Predictors of Persistent Post-Surgical Pain Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Observational Studies

Abstract

Objective Approximately one in four total knee replacement patients develop persistent pain. Identification of those at higher risk could help inform optimal management. Methods We searched MEDLINE, EMBASE, CINAHL, AMED, SPORTDiscus and PsycINFO for observational studies that explored the association between risk factors and persistent pain (≥3 months) after total knee replacement. We pooled estimates of association for all independent variables reported by > 1 study. Results Thirty studies (26,517 patients) reported the association of 151 independent variables with persistent pain after knee replacement. High certainty evidence demonstrated an increased risk of persistent pain with pain catastrophizing (absolute risk increase [ARI] 23%, 95% CI 12 to 35), younger age (ARI for every 10-year decrement from age 80, 4%, 95% CI 2 to 6), and moderate-to-severe acute post-operative pain (ARI 30%, 95% CI 20 to 39). Moderate certainty evidence suggested an association with female sex (ARI 7%, 95% CI 3 to 11) and higher pre-operative pain (ARI 35%, 95% CI 7 to 58). Studies did not adjust for both peri-operative pain severity and pain catastrophizing, which are unlikely to be independent. High to moderate certainty evidence demonstrated no association with pre-operative range of motion, body mass index, bilateral or unilateral knee replacement, and American Society of Anesthesiologists score. Conclusions Rigorously conducted observational studies are required to establish the relative importance of higher levels of peri-operative pain and pain catastrophizing with persistent pain after knee replacement surgery. Systematic review registration PROSPERO CRD42018065943

Socioeconomic Characteristics Associated With the Development of Chronic Pain After Pain Interference Experienced in Early Adulthood

“…Similarly to prior cross-sectional studies, we found that sex, race, marital status, baseline health, insurance coverage, obesity, and mental health concerns are correlated with pain problems. 4,[6][7][8][9][10][11][12][22][23][24] However, by differentiating pain onset from pain persistence in a longitudinal study, we found that some factors, such as obesity, were only associated with pain onset, while others, such as being formerly married, were only associated with pain persistence and not with the onset of new pain problems. Differentiating predictors of pain onset and persistence can help apply epidemiologic findings on the biopsychosocial correlates of chronic pain to the design of interventions intended to prevent the onset of chronic pain or else to treat chronic pain and prevent its recurrence.…”

“…Previous studies have identified younger age, female sex, racial identification other than White, mental health problems, violence, and pre-existing health conditions or comorbidities as predictors of pain persistence in longitudinal studies of adolescent populations and patients recruited in clinical settings (eg, postsurgical and poststroke populations). [22][23][24] Other studies focusing on lower back and musculoskeletal pain have suggested that fatigue, sleeping difficulties, smoking, poor coping mechanisms, and occupational hazards were additional predictors of pain persistence. [25][26][27][28] Our analysis confirmed several of the associations noted above and also identified that pain persistence was more likely among formerly married respondents and respondents experiencing greater pain interference, poor self-rated health, or health-related work limitations at baseline.…”

Biological and psychological factors affecting the sensory and jaw motor responses to orthodontic tooth movement

“…34 Converging evidence from multiple studies has shown that pain catastrophising, a personality trait characterized by negative emotional and cognitive responses to pain, 38,39 is one of the strongest contributors to pain, as it significantly heightens an individual's pain experience and contributes to pain chronicity and pain-related disability. 40,41 Catastrophic thinking builds on rumination (e.g. continually focusing and worrying about pain), magnification (the tendency to magnify the pain experience and its impact) and helplessness (the feeling that the pain cannot be controlled and, therefore, will get worse).…”

“…Converging evidence from multiple studies has shown that pain catastrophising, a personality trait characterized by negative emotional and cognitive responses to pain, 38,39 is one of the strongest contributors to pain, as it significantly heightens an individual's pain experience and contributes to pain chronicity and pain‐related disability 40,41 . Catastrophic thinking builds on rumination (e.g.…”

Preoperative Predictors of Prolonged Opioid Use in the 6 Months After Total Knee Arthroplasty

“…This is critical for developing optimal precision presurgical opioid risk stratification approaches. The current sample was a homogeneous cohort of patients undergoing unilateral total knee arthroplasty (TKA) for osteoarthritis, a population with substantial rates of prolonged postoperative opioid use (20%) 5,12,13,15,36 and persistent pain (25%) 37 …”