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Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty

A Multisite Randomized Clinical Trial

Riddle, Daniel L., PT, PhD1; Keefe, Francis J., PhD2; Ang, Dennis C., MD3; Slover, James, MD4; Jensen, Mark P., PhD5; Bair, Matthew J., MD6,7; Kroenke, Kurt, MD6,7; Perera, Robert A., PhD1; Reed, Shelby D., PhD2; McKee, Daphne, PhD2; Dumenci, Levent, PhD8

doi: 10.2106/JBJS.18.00621
Scientific Articles
Supplementary Content 1
Supplementary Content 2

Background: Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education.

Methods: A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure.

Results: Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), −0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, −0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups.

Conclusions: Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

1Department of Physical Therapy, Orthopaedic Surgery and Rheumatology, West Hospital (D.L.R.), and Department of Biostatistics (R.A.P.), Virginia Commonwealth University, Richmond, Virginia

2Pain Prevention and Treatment Research, Department of Psychiatry and Behavioral Sciences (F.J.K. and D.M.), and Duke Clinical Research Institute (S.D.R.), Duke University, Durham, North Carolina

3Section of Rheumatology, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina

4Department of Orthopaedic Surgery, New York University Medical Center, New York, NY

5Department of Rehabilitation Medicine, University of Washington, Seattle, Washington

6VA Center for Health Information and Communication, Indiana University School of Medicine, Indianapolis, Indiana

7Regenstrief Institute, Indianapolis, Indiana

8Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania

E-mail address for D.L. Riddle:

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E-mail address for M.P. Jensen:

E-mail address for M.J. Bair:

E-mail address for K. Kroenke:

E-mail address for R.A. Perera:

E-mail address for S.D. Reed:

E-mail address for D. McKee:

E-mail address for L. Dumenci:

Disclosure: This study was funded by grants from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (UL1TR000058) and the National Institute of Arthritis Musculoskeletal and Skin Diseases (NIAMS) (UM1AR062800). One author of this study (S.D.R.) also received personal fees as a consultant for Virginia Commonwealth University to conduct an economic evaluation of the intervention. The NIH or NIAMS had no role in the design, conduct, or presentation of study findings. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

Copyright © 2019 by The Journal of Bone and Joint Surgery, Incorporated
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