The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: A randomised controlled trial
Introduction
Osteoarthritis is a leading cause of pain and disability, affecting an estimated 10% percent of the population.1 Total joint arthroplasty (TJA) is the only definitive surgical intervention for treating advanced osteoarthritis of the hip or knee and is one of the highest volume elective surgeries performed, exceeding 100,000 procedures each year in Australia.2 While most people report substantial improvements in symptoms after TJA, there is a subset of patients who report ongoing pain, poor function and dissatisfaction after surgery,3 with an estimated 15% failing to achieve a clinically meaningful improvement at 12 months.4,5
Pre-surgery psychological distress is an important predictor of patient outcomes following TJA and co-morbidities including depression, anxiety, neuroticism, catastrophizing, poor self-esteem, and low self-efficacy, are consistently associated with less than expected symptom improvement, in both the short and longer term.6, 7, 8, 9, 10, 11 Up to 40% of people presenting for TJA self-report moderate to severe psychological distress,12 suggesting that a substantial proportion of patients undergoing TJA is at risk of poor response to surgery. Coinciding with rising TJA numbers, it is likely therefore, that the absolute number of dissatisfied patients will grow unless therapies that effectively target psychological well-being are implemented.
The efficacy of pre-surgery mind-body based interventions on post-surgery outcomes have been examined in a recent systematic review.13 The review which included 20 studies evaluating relaxation, guided imagery and hypnosis, demonstrated that the quality of evidence for the efficacy of mind-body therapies in improving post-surgical outcomes was limited. Most studies were limited by small sample sizes, short-term follow-up and a majority of interventions were initiated the day prior to surgery, without sufficient time to apply and practice learned techniques. Further appropriately conducted studies were recommended to address these limitations.
It has been postulated that therapies such as mindfulness training, whereby acceptance rather than avoidance of pain is promoted, may be more effective than therapies that aim to alter the context of the negative pain experience.14 A systematic review of randomised controlled trials in Mindfulness Based-Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) found evidence for the efficacy of MBSR in improving mental health.15 Mindfulness training has been shown to be efficacious for patients with fibromyalgia,16 arthritis17 and chronic pain,18 but its efficacy for improving post-surgical outcomes has not been established.
Given the established link between pre-operative psychological distress and sub optimal symptom improvement following TJA surgery, we sought to test whether pre-surgery mindfulness training would improve pain and function outcomes in distressed individuals post TJA. The aim of this study therefore, was to determine whether post-surgery pain and physical function could be improved in patients with psychological distress undergoing TJA, if surgery was preceded by a mindfulness-based intervention. We hypothesized that in patients with self-reported psychological distress, improvement in knee pain and function at 12 months post-surgery would be greater when TJA was preceded by an 8-week group-based Mindfulness-Based Stress Reduction (MBSR) program, compared with TJA surgery alone.
Section snippets
Trial design
The trial was a single-centre 2-group, parallel RCT conducted between September 2012 and May 2017. The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTRN12611001184965). The trial protocol has been published,12 and the full protocol is provided in Supplement 1. Protocol changes are summarized in Supplement 2 (s2-Methods 1). The trial was approved by the St. Vincent’s Hospital Human Research Ethics Committee (HREC-A 143/11) and participants gave
Results
Between September 2012 and December 2014, 139 individuals awaiting hip or knee arthroplasty were enrolled, of whom 12 subsequently withdrew prior to treatment allocation (Fig. 1). Of the 65 participants allocated to the intervention, 45 proceeded to arthroplasty. Reasons for not proceeding with surgery included: symptom improvement (n = 14), change of mind (n = 3), deceased (n = 2) and clinically unfit (n = 1). Of the 62 participants allocated to treatment as usual, six did not proceed with
Discussion
In patients with moderate to severe psychological distress, improvements in pain and function 12-months post-TJA were significantly greater for those in whom surgery was preceded by an 8-week MBSR program, compared to a treatment as usual group. While overall, substantial improvements in pain and function were achieved by both groups, a higher proportion of patients who underwent MBSR training prior to TJA experienced a clinically meaningful improvement in pain and function, compared to the
Conclusions
In patients with moderate to severe psychological distress, participating in a pre-surgery MBSR program resulted in greater improvements in pain and function after TJA. As up to 40% of people presenting for TJA report psychological distress12 and this is associated with an increased risk of ongoing pain and poor function following TJA,38,39 substantial reductions in the number of patients who report a poor response to TJA could be achieved if this program was more broadly implemented. What
Contributions
MD was a chief investigator, designed the trial, provided management oversight of the whole trial, wrote the statistical analysis plan, monitored data collection for the whole trial, and drafted and revised the paper. DC was a chief investigator, initiated the collaborative project, designed the trial, provided management oversight of the whole trial, drafted and revised the paper, SK was a chief investigator, designed the trial, provided management oversight of the whole trial, drafted and
Role of the funding source
The trial was funded by the Australian Research Council (DP120101249) and the funder had no role in the study’s design, conduct, nor reporting.
Data sharing
Reasonable requests for patient level data should be made to the corresponding author and will be considered by the trial Chief Investigators. Consent for data sharing was not obtained and ethics approval would be required from the study institution for future use of patient level data.
Declaration of Competing Interest
All authors have completed the Unified Competing Interest form and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work.
Acknowledgement
Associate Professor Dowsey holds an NHMRC Career Development Fellowship (APP1122526). Professor Choong holds an NHMRC Practitioner Fellowship (APP1154203).
References (39)
- et al.
Variations in pain and function before and after total knee arthroplasty: A comparison between Swedish and Australian cohorts
Osteoarthr Cartil
(2017) - et al.
Psychological attributes of preoperative total joint replacement patients: Implications for optimal physical outcome
J Arthroplasty
(2004) - et al.
Psychological and psychiatric factors related to health-related quality of life after total hip replacement - preliminary report
Eur Psychiatry
(2009) - et al.
Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty
Arch Gerontol Geriatr
(2005) - et al.
Predicting the longer term outcomes of total knee arthroplasty
Knee
(2010) - et al.
Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures
Complement Ther Med
(2013) - et al.
Altered anterior insula activation during anticipation and experience of painful stimuli in expert meditators
Neuroimage
(2013) - et al.
Responsiveness and clinically important differences for the WOMAC and SF-36 after hip joint replacement
Osteoarthr Cartil
(2005) - et al.
Responsiveness and clinically important differences for the WOMAC and SF-36 after total knee replacement
Osteoarthr Cartil
(2007) - et al.
Analyzing multiple endpoints in clinical trials of pain treatments: IMMPACT recommendations. Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
Pain
(2008)
Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: A quasi-experimental study
Arch Phys Med Rehabil
Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis
Osteoarthr Cartil
Stratified models of care
Best Pract Res Clin Rheumatol
Comparison of stratified primary care management for low back pain with current best practice (STarT Back): A randomised controlled trial
Lancet
Latent Class Growth Analysis predicts long term pain and function trajectories in total knee arthroplasty: A study of 689 patients
Osteoarthr Cartil
Development of a prognostic nomogram for predicting the probability of nonresponse to total knee arthroplasty 1 year after surgery
J Arthroplasty
Annual report
AOA Ed. Adelaide
What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients
BMJ Open
Cited by (17)
Introduction to OA, communication, and person-centered care
2022, Osteoarthritis Health Professional Training ManualSurgery for osteoarthritis
2022, Osteoarthritis Health Professional Training ManualResearch Buddy partnership in a MD–PhD program: lessons learned
2023, Research Involvement and Engagement