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  • Preoperative cognitive–behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial

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Original research
Preoperative cognitive–behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial
  1. Asokumar Buvanendran1,
  2. Amanda C Sremac1,
  3. Patricia A Merriman1,
  4. Craig J Della Valle2,
  5. John W Burns3 and
  6. Robert J McCarthy1
  1. 1Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA
  2. 2Orthopedic Surgery, Rush Medical College of Rush University, Chicago, Illinois, USA
  3. 3Behavioral Sciences, Rush Medical College of Rush University, Chicago, Illinois, USA
  1. Correspondence to Dr Robert J McCarthy, Anesthesiology, Rush Medical College of Rush University, Chicago, Illinois, USA; Robert_J_McCarthy{at}rush.edu

Abstract

Introduction Cognitive–behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes.

Methods The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects.

Results In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of −9 (95% CI −1 to −14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI −18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of −6 (−10 to −2, p=0.02).

Conclusions Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes.

Trial registration number ClinicalTrials.gov (NCT 01772329, registration date 21 January 2013).

  • chronic pain
  • acute pain
  • treatment outcome

Data availability statement

Data are available upon reasonable request. Deidentified participant data may be available from RJM (ORCID id:0000-0002-0966-5311), the corresponding author, on request and execution of a data use agreement.

https://doi.org/10.1136/rapm-2020-102258

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    Data availability statement

    Data are available upon reasonable request. Deidentified participant data may be available from RJM (ORCID id:0000-0002-0966-5311), the corresponding author, on request and execution of a data use agreement.

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    Footnotes

    • Correction notice This article has been corrected since it published Online First. The provenance and peer review statement has been included.

    • Contributors AB was involved in the conception or design of the study, drafting the article, critical revision of the article and final approval of the version to be published. AS was involved in the acquisition of the data, drafting the article, critical revision of the article and final approval of the version to be published. PM was involved in the preforming CBT sessions, acquisition of the data, drafting the article, critical revision of the article and final approval of the version to be published. CJDV was involved in data interpretation, drafting the article, critical revision of the article and final approval of the version to be published. JB was involved in conception or design of the study and data interpretation, drafting the article, critical revision of the article and final approval of the version to be published. RJM was involved in the oversight of the study, acquisition and analysis of the data, drafting the article, critical revision of the article and final approval of the version to be published.

    • Funding This study was supported in part by an investigator-initiated unrestricted grant from Pfizer (WI173357), to Rush University Medical Center with Principal investigator as Asokumar Buvanendran of the Department of Anesthesiology.

    • Disclaimer The funding organization had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.