Psychosocial Interventions to Reduce Post operative Pain in Total Knee Arthroplasty: A Systematic Review
Authors: Rojas Marcos Carolena , Schiller Nicholas , Braun Sebastian , Knauer Daniel , Yadeau Jacques , Nocon Allina , Jivanelli Bridget , Flevas Dimitrios A. , Sculco Thomas 
Published: July 2024

Background: Total knee arthroplasty (TKA) is a common surgical remedy for patients with end-stage osteoarthritis. Although TKA is generally effective, a significant number of patients experience chronic post-surgical pain. Psychosocial interventions have increasingly become an area of interest in pain management following surgical procedures. Purpose: We aimed to evaluate the impact of pre-operative, peri-operative, and post-operative psychosocial interventions on reducing the likelihood of developing chronic pain after TKA. Methods: We performed a systematic review following the Cochrane guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. A comprehensive search strategy was employed using PubMed, Embase, and Cochrane Central Register of Controlled Trials. Inclusion criteria were (1) patients undergoing; (2) pain outcome assessed ≥1 month post-operatively; (3) prospective and longitudinal study design (eg, randomized controlled trial, experimental non-randomized trial, cohort, case-control studies with measurement of exposure prior to outcome); (4) English language; and (5) psychosocial intervention (cognitive-behavioral, biopsychosocial, dialectical behavioral, psychoeducation, mindfulness, meditation, psychotherapy, relaxation, mind-body therapies, hypnosis). Exclusion criteria were non-primary literature (eg, review articles), non–peer-reviewed studies, and conference proceedings. The methodological quality of included studies was assessed using Cochrane’s tool for Risk of Bias 2 (RoB 2), the methodological index for non-randomized studies (MINORS), and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I). Results: Of 4297 studies reviewed with title and abstract, 4160 were excluded. Of the remaining 137 studies that underwent full-text review, 122 were excluded using the same inclusion and exclusion criteria, and 15 studies were included. Our review indicates a variable but positive impact of psychosocial interventions, such as pre-operative education, relaxation techniques, and cognitive-behavioral therapy, on post-TKA pain. Of the 15 included studies, 9 studies found that psychosocial interventions reduced post-TKA pain. Our review also suggests that cognitive-behavioral therapy may aid in reducing kinesiophobia, pain catastrophizing, and knee pain intensity. For the 12 randomized studies, the risk of bias was deemed “high” concerns for 3 studies, “some” concerns for 5 studies, and “low” concerns for 4 studies. For the 3 non-randomized studies, the risk of bias was deemed “moderate” due to confounding bias. Conclusions: This systematic review of level-I and level-II studies found that the integration of psychosocial interventions into care protocols for TKA offers benefits including improved patient satisfaction and quality of life and reduced health care costs. Limitations include heterogeneity in intervention types and outcomes measured and the varying levels of risk of bias across studies, which may affect the generalizability of the findings. The findings support a broader adoption of holistic, patient-centered approaches in pain management after TKA, emphasizing the importance of psychological well-being for optimal patient outcomes. However, the evidence is limited and constitutes a strong impetus for the further study of these interventions.