Home-administered pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES)


das Nair, R., Anderson, P., Clarke, S. et al. Home-administered pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES): study protocol for a randomised controlled trial. Trials. 2016 Jan 27; 17(1):54


Total knee arthroplasty is an effective procedure to manage chronic pain for those in the late stages of knee osteoarthritis. However, up to 20% of patients continue to experience pain, impairments, and distress even after their surgeries. These patients are often the ones who experience pre-operative mental health difficulties. In an effort to address the psychological distress that leads to and imposes negative effects on long-term functional outcomes, the present study evaluated the clinical and cost-effectiveness of home-administered psychological interventions prior to surgery. This randomized control trial assessed outcomes at 4 and 6 months post-randomization compared to baseline between two groups of patients: those receiving a “prehab” intervention (up to 10 sessions of cognitive behavioral therapy) with usual care, and those receiving only usual care. Patients were recruited from two UK National Health Service (NHS) hospitals and were included if they were over 18 years of age, listed for total knee arthroplasty, had osteoarthritis of the knee, and had anxiety or depression. The study excluded patients with comorbid severe psychiatric conditions or inflammatory arthritis. Additionally, patients receiving psychological interventions at the time of screening were excluded. In general, intervention patients experienced clinically significant benefits with regard to mood, pain, and physical functioning at six-month follow-up, with effect sizes ranging from small (d=0.005) to moderate (d=0.74). There were significant differences in physical function, in particular, between intervention and usual care cohorts. From a qualitative perspective, patients frequently reported that the intervention contributed to experiences of feeling relaxed, calm, and reassured, all while learning to better calibrate expectations. Some patients, however, did not find the intervention helpful. Despite some limitations to the study, it appears feasible to perform pre-operative cognitive behavioral interventions on medical patients undergoing total knee arthroplasty, although questions exist about the optimal number of sessions that patients can benefit from. Indeed, a very early signal suggests that such interventions may benefit patients over time with respect to their functioning in key domains. More research clearly needs to be done, building on specific feedback that participants provided in this very interesting investigation. 

We picked this article for several reasons. First, it engaged important issues related to a “hot” and trending topic – namely, the use of carefully constructed interventions with medical patients that are implemented prior to surgery. Historically, rehabilitation specialists have focused on improving outcomes after an “index” event such as surgery. This paradigm is rapidly shifting as researchers and clinicians recognize that the “prehab” period may be a rich time to intervene, bolstering resilience and thereby improving recovery. Second, it provides a roadmap, albeit a “work in progress” for individuals who are interested in developing and pursuing the implementation of pre-operative interventions. More importantly, the article provides a model of patient-centered research that robustly values the input of patients in the design of future trials – an approach that we, as a field, are aware is increasingly valuable. 

This month's Rehab Science Spotlight was chosen by Jim Jackson PsyD, VA-Tennessee Valley GRECC and Julie Van BA, Vanderbilt Medical Center.