Pain Catastrophizing Sabotages Joint Replacements

Pain Catastrophizing Sabotages Joint Replacements

Pain catastrophizing” is a relatively new term. In short, it’s a negative cognitive style. Laura Frey-Law & Steve George write that pain catastrophizing “at the extreme includes feelings and beliefs that the pain experienced is beyond the control of the individual and will inevitably result in the worst possible outcome” (in Sluka, 2016).

The instrument most commonly used for pain catastrophizing is the Pain Catastrophizing Scale (PCS). The PCS is free to use. Here is the manual from Michael Sullivan, and here is a printable version of the PCS.

Several studies suggest that the PCS consists of three dimensions:

  • magnification (“I worry that something serious may happen”),
  • rumination (“I can’t stop thinking about how much it hurts”), and
  • helplessness/pessimism (“It’s awful and I feel that it overwhelms me”).

There is strong evidence that pain catastrophizing is associated with greater pain and poorer function in patients with osteoarthritis, shoulder pain, and fibromyalgia. What is more, studies of low back pain and fibromyalgia found that catastrophizing predicts later pain, even though pain does not predict later pain catastrophizing. This suggests that catastrophizing isn’t just associated with pain — it may cause pain.

This appears true even after joint replacements. A recent systematic review examined pain catastrophizing in six studies of patients undergoing total knee replacements. Five of the six studies identified pain catastrophizing as a significant predictor of pain persisting 3 months or more after surgery, with one of the studies finding that pain catastrophizing predicted pain two years later. What is more, Riddle et al. (2010) found that patients undergoing total knee replacements with a preoperative PCS score of 16 or more were six times more likely to have a poor outcome. The authors defined a poor outcome as failing to achieve the minimal clinically important difference of 4 points on the WOMAC six months later.

So, if pain catastrophizing causes pain, then can we reduce the risk of pain by reducing pain catastrophizing?

There is preliminary evidence that we can. One cohort study examined the effects of a pain coping skills training compared to usual care after knee arthroplasty. The pain coping skills group focused on developing strategies for patients to cope with pain, including relaxation training, distraction, activity-rest cycling, and pleasant activity scheduling. Psychologists provided the pain coping skills sessions, half of which were within one month prior to surgery. Just two months after surgery, patients in the pain coping skills group reported greater reductions in pain severity, catastrophizing, and disability compared to the usual care group.

Psychologists may not be the only ones who can solve the problem of catastrophizing. Riddle et al. (2012) published a protocol of a randomized trial examining the effects of a pain coping program delivered by physical therapists. The researchers are tracking outcomes of patients who score high on the PCS and undergoing total knee arthroplasty. The study is interdisciplinary in nature; physical therapists in this study are receiving training from clinical psychologists, and nurses are providing arthritis education to participants. This study may provide a repeatable method for physical therapists, nurses, and clinical psychologists to cooperate and to maximize the benefit from knee replacements. The study is called the Knee Arthroplasty Pain Coping Skills Training (KASTPain) trial, and you can keep up with it here.

I won’t be surprised if Riddle and company find results similar to studies of cognitive-behavioral-based physical therapy after spinal surgery. There is evidence that physical therapy can assist in breaking the cycle of fear and disability, so perhaps we will see the same for pain catastrophizing.

Nonetheless, even though pain catastrophizing may sabotage joint replacements, we can at least identify those at risk for poor recovery.