1. How Positive and NegativeThinking CanAffect Overall
Performance and Pain: in application toTotal Knee
Arthroplasty
By: Kate Mroczynski, OTS

2. You are what you think
 Self fulfilling prophecy: “as any expectation, positive or
negative, about a situation or event that affects an individual
behavior in such a manner that it causes that expectation to
be fulfilled”
 If you believe something to be true, the likelihood of it
happening increases
 Positive thoughts = better outcome
 Negative thoughts = poorer outcome
 Can be applied to pain outcomes following surgery

3. TKA:Total KneeArthroplasty
 Arthritis is one of the leading causes of disability in the
United States
 Osteoarthritis is the most common form or arthritis
 21 million individuals in the United States
 Debilitating, severe pain, joint deformity
 Decreased quality of life
 Many choose to undergo a Total Knee Arthroplasy (TKA)

4. TKA:Total KneeArthroplasty
 TKA improves function and reduces pain for many individuals
with many having successful outcomes
 Still there is a significant percentage of individuals who report
large amounts of pain following surgery
 Studies have found as many as 15-30% of individuals report high
amounts of pain following their TKA initially
 In addition, a national survey found 20% of individuals report
moderate to severe pain one year post operative, despite
objective measures of success
 Psychological factors play a key role in pain and a person’s
perspective of a successful outcome

5. Data
 75 participants
 46 women
 29 men
 Mean age: 68.6 years
 R TKA: 45 participants
 L TKA: 30
 3 different hospitals in Canada
 7 different surgeons all using the same technique: “midline incision with para-
medial arthrotomy”
 Bicondylar femoral and tibial components were implanted and cemented
 All participants were administered questionnaires/assessed 1 week pre-
operative and 6 weeks post-operative

6. Measures: Pain and Function
 Western Ontario and McMaster University Osteoarthritis Index
(WOMAC)
 Self-administered assessment
 Participants rate themselves on pain, stiffness and physical
function
 Higher scores indicate greater pain and decreased functioning

7. Measures: Pain Catastrophizing
 Having an irrational thought and believing a situation is worse
than it actually is in reality
 13 item scale that rates factors such as
 Rumination: persistently focusing on the pain
 Magnification: increased unrealistic perception of the pain
 Helplessness: believing pain is out of the individual control
 Higher scores indicated greater catastrophizing and disability

8. Measures: Pain-Related Fears of Movement
 Tampa Scale for
Kinesiophobia used
 17 item questionnaire
 Addresses behavioral
avoidance and disability

9. Results
 Pre-surgical scores on measures of pain catastrophizing and
pain-related fears were positively correlated with post-surgical
measures of pain and decreased function
 The magnification subscale of pain catastrophizing was highly
correlated with increased post-surgical pain

10. Interpretation
 Psychological factors can influence pain outcomes adversely
 Negative thinking (catastrophizing events, rumination on pain,
helplessness) can have a negative effect on intensity and
persistence of pain following surgery
 Pain-related fears of movement predicted increased functional
difficulties due to the fact individuals will tend to avoid
movement
 Inactivity may lead to development
of co-morbidities, muscle atrophy,
chronic pain and social isolation

11. Neurological Effects  Negative thinking and catastrophizing
may have neurophysiological effects on
the brain altering an individual’s
response
 Greater levels of pain catastrophizing
are associated with decreased
responses to opioids within the brain
 Negative thinking may affect pain
inhibitory descending pathways and
facilitate neuroplastic changes in the
spinal cord, in turn making an
individual more sensitive to pain in the
CNS

12. Case Study
 73 year old female
 Diagnosis: Osteoarthritis
 s/p L TKA
 Rated pain 4/10 prior to movement
 High anxiety related to moving
 Apprehensive, nervous prior at beginning of session
 Described sharp pain
 “I can’t walk.” “I can’t do it” “Well it’s just so hard now, I
can’t bend my knee.” “I have been doing things my own way
for so long.”

13. What can be done?
Cognitive interventions
 Acknowledge pain
 Distraction strategies
 Guided imagery/mental practice
 Pursed lipped breathing: breath
in through your nose for 2 counts
and out through your mouth like
you are blowing out a candle
 Relaxation Strategies
 Therapeutic use of touch
Behavioral Interventions
• Exposure techniques have
been shown to be most
effective for fear of
movement

14. Distraction Strategies
 Have shown to reduce perception of pain i.e. listening to
preferred music, talking to an individual, focusing on a different
task
 Focus on positive outcomes, what the individual is looking
forward to following recovery
 Imaging in humans has shown that distraction from pain
activates structures at the beginning of descending inhibitory
systems such as parts of the prefrontal cortex, the rostral
anterior cingulate cortex, and the periaqueductal gray

15. Guided Imagery/Mental Practice
 Mental practice: imagining yourself doing the activity prior to activity
 11 participants s/p TKA performed 5 minutes of mental practice prior
to therapy
 Compared to the control group who only listened to music for 5
minutes, intervention group had increased improvement in ROM,
strength, quality of gait via the Tinetti Gait Assessment, and
functional ability via the Functional Independence Measure
 “Now I want you to imagine yourself sitting up on the edge of your
bed. Let’s work on straightening out your knee. Kick that foot up and
straighten your knee…hold it there…slowly lower your foot to the
floor…”

16. Therapeutic Use ofTouch
 Used in NICU settings to calm premature infants and shown to
reduce pain
 11 infants in the NICU were shown to have reduced heart rate, reduced
cry time and increased respiration if gentle human touch (GHT) was
used during heel stick
• Touch has been shown to reduce blood pressure, heart rate, cortisol levels
and increase oxytocin levels
• Massage has shown to effectively reduce pain levels
 Gate Theory:
 Pain receptors travel via less myelinated nerves taking longer to reach
the brain compared to a pressure signal from touch which travels via
more myelinated fibers
 This causes the touch stimulus to reach the brain faster essentially
closing the gate on the pain stimulus

17. In conclusion
 Positive and negative thinking can affect performance and
overall pain
 Negative perceptions prior to surgery can cause higher levels of
pain post surgery
 Cognitive and behavioral interventions to reduce pain following
TKA
 Exposure
 Mental practice
 Therapeutic touch

18. References
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in determining patient satisfaction after total knee replacement: data from the National
Joint Registry for England and Wales. Journal Of Bone & Joint Surgery, British Volume,
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Blackburn, J., Qureshi, A., Amirfeyz, R., & Bannister, G. (2012). Does preoperative anxiety
and depression predict satisfaction after total knee replacement?. The Knee, 19(5), 522-
524. doi:10.1016/j.knee.2011.07.008
Fell, N. (2001). The effectiveness of mental practice as a complement to traditional
therapy in rehabilitation outcomes of patients status-post total knee arthroplasty.
Field, T. (2010). Touch for socioemotional and physical well-being: A review.
Developmental Review, 30(4), 367-383. doi:10.1016/j.dr.2011.01.001
Guéguen, N. (2004). Nonverbal Encouragement of Participation in a Course: the Effect of
Touching. Social Psychology Of Education, 7(1), 89-98.

19. References continued
Herrington, C. J., & Chiodo, L. M. (2014). Human Touch Effectively and Safely Reduces Pain in the Newborn Intensive Care Unit. Pain
Management Nursing, 15(1), 107-115. doi:10.1016/j.pmn.2012.06.007
Logan, D. E., & Rose, J. B. (2005). Is postoperative pain a self-fulfilling prophecy? Expectancy effects on postoperative pain and patient-
controlled analgesia use among adolescent surgical patients. Journal Of Pediatric Psychology, 30(2), 187-196. doi:10.1093/jpepsy/jsi006
Nelson, D. W., & Knight, A. E. (2010). The power of positive recollections: reducing test anxiety and enhancing college student efficacy
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Ruscheweyh, R., Kreusch, A., Albers, C., Sommer, J. & Marziniak, M. (2011). The effect of distraction strategies on pain perception and
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Sullivan, M., Tanzer, M., Reardon, G., Amirault, D., Dunbar, M., & Stanish, W. (2011). The role of presurgical expectancies in predicting
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Sullivan, M., Tanzer, M., Stanish, W., Fallaha, M., Keefe, F., Sommonds, M. & Dunbar, M. (2009). Psychological determinants of
problematic outcomes following Total Knee Arthroplasty (English). Pain (Amsterdam), 143(1-2), 123-129.
http://literarydevices.net/self-fulfilling-prophecy/
https://my.clevelandclinic.org/health/diseases_conditions/hic_Understanding_COPD/hic_Pulmonary_Rehabilitation_Is_it_for_You/hic_
Pursed_Lip_Breathing

20. Questions?
 Thank you!