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Hoevenaars EHW, Smolders JMH, Veenstra K, O'Dowd J, Heesterbeek PJC. Improvement in functional outcome 1 year after nonsurgical multidisciplinary treatment for chronic pain after total knee arthroplasty: A prospective cohort study. Knee Surg Sports Traumatol Arthrosc 2024; 32:461-472. [PMID: 38284904 DOI: 10.1002/ksa.12058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024]
Abstract
PURPOSE The purpose of this study was to evaluate a multidisciplinary intervention developed for patients with debilitating chronic pain after total knee arthroplasty (TKA) unresponsive to existing treatment options. METHODS A treatment-based prospective cohort study was caried out in 30 TKA patients with debilitating chronic pain at least 1 year after TKA. The treatment was a multidisciplinary intervention. Main inclusion criteria: no indication for surgery. Primary outcome was function measured by KOOS-PS, OKS, OKS-APQ and WORQ. Secondary outcome measures were pain, fear of movement, self-efficacy, quality of life (QoL), health care and pain medication use, work rehabilitation and patient satisfaction. The assessments took place pre- and directly posttreatment, at 1, 3 and 12 months follow-up. The clinical relevance was assessed by predefined minimal important clinical change (MCIC). RESULTS At baseline patients were on average 64.7 (±7.9) years old, 67% were female, and they had knee pain for 42 (10-360) months. The results at 12-month follow-up: first, a significant improvement was shown in function, pain, fear of movement, self-efficacy and QoL. Second, in 38.5%-69.2% of patients clinical relevant improvement was shown for functional outcome, 31% for pain, and 50% for self-efficacy. Third, 42% of patients reported 'no healthcare use in the past three months'. CONCLUSION One year after a multidisciplinary treatment a clinically relevant improvement was shown in terms of function, pain, self-efficacy and QoL. It seems to be a promising treatment option in this difficult-to-treat patient group with debilitating chronic pain after TKA. Future research should examine the effect of the treatment in a larger study population, considering a control group, and focusing on the working population and evaluating cost-efficacy. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - José M H Smolders
- Department of Orthopedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Kirsten Veenstra
- Department of Orthopedics, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - John O'Dowd
- Hampshire Hospitals NHS Trust, Basingstoke, UK
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2
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Moore A, Wylde V, Bruce J, Howells N, Bertram W, Eccleston C, Gooberman-Hill R. Experiences of recovery and a new care pathway for people with pain after total knee replacement: qualitative research embedded in the STAR trial. BMC Musculoskelet Disord 2022; 23:451. [PMID: 35562815 PMCID: PMC9103301 DOI: 10.1186/s12891-022-05423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background Approximately 20% of people experience chronic postsurgical pain after total knee replacement. The STAR randomised controlled trial (ISCRTN92545361) evaluated the clinical- and cost-effectiveness of a new multifaceted and personalised care pathway, compared with usual care, for people with pain at three months after total knee replacement. We report trial participants’ experiences of postoperative pain and the acceptability of the STAR care pathway, which consisted of an assessment clinic at three months, and up to six follow-up telephone calls over 12 months. Methods Semi-structured interviews were conducted with 27 people (10 men, 17 women) between February 2018 and January 2020. Participants were sampled purposively from the care pathway intervention group and interviewed after completion of the final postoperative trial questionnaire at approximately 15 months after knee replacement. Interviews were audio-recorded, transcribed, anonymised and analysed using inductive thematic analysis. Findings Many participants were unprepared for the severity and impact of postoperative pain, which they described as extreme and constant and that tested their physical and mental endurance. Participants identified ‘low points’ during their recovery, triggered by stiffening, pain or swelling that caused feelings of anxiety, depression, and pain catastrophising. Participants described the STAR assessment clinic as something that seemed “perfectly normal” suggesting it was seamlessly integrated into NHS care. Even in the context of some ongoing pain, the STAR care pathway had provided a source of support and an opportunity to discuss concerns about their ongoing recovery. Conclusions People who have knee replacement may be unprepared for the severity and impact of postoperative pain, and the hard work of recovery afterwards. This highlights the challenges of preparing patients for total knee replacement and suggests that clinical attention is needed if exercise and mobilising is painful beyond the three month postoperative period. The STAR care pathway is acceptable to people with pain after total knee replacement. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05423-5.
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Affiliation(s)
- Andrew Moore
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - Vikki Wylde
- Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - Wendy Bertram
- Bristol Medical School, University of Bristol, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | - Christopher Eccleston
- Centre for Pain Research, The University of Bath, Bath, UK.,Department of Clinical and Health Psychology, The University of Ghent, Ghent, Belgium
| | - Rachael Gooberman-Hill
- Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
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3
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Edwards RR, Campbell C, Schreiber KL, Meints S, Lazaridou A, Martel MO, Cornelius M, Xu X, Jamison RN, Katz JN, Carriere J, Khanuja HP, Sterling RS, Smith MT, Haythornthwaite JA. Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study. BMC Musculoskelet Disord 2022; 23:302. [PMID: 35351066 PMCID: PMC8966339 DOI: 10.1186/s12891-022-05239-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/16/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors. METHODS This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity. RESULTS The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain. CONCLUSIONS This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.
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Affiliation(s)
- Robert R Edwards
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA.
| | - Claudia Campbell
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristin L Schreiber
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Samantha Meints
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Asimina Lazaridou
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Marc O Martel
- Faculties of Dentistry & Medicine, McGill University, Strathcona Anatomy & Dentistry building 3640 University Street, Montreal, Qc, H3A 2B2, Canada
| | - Marise Cornelius
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Xinling Xu
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Robert N Jamison
- Department of Anesthesiology, Perioperative & Pain Medicine, Harvard Medical School, Brigham & Women's Hospital, Pain Management Center, 850 Boylston St, MA, 02467, Chestnut Hill, USA
| | - Jeffrey N Katz
- Departments of Medicine and Orthopedic Surgery, Orthopedic and Arthritis Center for Outcomes Research, Harvard Medical School, Brigham & Women's Hospital, Boston, MA, USA
| | | | - Harpal P Khanuja
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert S Sterling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael T Smith
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer A Haythornthwaite
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Wylde V, Sanderson E, Peters TJ, Bertram W, Howells N, Bruce J, Eccleston C, Gooberman-Hill R. Screening to identify postoperative pain and cross-sectional associations between factors identified in this process with pain and function, three months after total knee replacement. Arthritis Care Res (Hoboken) 2020; 74:790-798. [PMID: 33207083 PMCID: PMC9311148 DOI: 10.1002/acr.24516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/09/2022]
Abstract
Objective To describe the screening and recruitment process of a randomized trial and evaluate associations with knee pain and function 3 months after total knee replacement (TKR). Methods In order to screen for a multicenter trial, a total of 5,036 patients were sent the Oxford Knee Score (OKS) questionnaire 10 weeks post‐TKR. Patients who reported pain in their replaced knee (score of ≤14 on the OKS pain component) completed a second OKS questionnaire 12 weeks post‐TKR. Those patients who were still experiencing pain 12 weeks post‐TKR completed a detailed questionnaire 13 weeks post‐TKR. These data were used to characterize pain in a cross‐sectional analysis. Multivariable regression was performed in order to identify factors associated with pain and function at 13 weeks post‐TKR. Results We received OKS questionnaires from 3,058 of 5,063 TKR patients (60%), and 907 of the 3,058 (30%) reported pain in their replaced knee 10 weeks post‐TKR. By 12 weeks, 179 of 553 patients (32%) reported improved pain (score of >14 on the OKS pain component). At 13 weeks, 192 of 363 patients (53%) who completed a detailed questionnaire reported neuropathic pain, 94 of 362 (26%) reported depression symptoms, and 95 of 363 (26%) anxiety symptoms. More severe pain at 13 weeks postoperatively was associated with poorer general health, poorer physical health, more pain worry, and lower satisfaction with surgery outcome. More severe functional limitation was associated with higher levels of depression, more pain worry, lower satisfaction with surgery outcome, and higher pain acceptance. Conclusion Screening after TKR identified individuals with pain. We identified several potential targets (physical and mental health outcomes, acceptance of pain, and quality of life) for tailored intervention to improve outcomes for patients. Future trials of multidisciplinary interventions warranted.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, UK, Warwick
| | - Emily Sanderson
- Bristol Trials Centre (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Trials Centre (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Wendy Bertram
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | | | - Julie Bruce
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | | | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, UK, Warwick
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Moore AJ, Gooberman-Hill R. Why don't patients seek help for chronic post-surgical pain after knee replacement? A qualitative investigation. Health Expect 2020; 23:1202-1212. [PMID: 32648336 PMCID: PMC7696127 DOI: 10.1111/hex.13098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022] Open
Abstract
Background Although many people are satisfied with their outcome after total knee replacement surgery for osteoarthritis, around 20% report chronic post‐surgical pain. People are often disappointed and unsure about whether their pain is normal and what can be done about it. Given the high prevalence of long‐term post‐operative pain after knee replacement, there is potentially a large hidden population with an unaddressed need for care. Objective In this study, we focus on understanding why some people choose not to consult health care for chronic post‐surgical pain after knee replacement. Methods Semi‐structured interviews were conducted with people who had received total knee replacement, at either of two National Health Service hospitals in the United Kingdom, and who had chronic post‐surgical pain (n = 34, age 55‐93 years). Data were audio‐recorded, transcribed and analysed thematically. Results We found an overall sense of futility amongst participants who believed that nothing further could be done for their on‐going pain. People's perception of their pain was often discordant with that of surgeons and physicians. Other factors that contributed to decisions not to seek help included low expectations about effectiveness and the risks involved in further treatment, treatment burden, participants' prioritization of other health conditions and views about candidacy. Many accepted their on‐going pain. Conclusion Our study indicates why some people with chronic pain after knee replacement do not seek further health care. Understanding patients' beliefs and expectations about chronic post‐surgical pain can inform approaches that might enable people to seek help in the future.
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Affiliation(s)
- Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Abstract
Despite a good outcome for many patients, approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Chronic pain after TKA can affect all dimensions of health-related quality of life, and is associated with functional limitations, pain-related distress, depression, poorer general health and social isolation. In both clinical and research settings, the approach to assessing chronic pain after TKA needs to be in-depth and multidimensional to understand the characteristics and impact of this pain. Assessment of this pain has been inadequate in the past, but there are encouraging trends for increased use of validated patient-reported outcome measures. Risk factors for chronic pain after TKA can be considered as those present before surgery, intraoperatively or in the acute postoperative period. Knowledge of risk factors is important to guide the development of interventions and to help to target care. Evaluations of preoperative interventions which optimize pain management and general health around the time of surgery are needed. The causes of chronic pain after TKA are not yet fully understood, although research interest is growing and it is evident that this pain has a multifactorial aetiology, with a wide range of possible biological, surgical and psychosocial factors that can influence pain outcomes. Treatment of chronic pain after TKA is challenging, and evaluation of combined treatments and individually targeted treatments matched to patient characteristics is advocated. To ensure that optimal care is provided to patients, the clinical- and cost-effectiveness of multidisciplinary and individualized interventions should be evaluated.
Cite this article: EFORT Open Rev 2018;3:461-470. DOI: 10.1302/2058-5241.3.180004
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
| | - Andrew Beswick
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, UK
| | - Ashley Blom
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK.,North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | | | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
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Wylde V, Bertram W, Beswick AD, Blom AW, Bruce J, Burston A, Dennis J, Garfield K, Howells N, Lane A, McCabe C, Moore AJ, Noble S, Peters TJ, Price A, Sanderson E, Toms AD, Walsh DA, White S, Gooberman-Hill R. Clinical- and cost-effectiveness of the STAR care pathway compared to usual care for patients with chronic pain after total knee replacement: study protocol for a UK randomised controlled trial. Trials 2018; 19:132. [PMID: 29467019 PMCID: PMC5822621 DOI: 10.1186/s13063-018-2516-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/30/2018] [Indexed: 12/27/2022] Open
Abstract
Background Approximately 20% of patients experience chronic pain after total knee replacement. There is little evidence for effective interventions for the management of this pain, and current healthcare provision is patchy and inconsistent. Given the complexity of this condition, multimodal and individualised interventions matched to pain characteristics are needed. We have undertaken a comprehensive programme of work to develop a care pathway for patients with chronic pain after total knee replacement. This protocol describes the design of a randomised controlled trial to evaluate the clinical- and cost-effectiveness of a complex intervention care pathway compared with usual care. Methods This is a pragmatic two-armed, open, multi-centred randomised controlled trial conducted within secondary care in the UK. Patients will be screened at 2 months after total knee replacement and 381 patients with chronic pain at 3 months postoperatively will be recruited. Recruitment processes will be optimised through qualitative research during a 6-month internal pilot phase. Patients are randomised using a 2:1 intervention:control allocation ratio. All participants receive usual care as provided by their hospital. The intervention comprises an assessment clinic appointment at 3 months postoperatively with an Extended Scope Practitioner and up to six telephone follow-up calls over 12 months. In the assessment clinic, a standardised protocol is followed to identify potential underlying causes for the chronic pain and enable appropriate onward referrals to existing services for targeted and individualised treatment. Outcomes are assessed by questionnaires at 6 and 12 months after randomisation. The co-primary outcomes are pain severity and pain interference assessed using the Brief Pain Inventory at 12 months after randomisation. Secondary outcomes relate to resource use, function, neuropathic pain, mental well-being, use of pain medications, satisfaction with pain relief, pain frequency, capability, health-related quality of life and bodily pain. After trial completion, up to 30 patients in the intervention group will be interviewed about their experiences of the care pathway. Discussion If shown to be clinically and cost-effective, this care pathway intervention could improve the management of chronic pain after total knee replacement. Trial registration ISRCTN registry (ISRCTN92545361), prospectively registered on 30 August 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2516-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. .,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
| | - Wendy Bertram
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,North Bristol NHS Trust, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.,North Bristol NHS Trust, Bristol, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Kirsty Garfield
- Bristol Randomised Controlled Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Athene Lane
- Bristol Randomised Controlled Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Candy McCabe
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Sian Noble
- Bristol Randomised Controlled Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Oxford, UK
| | - Emily Sanderson
- Bristol Randomised Controlled Trials Collaboration, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Toms
- Exeter Knee Reconstruction Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre and NIHR Nottingham BRC, University of Nottingham, Nottingham, UK
| | - Simon White
- Cardiff & Vale Orthopaedic Centre, University Hospital Llandough, Penarth, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Wylde V, Howells N, Bertram W, Moore AJ, Bruce J, McCabe C, Blom AW, Dennis J, Burston A, Gooberman-Hill R. Development of a complex intervention for people with chronic pain after knee replacement: the STAR care pathway. Trials 2018; 19:61. [PMID: 29361982 PMCID: PMC5781277 DOI: 10.1186/s13063-017-2391-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/07/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Approximately 20% of people who have total knee replacement experience chronic pain afterwards, but there is little evidence about effective interventions for managing this type of pain. This article describes the systematic development and refinement of a complex intervention for people with chronic pain after knee replacement. The intervention is a care pathway involving an assessment clinic and onward referral, with telephone follow-up as required. In the design of this multistage study, we chose to focus on ensuring that the intervention was deliverable, implementable and acceptable. METHODS In line with the UK Medical Research Council's recommendations for comprehensive development of complex interventions, multiple phases of work were undertaken. Following on from initial development work to design the intervention, the draft intervention content was refined through consensus questionnaires with 22 health professionals and discussion at meetings with 18 healthcare professionals. Testing of intervention delivery and acceptability to patients was undertaken by two health professionals delivering the assessment clinic to ten patients. Views about future implementation within the context of a randomised trial were evaluated through a questionnaire based on the Normalisation Measure Development (NoMAD) instrument with ten health professional stakeholders. RESULTS Consensus work with health professionals ensured the components of the intervention were appropriate and informed a number of substantive changes to improve the intervention. Testing of intervention delivery identified a number of logistical issues that were then addressed in the development of a comprehensive intervention training manual. Engagement with stakeholders indicated that the intervention could be successfully implemented in a clinical setting for evaluation in a randomised trial. CONCLUSIONS This work has informed the development and refinement of a complex intervention for people with chronic pain after knee replacement. The next stage is to evaluate the clinical and cost-effectiveness of the STAR care pathway in a multicentre randomised trial.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. .,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK.
| | - Nicholas Howells
- North Bristol NHS Trust, Brunel Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Wendy Bertram
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,North Bristol NHS Trust, Brunel Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew J Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Candy McCabe
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol, BS16 1QY, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
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9
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Wylde V, Beswick AD, Dennis J, Gooberman-Hill R. Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review. BMJ Open 2017; 7:e018105. [PMID: 29101145 PMCID: PMC5695416 DOI: 10.1136/bmjopen-2017-018105] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/24/2017] [Accepted: 09/15/2017] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR). DESIGN The systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3 months postoperatively and pain at 6 months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6 months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR. RESULTS After removal of duplicates, 16 430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres. CONCLUSION This systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients' outcomes after TKR.
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Affiliation(s)
- Vikki Wylde
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
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Jones JE, Jones LL, Keeley TJH, Calvert MJ, Mathers J. A review of patient and carer participation and the use of qualitative research in the development of core outcome sets. PLoS One 2017; 12:e0172937. [PMID: 28301485 PMCID: PMC5354261 DOI: 10.1371/journal.pone.0172937] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background To be meaningful, a core outcome set (COS) should be relevant to all stakeholders including patients and carers. This review aimed to explore the methods by which patients and carers have been included as participants in COS development exercises and, in particular, the use and reporting of qualitative methods. Methods In August 2015, a search of the Core Outcomes Measures in Effectiveness Trials (COMET) database was undertaken to identify papers involving patients and carers in COS development. Data were extracted to identify the data collection methods used in COS development, the number of health professionals, patients and carers participating in these, and the reported details of qualitative research undertaken. Results Fifty-nine papers reporting patient and carer participation were included in the review, ten of which reported using qualitative methods. Although patients and carers participated in outcome elicitation for inclusion in COS processes, health professionals tended to dominate the prioritisation exercises. Of the ten qualitative papers, only three were reported as a clear pre-designed part of a COS process. Qualitative data were collected using interviews, focus groups or a combination of these. None of the qualitative papers reported an underpinning methodological framework and details regarding data saturation, reflexivity and resource use associated with data collection were often poorly reported. Five papers reported difficulty in achieving a diverse sample of participants and two reported that a large and varied range of outcomes were often identified by participants making subsequent rating and ranking difficult. Conclusions Consideration of the best way to include patients and carers throughout the COS development process is needed. Additionally, further work is required to assess the potential role of qualitative methods in COS, to explore the knowledge produced by different qualitative data collection methods, and to evaluate the time and resources required to incorporate qualitative methods into COS development.
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Affiliation(s)
- Janet E. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Laura L. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Melanie J. Calvert
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jonathan Mathers
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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