EFFECTIVENESS OF PREOPERATIVE PHYSIOTHERAPY IN PATIENTS SCHEDULED FOR A TOTAL KNEE ARTHROPLASTY WHO CATASTROPHIZE ABOUT THEIR PAIN: RANDOMIZED CLINICAL TRIAL

M. Terradas-Monllor^1,2,3, M. Ochandorena-Acha^1,2, H. Beltran-Alacreu⁴, E. García Oltra⁵, F. Collado Saenz⁵, J. Hernandez-Hermoso⁵

¹University of Vic - Central University of Catalonia, Faculty of Health Sciences and Welfare, Vic, Spain, ²Research Group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O), Vic, Spain, ³Hospital Clinic de Barcelona, Pain Medicine Section, Anaesthesiology Deptspasp, Barcelona, Spain, ⁴Toledo Physiotherapy Research Group (Gifto), Faculty of Physical Therapy and Nursing, Universidad de Castilla-La Mancha, Toledo, Spain, ⁵Orthopedic Surgery Department, Germans Trias I Pujol University Hospital, Badalona, Spain

Background: Preoperative pain catastrophizing and moderate-to-severe pain emerged as significant predictors for poor outcomes after total knee arthroplasty (TKA). Interventions such as multimodal physiotherapy and pain neuroscience education are feasible and effective in reducing such risk factors. However, its influence on postoperative outcomes remains unclear.

Purpose: The primary aim of the present study was to investigate the effectiveness of preoperative physiotherapy on postoperative pain after a TKA in symptomatic osteoarthritis patients who catastrophize about their pain. Secondarily, health functioning, pain catastrophizing and self-efficacy were assessed.

Methods: This is a single-blind, three-armed, parallel groups randomized controlled trial performed in a home-based setting between September 2019 and January 2023. A total of 40 subjects scheduled for a TKA due to symptomatic osteoarthritis and a score of ≥ 20 on the Pain Catastrophizing Scale (PCS) were recruited. The participants allocated to the first group received three preoperative sessions of pain neuroscience education and coping skills training (PNE+CST). In contrast, the second group received eight preoperative sessions of multimodal physiotherapy (MPT), composed of pain neuroscience education, therapeutic exercise training and manual therapy. The control group received the usual care, divided into group-based, preoperative biomedical education; early inpatient physiotherapy; and home-based postoperative physiotherapy. Pain intensity was assessed using the Western Ontario and McMaster University Index’s pain subscale and a Visual Analogue Scale (VAS) while resting, walking, and knee flexion. Health functioning was assessed using the WOMAC scale, pain catastrophizing using the PCS, and self-efficacy using the Chronic Pain Self-Efficacy Scale (CPSES). All outcomes were measured before and after the intervention and one month after surgery. The Kruskall-Wallis test was used for comparisons across and between groups. If significant, pairwise Dunn’s test was computed (p<0.05).

Results: No differences were observed between groups at baseline. In the post-intervention assessment, when compared to the control group (n=15), subjects allocated in the PNE+CST group (n=13) showed lower pain levels during walk (p=0.015), knee flexion (p=0,006), pain catastrophizing (p=0,008) and higher self-efficacy (p=0,022). While MPT subjects (n=12) displayed lower pain levels during rest (p=0.025), WOMAC pain scores (p=0,046), WOMAC scores (p=0,006), pain catastrophizing (p<0,001) and higher self-efficacy (p<0,001). One month after surgery, PNE+CST group (n=11) showed lower pain levels during rest (p=0.013), during walk (p=0,022) knee flexion (p=0,001), WOMAC scores (p=0,049), pain catastrophizing (p=0,006) and higher self-efficacy (p=0,014). At the same time, MPT subjects (n=11) displayed lower pain levels during walk (p=0.016), WOMAC scores (p=0,038), pain catastrophizing (p=0,015) and higher self-efficacy (p=0,009).

Conclusions: Both preoperative PNE+CST and MPT interventions effectively reduced pain catastrophizing and pain intensity prior to a TKA. Reducing such risk factors appears to influence postoperative results showing better pain levels, health functioning, lower pain catastrophizing and higher self-efficacy 1 month after surgery. Further research with longer follow-up is needed.

Implications: Many authors highlight the importance of delivering tailored and targeted interventions for subjects at-risk for poor outcomes after a TKA. However, a few studies have assessed them, and the results are conflicting. The present study shows that preoperative physiotherapy might be an effective treatment for these patients improving their short-term postoperative outcomes.

Funding acknowledgements: This work was funded by The Catalan Board of Physiotherapists (Spain).

Keywords:
total knee arthroplasty
physiotherapy
pain catastrophizing

Topics:
Pain & pain management
Education: clinical
Musculoskeletal

Did this work require ethics approval? Yes

Institution: Hospital Germans Trias i Pujol

Committee: Human Research Ethics Committee of the Hospital Germans Trias i Pujol

Ethics number: PI-18-239