyd, George Langkamer, Robert Spencer, Mark Shannon, Evert Smith, John Dixon, and Sarah Whitehouse (Avon Orthopedic Centre, Bristol, England); Clement Sledge, Frederick Ewald, Robert Poss, John Wright, Scott Martin, John Kwon, and Yvette Valderamma (Brigham and Women's Hospital, Boston, MA, USA); Steven Harwin and Michael Lichardi (Beth Israel Medical Center, New York, NY, USA); Mark Mehlhoff, Linda Weiler, and Tom Cahalan (Iowa Medical Clinic, Cedar Rapids, IA, USA); Richard Cronk and Allyson Sandago (Neuromuscular and Joint Center, Corvallis, OR, USA); Stephen Rackemann and Emma McLaughlin (The Knee Centre, Gold Coast, QLD, Australia); Peter Lewis, Robert Bauze, Gordon Morrison, Tom Stevenson, and Jane Stirling (Queen Elizabeth Hospital, Adelaide, SA, Australia); and James Waddell, Emil Schemitsch, and Jane Moreton (Saint Michael's Hospital, Toronto, ON, Canada).
Investigation performed at the Department of Orthopaedics, Freeman Hospital, Newcastle Upon Tyne, United Kingdom

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jun 01;89(6):1161-1169. doi: 10.2106/JBJS.F.00914
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Background: Preoperative psychological distress has been reported to be an important risk factor for poor outcome following lower-extremity arthroplasty. We determined the independent impact of preoperative psychological distress on three, twelve, and twenty-four-month WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain and function scores and on change scores over those time periods.

Methods: Data were obtained from an international group of 952 patients in thirteen centers participating in the Kinemax Outcomes Study. Patients completed the WOMAC and Short Form-36 (SF-36) questionnaires. The mental health (MH) scale of the SF-36 was used to quantify the impact of psychological distress on WOMAC pain and function scores. We also dichotomized patients into groups with and without psychological distress on the basis of evidence-based cut-points. Repeated-measures models were used to derive mean preoperative and three, twelve, and twenty-four-month WOMAC pain and function scores and general linear models were used to derive change scores for patients with and without psychological distress after adjustment for covariates.

Results: Psychological distress, when examined on a continuous scale, was found to predict pain and function at all time-points. WOMAC pain scores for psychologically distressed patients were 3 to 5 points lower, depending on the time-frame, than the scores for the non-distressed patients, after adjustment for covariates. WOMAC function scores did not differ significantly between the two groups following surgery. The changes in the WOMAC pain and function scores for the psychologically distressed patients were not significantly different from those for the non-distressed patients.

Conclusions: Many patients with psychological distress demonstrate a substantial decrease in that distress following surgery. Patients who are distressed have slightly worse pain preoperatively and for up to two years following knee arthroplasty as compared with patients with no psychological distress. With the exception of preoperative scores, these differences are not likely to be measurable at the individual patient level. WOMAC pain and function change scores do not differ between patients with and without distress after adjustment for covariates.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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