Psychological interventions in the pain management after hip and knee arthroplasty: a mini review

Introduction

Joint arthroplasty is one of the most effective therapeutic methods for patients with severe osteoarthritis (OA), hip fragility fracture caused by osteoporosis, and osteonecrosis of the femoral head (1). Most of the pain or functional disability induced by these diseases can be improved by the surgery. But still some patients do not report amelioration of their performance after the arthroplasty surgery, although their radiologic findings are normal (2). The major cause for this abnormal phenomenon may be the persistent post-surgical pain, which results in the emotional upset and individual suffering (3). This chronic pain can last from 3 months to more than 1 year in about 20% patients, which has a negative impact on clinical outcomes (4,5). Apart from the persistent chronic pain, acute pain is another commonly anticipated problem after surgery. It will directly delay the healing process and increase the post-surgery morbidity (6). Moreover, acute pain is of great significance in the occurrence of chronic post-surgical pain (7,8). Thus, the management of post-surgical acute and chronic pain has a direct relationship with the outcomes of knee and hip arthroplasty.

However, the establishment of guidelines and standards for pain management is not easy. As a psychological experience, pain is induced by complex interactions between sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions (9,10). But the causes for pain are not just psychological, age, surgical trauma, nerve damage, and surgery types are other risk factors that must be considered (3). The combination and interaction of these psychological and physical factors makes the interventions for reducing pain harder. When treated with analgesics, the patients have to suffer the risk of drug addiction due to the gradually diminishing pain-reducing efficacy. Besides, other side effects, like nausea, vomiting, and constipation limit the safe and effective doses (11,12). Fortunately, the psychological research on pain predictors helps medical staff to know how the pain symptom occurs and what methods may reduce it. Several studies have proved that the pain can be exacerbated and inhibited by the affective and cognitive variables, which are considered as consistent predictors of both acute pain and chronic pain (13). The level of pain that a patient suffers is closely related to the pain intensity, catastrophizing, and fear. Therefore, distraction, imagery, relaxation, and suggestion have been employed to alter the awareness of pain (14). Except the negative psychological variables, studies on positive psychological variables support that these factors can act as buffers or adaptive coping strategies for reducing pain (15,16). Based on these conditions, psychological interventions for pain management are taken as potential methods in clinical nursing.

The routine psychological interventions are not included in general rehabilitation principles after knee or hip arthroplasty. Some psychological coping strategies have been introduced to minimize the effects of pain, but there are no particular guidelines to follow to reduce pain notably. Because the psychological interventions are different based on the surgery types, technique mechanism, and pain-specific information (17). But considering the evidence of psychological interventions in pain relieving, it is logical to involve this method in facilitating recovery from joint arthroplasty. Herein, we review the predictors for post-surgical pain, and the psychological interventions which can affect the pain perception, rehabilitation, and other treatment outcomes after arthroplasty. We expect to define the effective intervention methods in post-surgical pain management.

Predictors for post-surgical pain

The post-surgical pain can be divided into acute and chronic pain according to a specific timeline. The pain that occurs suddenly after surgery and lasts less than 3 months is considered as acute pain, and the ongoing or recurrent pain lasting for more than 3 months is considered as chronic pain (18). Thus, the predictors are respectively elaborated depending on the type of pain.

Acute pain

The postoperative acute pain is related to age, preoperative chronic pain, epidural analgesia, preoperative anxiety, and depression (19). Among these factors, young age, preoperative moderate to intense pain, preoperative chronic pain, anxiety, and depressive mood demonstrate higher risk for reporting acute post-surgical pain. Compared with male, female patients are more likely to suffer acute pain after arthroplasty (15). They also report higher levels in anxiety and depression. On the other hand, male patients usually represent higher levels of optimism and lower levels of pain catastrophizing (20). These four psychological variables (anxiety, depressive mood, optimism, and catastrophizing) correlate significantly with acute post-surgical pain. Optimism correlates inversely with postoperative acute pain, and the other three variables have positive relationship with this symptom. The difference in psychological status is the major cause for the variational pain intensity in male and female. Patients with optimism mood will confront surgery and the acute pain more positively. They generally pay less attention to pain stimuli, but more attentive to their hopeful medium-term life, which helps them to go through the short-term period pain after surgery (21,22). Nevertheless, patients who have a more negative emotion commonly report a higher risk to bear acute post-surgical pain. Because these emotions can induce high pain sensitivity, pessimistic prospect of the surgery, and maladaptive pain-coping strategies (23,24). Thus, we can conclude that the arthroplasty outcomes are related with the patients’ psychological status.

Except the four variables mentioned above, several other psychological factors have been assessed in the post-surgical pain management. The distress, response expectancy, and psychological robustness have impact on acute pain either (25). The distress mood is similar to depression and pain catastrophizing. Patients having this feeling may angry or upset, and directly influence the surgical outcomes (26). The preoperative response expectancy on pain experience can predict the intensity variation of acute pain immediately after surgery. The action of psychological robustness is like optimism, and it has negative relationship with pain at rest and movement evoked pain (27). Besides, various pain thresholds are evaluated in different surgeries to predict acute postoperative pain, including heat, electrical stimulation, pressure, supra-threshold cold and heat, noxious stimuli, and pain tolerance (28-31). These static psychological tests can predict the acute pain in some extent, but the sensitivity is not enough to estimate pain incidence and intensity (31). Due to the distinction of severity of symptoms, preoperative waiting period, surgery types, and surgeons, it is necessary to make individual psychological pain test based on the different preoperative conditions. The included studies are shown in Table 1.

Table 1 The psychological predictors for post-operative acute pain
Full table

Chronic pain

Unlike acute post-surgical pain, the occurrence of chronic pain is complex and the predictors are more complicated. This persistent pain symptom usually comes from the long-period preoperative suffering and transition from acute postoperative pain. Hence, several predictors for chronic pain are similar to acute pain, like age and some psychological variables. Patients with higher preoperative pain scores and older age are susceptible population to suffer postoperative chronic pain (36). Additionally, the severity of OA and the time these patients spend on waiting for the arthroplasty are positively correlated with the intensity of chronic pain (37,38). Especially the overlong waiting time between first visit and surgical intervention, it can induce the postoperative chronic pain and the worse function recovery (39). The low quality of life during the long-term waiting and the urgent demand of relieving severe symptoms may cause negative emotion, like anxiety, depression, and anger, which are high risk factors for postoperative chronic pain (38). Except the variables mentioned above, other social factors can predict the pain symptom with low sensitivity, like education level, living alone or with partner, and household income level.

Mechanical factors also play vital role in the occurrence of postoperative chronic pain. Several modifications and adaptations will happen after the prostheses are implanted (36). The reaction type and extent depend on the characteristics of prostheses, the quality of host tissue, and the biomechanical conditions (40,41). The shear stress and wear debris production can induce bone loss, osteolysis, and inflammation surrounding the prosthetic implant, leading to the aseptic loosening of the implant and simultaneous chronic pain (42). Fortunately, these postoperative physiological and pathological variables can be detected by radiography examination, like X-ray and dual-energy X-ray absorptiometry (DXA). A suitable prosthetic implant and revision surgery can solve most of the problems and notably relieve the postoperative pain.

However, the psychological predictors are more intricate. Some of them are same as the predict factors of acute pain, including depression, distress, anxiety, and pain catastrophizing. The psychological distress and depression result in worse symptoms at baseline, and they are more likely to cause worse pain scores before and after surgery (43). The duration of pain symptom can be as long as 1 to 2 years (44). And the intensive preoperative anxiety is another risk for the postoperative emotional disturbances and may also cause chronic pain with unclear predisposition, leading to unsatisfying surgical outcomes and extended healing process (45). Moreover, the fear of recurrent pain or preoperative injury causes exaggerated negative postoperative psychological response to pain or the anticipation of pain (46). According to the fear-avoidance model of pain, the persistent fear-avoidance behavior is correlated to worse postoperative pain and disability due to the positive regulation mechanism between pain catastrophizing and pain symptom (47,48). Meanwhile, patients with improvements in these negative emotions usually lead to greater improvements in pain scores, indicating that the mental status is closely related to the postoperative chronic pain symptom (49,50).

Optimism, self-efficacy and relevant psychological mood have negative correlation with the incidence of chronic pain, at the same time, they have positive influence on rehabilitation quality and surgical outcomes (51). The self-efficacy theory has proved that higher scores in self-confidence, optimism, and motivation lead to better improvement of symptoms after surgery (52). Patients with these emotions trend to focus on rehabilitation and home exercise adherence rather than worry about surgical trauma or the recurrent pain (53,54). The sense of coherence is another inverse predictor for chronic pain. When patients suffer from OA or the related operation, weak sense of coherence can induce more severe disability in physical and mental dimensions (55). Strong sense of coherence brings comprehensible, manageable, and meaningful feelings from the environment to patients (56). They will have effective coping strategies to decrease the level of anxiety and depression, displaying the low risk of post-surgical chronic pain (57).

We can conclude that the pain predictors induced by physical operation can be tested and corrected precisely. But the symptoms induced by social aspects or psychological mood are difficult to quantify, which hampers the pain management after arthroplasty. Therefore, the preoperative and postoperative psychological treatment is necessary and effective. The included studies are shown in Table 2.

Table 2 The psychological predictors for post-operative chronic pain
Full table

Psychological interventions

The most commonly used psychological interventions are cognitive behavior therapy (CBT), psychoeducation (PE), and relaxation therapy (RT). We summarized these contents and listed the application methods in this part. The included studies are shown in Table 3.

Table 3 The psychological interventions for post-operative pain
Full table

CBT

CBT is the first-line psychosocial treatment for patients before and after arthroplasty. This theory is developed based on the studies of Beck and Ellis, and aims to help people with psychological dysfunctional symptoms (75,76). For patients who are undergoing arthroplasty, the ABC model (Activating events-Beliefs-Consequences) is crucial in the pain relief (77). Briefly, the long term preoperative severe symptoms and pain after surgery are activating event to patients. The event will interact with the negative or irrational belief to make patients misunderstand that there is no pain in the successful surgery, which is actually impossible for any types of surgery (78). Finally, a maladaptive behavior or cognitive consequence occurs, and they feel pain and doubt the effect of arthroplasty. The deepening doubt and depression moods make them feel that the pain symptom always exists and will last forever (78,79). The knowledge of CBT is a helpful guide for patients to find appropriate cognitive and consequently adaptive behavior to cope with pain. Lots of studies have proved that CBT is effective for solving pain or pain related problems in patients from young age to elder (80,81).

According to the basic principles of CBT, the pain itself is not the core if we want to reduce the pain symptoms (82). We must focus on the interpretation of pain, helping patients to know that how the pain occurs and what they will suffer postoperatively. The changing of their thoughts about the occurrence of pain and the cognition of surgery is helpful to correct their behavioral consequences (83). Meanwhile, the positive behaviors also have powerfully positive influence on their perception of pain. The active exercise promotes fast recovery of functions, improves the surgical outcomes, and relieves the pain symptoms. A positive feedback relationship exists in the pain cognition and response behavior. Another principle is here-and-now, meaning that it is usually more fruitful to focus on current processes rather than the past (84). Telling the patients to feel the functional improvement after daily exercise instead of feeling anxious about the pain they suffered preoperative or the pain they may suffer during the exercise. More importantly, patients have to see that the pain is not a single issue as it comes from the interactions with thoughts, emotions, behavior, physiology, and environment (10). Although it is difficult for doctors and nurses to consider all these factors systematically, the more factors we take in, the better pain-reducing effect we will obtain.

For clinical application, few standardized CBT protocol is widely accepted and it is variable in number of sessions and specific techniques (82). It is commonly used by the combination of patients’ education and practice (65). The occurrence mechanism of OA, the process of arthroplasty, the anatomy of hip and knee, the thoughts and feelings about pain, the cognitive methods, and other information about pain and surgery are suitable for education (85). Although the education contents are distinguishing, almost all of the researchers reported notable improvement in functional recovery and pain relief after total hip arthroplasty (THA) and total knee arthroplasty (TKA) (65,86,87).

PE

PE is regarded as a simple therapeutic method compared with CBT, and it is often the part of CBT (78). Different from the CBT which aims to change patients’ belief and the related emotion or behavior, PE focuses on the information given to the patients (88). Patients who are enrolled into PE program will receive advice and suggestions on how to deal with pain symptoms before and after surgery. This psychological therapeutic method usually does not require any highly developed theoretical background for both therapists and patients, indicating that it is easy to employ in clinical nursing and an important add-on to pharmacological treatment (89). Based on this condition, PE is widely used in the management of inpatients, including education for hospitalization and preoperative conversation. The advantage of this method is the improvement in the care quality perceived by the patients, the better therapeutic alliance, and the better pharmacological adherence (90). It provides a therapeutic alliance between doctors and patients according to collaboration, information, and trust (91).

The mechanism of action of PE can be divided into three levels (90). The first level is the elemental mechanism. It helps patients to be aware of the pain symptom, improves the treatment adherence, and facilitates early diagnosis of other pain related symptoms. The second level is the secondary mechanism. According to the awareness of first level, therapists help patients to control their emotion, avoid anxiety, depression, and distress, and alleviate the effect of pain catastrophizing. The third level is the place to set desirable objectives. Patients in this level generally meet the fits of the first two levels. They are told developed knowledge about the pain, and know how to cope with the psycho-social consequences induced by the postoperative pain. The surgical outcomes, quality of life, and rehabilitation satisfaction are notably improved (88,92,93).

Several classical PE theories are introduced in clinical practice, including ecological systems theory, cognitive-behavioral theory, learning theory, group practice models, stress and coping models, social support models, and narrative approaches (94-96). These models release the postoperative pain symptoms through providing framework for assessing/helping patients to know their diseases, reducing isolation, allowing adaptive coping strategies with pain, recognizing personal strengths, and generating psycho-growth (92,97,98). However, this intervention method cannot be used alone to treat the pain symptoms due to the special condition in THA and TKA. The effectiveness of surgical trauma and psychological factors are usually very strong. Simply watching video, having conversation, or reading books are difficult to reverse the strong negative factors. Two RCT studies demonstrated that PE was insufficient to change behavior or improve surgical outcomes alone (69,70). Combination of PE with other psychological or physical interventions is a better option for the clinical application for postoperative pain management.

RT

RT is a special psychological intervention. It uses simple techniques to help patients to reduce physical and psychological discomfortable feelings, finally achieving a state of relaxation both physically and mentally (99). This technique can improve the negative effects caused by stress, disease, and surgery through some skills, like controlled breathing, focused muscle relaxation, and postural awareness and management (100). During the process of finishing these exercises, the preoperative anxiety and postoperative pain will be reduced in some extent (101). Based on the theory of Benson, a particular brain wave pattern, named alpha waves, will present during relaxation process, and these brain waves can make people feel well-being and happiness (102). In addition to changing the psychological mood, RT can induce some physiological reactions which are helpful to release anxiety and pain, including decreased oxygen consumption, carbon dioxide elimination, blood pressure, heart and respiratory rate, norepinephrine responsivity, increased heart rate variability, and alterations in cortical and subcortical brain regions (103-106).

Although techniques in RT are different, several common principles should be followed before this intervention (102). The first one is the appropriate surrounding environment (107). The inpatient ward is not suitable for relaxation as the noisy and privacy-free environment is hard for patients to focus on the exercise. An independent treatment room for one or two patients may be useful to realize the mental and physical relaxation before and after surgery. The second one is the personal emotion (108). Patients with severe acute pain symptoms or uncomfortable clothes are not the best candidates for RT. The psychological force and strained moods have negative influence on relaxation. Thus, participants must release in the exercise, indicating that a detailed psychological education is necessary to improve their treatment adherence. The last one is the treatment time (109). Because of the physiological reactions induced by RT, it is inappropriate to take relaxation intervention after meal or before sleep.

For the clinical application, meditation, yoga, Tai Chi, progressive muscle relaxation, biofeedback, and breathing exercises are the commonly used methods (110). Moreover, combination with guided imagery is another normal option for the clinical application of RT. After the patients are relaxed, images of relaxation or comforting place can help relieve the specific symptoms, such as pain (111,112). Other relaxation techniques, including hand and foot ‘‘M’’ technique and soothing biorhythmic music, are applicable nondrug intervention with no side effects (113,114). These methods can decrease the postoperative anxiety and pain levels, but some studies proved that the effect was not significant, suggesting that the evidence was encouraging but not conclusive (115). Like the PE, using relaxation alone may be not sufficient for improving the postoperative pain symptoms (78). It can complement analgesics or other nondrug interventions to improve the postoperative pain management in THA and TKA patients (73).

Conclusions

The joint arthroplasty is different from other types of surgeries. Patients who are willing to bear this surgery usually suffer long-term low quality of life due to the joint pain, activity limitation, and disability. These symptoms may induce complex psychological complications, including anxiety, fear, depression, and anger. All of these mental emotions are high risks for the occurrence of postoperative acute pain and chronic pain. Unfortunately, pharmaceutical and physical treatment is useless to most of the mental symptoms. But a few systematical psychological interventions are employed in the clinical nursing and rehabilitation procedures. We summarized some commonly used psychological interventions for the application and efficacy of pain management in the review. The CBT has been proved to have the best postoperative pain-reducing effect, and it can help patients to establish adaptive coping strategies on both mind and behavior. The PE and RT are insufficient when they are used alone, but they can act as the vital supplementary aids for other drug or nondrug interventions. We hope this review can help medical staff more comprehensively understand the generation mechanism of pain induced by joint arthroplasty and establish diversified psychological interventions for patients who are suffering the postoperative pain.

Acknowledgments

Funding: This study was supported by the Postgraduate Research & Practice Innovation Program of Jiangsu Province (SJKY19_0061), and Nanjing Science and Technology Development Project (201803026).

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aoj.2019.12.06). QJ serves as an Editor-in-Chief of Annals of Joint from Mar 2013 to Feb 2021. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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