Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review

Figures & data

Table 1 Mapped medical subject headings (MeSH) terms and keywords employed in electronic search strategy

Concept	MeSH terms	Keywords
Catastrophizing	Catastrophization; behavioral symptoms; behavioral medicine; stress, psychological; health behavior; psychology, social; mental disorders; anxiety; anxiety disorders; neurotic disorders; personality; attitude to health	Catastrophiz*; emotional; attitud*; coping; pain catastrophizing scale; PCS
Total knee arthroplasty	General surgery; postoperative complications; total knee replacement	Surgery; post-surg*; postsurg*; post-operati*; postoperati*; TKA; TKR
Risk factors	Risk; proportional hazards models; regression analysis; logistic models; risk factors; models, statistical; survival analysis; epidemiologic research design; epidemiology; epidemiologic methods; epidemiologic studies; models, psychological	Risk factor*; predict*
Chronic pain	Pain; postoperative; chronic pain; pain, intractable	Pain

Abbreviations: PCS, Pain Catastrophizing Scale; TKA, total knee arthroplasty; TKR, total knee replacement.

Table 2 Quality assessment of studies included in systematic review

	Edwards et al^Citation5, 2009 [S1]	Forsythe et al^Citation24, 2008 [S2]	Masselin-Dubois et al^Citation25, 2013 [S3]	Noiseux et al^Citation26, 2014 [S4]	Riddle et al^Citation27, 2010 [S5]	Sullivan et al^Citation28, 2011 [S6]
Q1–Clear description of selection of study subjects	1	1	1	1	0	1
Q2–Formal power/sample size calculation	0	0	0	0	1	0
Q3–Number of subjects assessed for eligibility vs enrolled adequately described	0	1	1	1	1	0
Q4–Sufficient description of characteristics of subjects	1	1	1	1	0	1
Q5–Participation rate ≥80% for study groups	0	0	0	0	0	0
Q6–Attrition documented	0	1	1	1	1	0
Q7–Pain catastrophizing exposure measured with valid and reliable tool	1	1	1	1	1	1
Q8–Pain outcome(s) measured with valid and reliable tool	0	1	1	1	1	1
Q9–Distribution of comorbidities/covariates provided for study groups	1	N/A	1	N/A	N/A	1
Q10–Comorbidity/covariates measured identically in study groups	1	1	1	1	1	1
Q11–Results adjusted for potential confounders (minimally: age, sex, and pre-op pain rating)	1	0	1	1	1	1
Q12–Results adjusted for psychosocial factors (minimally: anxiety and depression)	0.5	0	1	1	1	0.5
Q13–Appropriate analysis techniques used	1	0	1	1	1	1
Q14–Sufficient info given on association (effect) sizes	1	1	1	1	1	1
Obtained score	8.5	8.5	12	11	10	9.5
Potential score	14	13	14	13	13	14
Quality rating, % (obtained/potential score × 100)	61	65	86	85	77	68

Note: N/A, not applicable (presentation of covariate distribution across study [S1–S6] groups is not appropriate in case–control studies, since baseline covariates are confounded by outcome).

Figure 1 Flow chart showing numbers of studies screened, assessed for eligibility, and included in the present review. Also shown are reasons for exclusions at each stage and numbers of articles excluded.

Abbreviation: TKA, total knee arthroplasty.

Table 3 Characteristics of studies included in systematic review

Study ID	Reference	Country	Patient Population	N	Age (years)	Female, N (%)	BMI (kg/m^2)	Study design	Follow-up (months)	Outcomes reported
S1	Edwards et al^Citation5	USA	TKA	43	72±7	25 (58)	NR	Cohort with lagged analysis	1, 3, 6, 12	Overall and nighttime pain severity
S2	Forsythe et al^Citation24	Canada	TKA	55	69 (range, 49–85)	35 (64)	NR	Case–control	24	Non-zero pain presence
S3	Masselin-Dubois et al^Citation25	France	TKA	89	69±9	65 (73)	NR	Cohort and case–control	3	Clinically-meaningful pain presence and intensity
S4	Noiseux et al^Citation26	USA	TKA	215	62±10	125 (58)	38±11	Case–controla	6	Moderate-to-severe pain presence
S5	Riddle et al^Citation27	USA	TKA/UKA	140	64b	71 (45)b	31±7b	Case–controla	6	Failure to meaningfully reduce pain
S6	Sullivan et al^Citation28	Canada	TKA	120	67 (range 50–85)	73 (61)	31 (range 20–45)	Cohort	12	Pain intensity

Notes:

a The authors described the study as a cohort study, although cases and controls were defined by outcome

b based on 157 patients eligible for follow-up, although only 140 completed follow-up.

Abbreviations: BMI, body mass index; NR, not reported; TKA, total knee arthroplasty; UKA, unicompartmental knee arthroplasty.

Table 4 Exposures, outcomes, analyses, confounders, and results of studies included in systematic review

Study ID	Author	Catastrophizing (exposure) definition	Outcome (pain) definition	Catastrophizing over follow-up	Pain over follow-up	Analysis	Adjusted covariates	Main results
S1	Edwards et al^Citation5	CSQ-Catastrophizing [C] Subscale, assessed at previous time point (Continuous)	Pain severity: 1) global daily pain, past 24 hours (0–100 scale) and; 2)Nighttime pain (0–100 scale) (Continuous)	CSQ-C (0–36) Pre-op: 3.8±3.9 1 month: 4.5±6.4 3 months: 4.4±5.1 6 months: 4.0±5.4 12 months: 3.8±5.4	Global daily pain (0–100) Pre-op: 58.8±23.0 1 month: 29.8±26.6 3 months: 21.0±25.9 6 months: 13.3±19.9 12 months: 11.0±19.7; Nighttime pain (0–100) Pre-op: 40.7±32.1 1 month: 31.5±29.8 3 months: 18.1±23.7 6 months: 11.6±19.6 12 months: 8.9±16.8	Lagged analysis (GEE used to model correlation of repeated measures within subjects)	Time point, overall pain,^a nighttime pain,^a depression^a	1) Estimate =2.1; SE =2.2; t=0.9; P=0.35; 2) Estimate =5.1; SE =2.5; t=2.0; P=0.04
S2	Forsythe et al^Citation24	PCS Total [T] and subscales for Helplessness [H], Magnification [M], and Rumination [R] (Continuous)	Non-zero pain presence on 1) SF-MPQ-PRI; and 2) SF-MPQ-VAS (Dichotomous)	PCS-T (0–52) Pre-op: 9.8±8.7 3 months 10.0±8.2 12 months: 8.8±9.6 24 months: 9.8±9.3	SF-MPQ-PRI (0–45): Pre-op: 17.8±8.1 3 months: 10.1±8.3 12 months: 8.4±9.3 24 months: 7.6±8.7; SF-MPQ-VAS (0–10): Pre-op: 6.8±1.9 3 months: 3.3±2.7 12 months: 2.7±3.0 24 months: 2.2±2.3	Mann–Whitney U with ROC curve analysis (with vs without pain at follow up)	N/A (insufficient N)	1) PCS-R, P=0.043, AUC =0.70, 95% CI, 0.54–0.86; PCS-T, P=0.028, AUC =0.71, 95% CI, 0.56–0.87; 2) Catastrophizing NS (P’s from 0.56 to 0.71)
S3	Masselin-Dubois et al^Citation25	PCS with subscales for Helplessness [H], Magnification [M], Rumination [R], and Total [T] (Continuous)	1) Clinically-meaningful pain: BPI ≥3/10 (Dichotomous); and 2) Pain intensity: BPI score (Continuous)	PCS-T (0–52) Pre-op (all patients): 19.4±11.2 3 months (patients with BPI ≥3/10) 3.3±2.7	% BPI ≥3/10: Pre-op: 84 3 months: 50.6	Multivariable logistic and linear regression	Baseline: age, sex, radiotherapy, chemotherapy, BPI, pain duration (yrs), anxiety, depression	1) Catastrophizing NS, P>0.05; 2) PCS-M β=0.14, SE =0.05; t=2.06; P=0.04
S4	Noiseux et al^Citation26	PCS score (Continuous)	Moderate to severe pain intensity: NRS ≥8/21 (Dichotomous)	NR	Pain with ROM (%): Pre-op: Low: 48% Moderate: 35% Severe: 17% 6 months: Low: 84% Moderate:14% Severe: 2%	Multivariable logistic regression	Baseline: age, sex, comorbidity score, marital status, RA status, ethnicity, pain score, surgeon, hospital, TSK, depression, anxiety, treatment received (TENS vs placebo)b	Catastrophizing NS, P>0.05
S5	Riddle et al^Citation27	High catastrophizers: top tertile of obtained scores (PCS ≥16) (Dichotomous)	Treatment failure: 1) <50% improvement; and 2) <4 points improvement in WOMAC pain score (Dichotomous)	NR	WOMAC pain % improvement: 6 months: 53.6±39%	Multivariable logistic regression	Baseline: age, sex, comorbidity score, RA status, ethnicity, pain score, surgeon, hospital, TSK	1) OR =2.67 (1.2–6.1); 2) OR =6.04 (1.75–20.81)
S6	Sullivan et al^Citation28	PCS score (Continuous)	Pain severity: WOMAC pain scale (Continuous)	PCS-T (0–52) Pre-op: 12.9±11.2	WOMAC pain score (0–20): Pre-op: 10.6±3.5 6 months: 3.5±3.7	Multivariable linear regression	Baseline: age, sex, BMI, comorbidities, pain, physical function, surgery duration, surgeon, TSK, depression	β=0.27, P<0.05

Note:

a Measured at previous time point

b study was nested within an existing RCT.

Abbreviations: AUC, area under the curve; BMI, body mass index (kg/mg²); BPI, Brief Pain Inventory; CI, confidence interval; CSQ, Coping Strategies Questionnaire; GEE, generalized estimating equations; NR, not reported; NRS, Numerical Rating Scale; NS, not significant; OR, odds ratio; PCS, Pain Catastrophizing Scale; Pre-op, preoperative; PRI, Pain Rating Index; RA, rheumatoid arthritis; ROM, range of motion; SF-MPQ, Short-Form McGill Pain Questionnaire; TENS, transcutaneous electrical nerve stimulation; TSK, Tampa Scale of Kinesiophobia; WOMAC, Western Ontario and McMaster University Osteoarthritis Index; VAS, visual analog scale; vs, versus.

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