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BACKGROUND Pain-coping strategies and appraisals are responses to the pain experience. They can influence patient-reported and physical performance outcome measures in a variety of disorders, but the associations between a comprehensive profile of pain-coping responses and preoperative pain/function and physical performance measures in patients scheduled for knee arthroplasty have not been examined. Patients with moderate to high pain catastrophizing (a pain appraisal approach associated with an exaggerated focus on the threat value of pain) may represent an excellent study population in which to address this knowledge gap. QUESTIONS/PURPOSES We asked the following questions among patients with high levels of pain catastrophizing who were scheduled for TKA: (1) Do maladaptive pain responses correlate with worse self-reported pain intensity and function and physical performance? (2) Do adaptive pain-coping responses show the opposite pattern? As an exploratory hypothesis, we also asked: (3) Do maladaptive responses show more consistent associations with measures of pain, function, and performance as compared with adaptive responses? METHODS A total of 384 persons identified with moderate to high levels of pain catastrophizing and who consented to have knee arthroplasty were recruited. The sample was 67% (257 of 384) women and the mean age was 63 years. Subjects were consented between 1 and 8 weeks before scheduled surgery. All subjects completed the WOMAC pain and function scales in addition to a comprehensive profile of pain coping and appraisal measures and psychologic health measures. Subjects also completed the Short Physical Performance Battery and the 6-minute walk test. For the current study, all measures were obtained at a single point in time at the preoperative visit with no followup. Multilevel multivariate multiple regression was used to test the hypotheses and potential confounders were adjusted for in the models. RESULTS Maladaptive pain responses were associated with worse preoperative pain and function measures. For example, the maladaptive pain-coping strategy of guarding and the pain catastrophizing appraisal measures were associated with WOMAC pain scores such that higher guarding scores (β = 0.12, p = 0.007) and higher pain catastrophizing (β = 0.31, p < 0.001) were associated with worse WOMAC pain; no adaptive responses were associated with better WOMAC pain or physical performance scores. Maladaptive responses were also more consistently associated with worse self-reported and performance-based measure scores (six of 16 associations were significant in the hypothesized direction), whereas adaptive responses did not associate with better scores (zero of 16 scores were significant in the hypothesized direction). CONCLUSIONS The maladaptive responses of guarding, resting, and pain catastrophizing were associated with worse scores on preoperative pain and performance measures. These are pain-related responses surgeons should consider when assessing patients before knee arthroplasty. TKA candidates found to have these pain responses may be targets for treatments that may improve postoperative outcome given that these responses are modifiable. Future intervention-based research should target this trio of maladaptive pain responses to determine if intervention leads to improvements in postsurgical health outcomes. LEVEL OF EVIDENCE Level I, prognostic study.

Psychologic status is associated with poor outcome after knee arthroplasty yet little is known about which specific psychologic disorders or pain-related beliefs contribute to poor outcome. To enhance the therapeutic effect of a psychologic intervention, the specific disorders or pain-related beliefs that contributed to poor outcome should be identified. We therefore determined whether specific psychologic disorders (ie, depression, generalized anxiety disorder, panic disorder) or health-related beliefs (ie, self-efficacy, pain catastrophizing, fear of movement) are associated with poor outcome after knee arthroplasty. We conducted a cohort study of 140 patients undergoing knee arthroplasty at two hospitals. Patients completed a series of psychologic measures, provided various sociodemographic data, and were followed for 6 months. Patients were dichotomized to groups with either a favorable or a poor outcome using WOMAC pain and function scores and evidence-based approaches. After adjusting for confounding variables, we found pain catastrophizing was the only consistent psychologic predictor of poor WOMAC pain outcome. No psychologic predictors were associated consistently with poor WOMAC function outcome. An intervention focusing on pain catastrophizing seems to have potential for improving pain outcome in patients prone to catastrophizing pain.

The purpose of our study was to determine if a previously published clinical decision rule designed to estimate the probability of proximal deep vein thrombosis in outpatients is valid when applied exclusively to outpatients with musculoskeletal disorders. We also sought to determine whether probability estimates differed for patients with or without trauma, fracture, or recent orthopaedic surgery. Data collected from outpatients with surgical and nonsurgical musculoskeletal disorders (n = 464) were extracted from the datasets of three previously published studies done on heterogeneous groups of patients (n = 3424). Followup for all patients was 3 months. Testing of all patients for thromboembolic disease was done using validated diagnostic procedures. Probability estimates for orthopaedic outpatients were consistent with estimates from published studies. The proportion of patients who had venous thromboembolism was 5.6% (95% confidence interval, 3.5-8.7%) for the low probability group, 14.1% (95% confidence interval, 8.6-22.4%) for the moderate probability group, and 47.4% (95% confidence interval, 35.3-60%) for the high probability group. Validity estimates for patients with and without recent trauma, surgery, or fracture differed, but not dramatically. The validity of the clinical decision rule as applied to outpatients with musculoskeletal disorders was supported.

Prompt diagnosis of proximal lower extremity deep vein thrombosis in outpatients is critical because of the risk of pulmonary embolism. Our purpose was to determine the accuracy of orthopaedists' clinical decisions regarding the diagnosis of proximal deep vein thrombosis in outpatients. A nationally representative random sample of 2300 orthopaedists received a survey of six clinical vignettes. They were asked to estimate the probability of proximal lower extremity deep vein thrombosis using defined criteria and to specify their planned diagnostic tests. A clinical decision rule and evidence-based diagnostic test recommendations from the general literature served as the gold standard for comparison. Six-hundred seventy-six (29%) surgeons completed the survey. The orthopaedists' planned diagnostic tests differed from the gold standard, but these differences varied depending on the probability of deep vein thrombosis. For the moderate and high risk vignettes, the diagnostic test recommendations agreed with the gold standard approximately 70% of the time. With the exception of gender, no differences were found between respondents and nonrespondents. Orthopaedists' approach to the diagnosis of deep vein thrombosis in outpatients potentially could be improved by applying a clinical decision rule and current evidence on diagnostic test usage.