This study examined psychological factors that may predict problematic outcomes following total knee arthroplasty (TKA). 75 patients completed measures of pain catastrophizing, pain-related fears, depression, and pain/function before and 6 weeks after TKA surgery. Results showed that pre-surgical pain and pain catastrophizing uniquely predicted greater post-surgical pain severity. Pre-surgical pain-related fears predicted worse function at follow-up in initial analyses but not when accounting for other medical factors. The findings suggest different psychological factors may influence post-surgical pain versus function. Targeting psychological risk factors could potentially improve outcomes after TKA.

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Psychological determinants of problematic
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Article in Pain · June 2009
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2. Psychological determinants of problematic outcomes following Total
Knee Arthroplasty
Michael Sullivan a,*, Michael Tanzer b
, William Stanish c
, Michel Fallaha d
, Francis J. Keefe e
,
Maureen Simmonds f
, Michael Dunbar c
a
Department of Psychology, McGill University, 1205 Docteur Penfield, Montréal, Que., Canada H3A 1B1
b
Department of Surgery, McGill University, Montréal, Qc, Canada
c
Department of Surgery, Dalhousie University, Halifax, NS B3H 3A7, Canada
d
Department of Surgery, Université de Montréal, Montréal, Qc H1T 2M4, Canada
e
Duke Pain Prevention and Treatment Research Program, Duke University, Durham, NC 27710, USA
f
School of Physical and Occupational Therapy, McGill University, Montréal, Qc H3G 1Y5, Canada
a r t i c l e i n f o
Article history:
Received 30 July 2008
Received in revised form 6 January 2009
Accepted 17 February 2009
Keywords:
Arthritis
TKA
Pain catastrophizing
Fear of movement
Depression
Surgical outcomes
Pain
a b s t r a c t
The primary objective of the present study was to examine the role of pain-related psychological factors
in predicting pain and disability following Total Knee Arthroplasty (TKA). The study sample consisted of
75 (46 women, 29 men) individuals with osteoarthritis of the knee who were scheduled for TKA. Mea-
sures of pain severity, pain catastrophizing, depression, and pain-related fears of movement were com-
pleted prior to surgery. Participants completed measures of pain severity and self-reported disability
6 weeks following surgery. Consistent with previous research, cross-sectional analyses revealed signifi-
cant correlations among measures of pre-surgical pain severity, pain catastrophizing, depression and
pain-related fears of movement. Prospective analyses revealed that pre-surgical pain severity and pain
catastrophizing were unique predictors of post-surgical pain severity (6-week follow-up). Pain-related
fears of movement were predictors of post-surgical functional difficulties in univariate analyses, but
not when controlling for pre-surgical co-morbidities (e.g. back pain). The results of this study add to a
growing literature highlighting the prognostic value of psychological variables in the prediction of
post-surgical health outcomes. The results support the view that the psychological determinants of
post-surgical pain severity differ from the psychological determinants of post-surgical disability. The
results suggest that interventions designed to specifically target pain-related psychological risk factors
might improve post-surgical outcomes.
Ó 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
1. Introduction
Arthritis is the leading cause of disability in North America.
Osteoarthritis (OA) is the most common form of arthritis, affecting
approximately 21 million people in the United States and three
million people in Canada. Patients with severe OA of the knee
who experience significant pain and pain-related disability, or joint
deformity may be considered candidates for Total Knee Arthro-
plasty (TKA) [13,49,55,63].
TKA improves function and yields significant pain relief for the
majority of patients who undergo the procedure [20,36,60]. There
are indications, however, that 15–30% of patients may continue to
experience significant pain following surgery [2,18,36,43,54,
57,62]. The number of patients reporting ongoing symptoms of
pain decreases through the first year post-surgery, yet as many
as 20% of patients report moderate to severe pain one year post-
surgery [2,31]. Studies have shown that, for many patients, pain
persists following TKA, in spite of objective indicators of surgical
success [8,31,45].
Considerable research has accumulated indicating that medical
status variables alone cannot fully account for symptoms of pain
and disability associated with OA [33,39–41]. Biopsychosocial
models have been put forward suggesting that a complete under-
standing of pain-related outcomes will require consideration of
physical, psychological and social factors [40,77,81]. Research has
supported the view that psychological factors play a significant
role in the experience of pain and disability associated with arthri-
tis [33,37,41,42].
In other domains of research, variables such as pain catastro-
phizing, pain-related fears of movement, and depression have been
identified as risk factors for prolonged pain and disability
[50,67,82]. High levels of pain catastrophizing predict
ongoing pain, and more severe disability in individuals with
0304-3959/$36.00 Ó 2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2009.02.011
* Corresponding author. Tel.: +1 514 398 5677; fax: +1 514 343 4896.
E-mail address: michael.sullivan@mcgill.ca (M. Sullivan).
PAINÒ
143 (2009) 123–129
w w w .e l se v ie r .c o m/ lo c a t e/ p a in

3. musculoskeletal conditions [10,23,51,70]. Pain catastrophizing has
also been shown to predict post-surgical pain [29,58]. Pain-related
fears of movement have been shown to be significant determinants
of disability associated with low back pain. Depressive symptoms
have also been implicated as factors contributing to the transition
from acute to chronic pain [14,19,65,73].
Pain catastrophizing, pain-related fears of movement, and
depressive symptoms may be overlapping or unique risk factors
for problematic TKA outcomes. To date, research has yet to simulta-
neously examine the role of pain catastrophizing, pain-related fears
of movement and depressive symptoms as risk factors for problem-
atic recovery following TKA. From a clinical perspective, such re-
search is important because it could help identify which of these
factors should be key targets for psychosocial interventions de-
signed to improve TKA outcomes. From a theoretical perspective,
the predictive value of biopsychosocial conceptualizations will in-
crease as research begins to address more directly how different
model-relevant constructs summate or interact to give rise to
pain-related outcomes.
In the present study, patients scheduled for TKA were assessed
one week prior to surgery and then again 6-weeks post-surgery.
Analyses examined the value of pre-surgical measures of pain
catastrophizing, pain-related fears of movement and depressive
symptoms in the prediction of post-surgical pain severity and
physical function.
2. Methods
2.1. Participants
The study sample consisted of 75 (46 women, 29 men) individ-
uals who had been scheduled for TKA at one of three hospitals in
Eastern Canada. The mean age of the sample was 68.6 years with
a range of 48 to 91 years. The majority of the samples were married
(85%) and had completed at least 12 years of education (90%).
Forty-five patients had TKA of the right knee and 30 had TKA of
the left knee.
2.2. Measures
2.2.1. Pain and function
The Western Ontario and McMaster University Osteoarthritis
Index (WOMAC) was used to assess clinical health status relevant
to TKA outcomes [4]. The WOMAC is a self-administered instru-
ment that yields a total score and subscale scores for (1) Pain, (2)
Stiffness, and (3) Physical Function. For the purposes of the present
study, only the subscale scores for pain and physical function are
reported. Scores on the Pain and Function subscales were con-
verted to a 0–100 scale to facilitate cross-scale and cross-study
comparison [6,9]. Higher scores reflect worse pain and function.
Since the conversion to 100-point scales simply involves multipli-
cation by a constant, the psychometric properties of the instru-
ment are not affected. The WOMAC has been shown to be a valid
and reliable index of health functioning associated with OA, and
has been shown to be sensitive to changes in function subsequent
to TKA [3–5].
2.2.2. Co-morbidities
Common co-morbid conditions that can influence TKA out-
comes include hypertension, osteoarthrosis of other joints, diabe-
tes mellitus, chronic obstructive pulmonary disease (COPD), and
history of tobacco use. Co-morbidity was assessed with the Charl-
son Co-morbidity Index [CCI; 15]. On this measure, respondents
are asked to indicate the presence and severity of 13 different
health conditions. The number of different health conditions en-
dorsed by the respondent is summed to yield a total score [15].
2.2.3. Pain catastrophizing
The Pain Catastrophizing Scale [PCS; 72] consists of 13 items
describing different thoughts and feelings that individuals may
experience when they are in pain. The PCS yields a total score and
subscale scores for rumination, magnification and helplessness.
The PCS total and PCS subscales have been shown to have good to
high internal consistency (Cronbach’s [17] alphas: total = .87, rumi-
nation = .87, magnification = .66, helplessness = .78), and to be
associated with heightened pain, and disability [68–70,72]. In the
present study, Cronbach’s [17] alphas were .94 (PCS Total), .88
(rumination), .83 (magnification), and .89 (helplessness).
2.2.4. Pain-related fears of movement
The Tampa Scale for Kinesiophobia [TSK; 47] is a 17-item ques-
tionnaire that assesses pain-related fear of movement. The TSK has
been shown to be internally reliable (coefficient alpha = .77)
[46,80]. The TSK has been associated with various indices of behav-
ioural avoidance and disability in patients with a variety of health
conditions including OA [16,59,70].
2.2.5. Depressive symptoms
The Patient Health Questionnaire-9 (PHQ-9) was used as a mea-
sure of depressive symptom severity. The PHQ-9 is a 9-item ques-
tionnaire that asks respondents to indicate the frequency with
which they experience each of the nine symptoms considered in
the diagnostic criteria for Major Depression [66]. The PHQ-9 has
been shown to be a valid and reliable measure of depressive symp-
toms in patients with a variety of medical conditions [27,34,48].
2.2.6. Analgesic consumption
A variety of analgesics were used for pain control post-opera-
tively. Two separate indices of 48-h analgesic consumption were
derived: total NSAID consumption (aspirin equivalent units) and
total opioid consumption (morphine equivalent units). For NSAIDS,
the following conversions were applied: aspirin 650 mg = acetomi-
nophen 650 mg = ibuprofen 200 mg = naproxen 125 mg [30]. For
opioids, the following conversions were applied: IV morphine
1 mg = oxycodone 1.5 mg = hydromorphone .15 mg; PO morphine
6 mg = oxycodone 3 mg = hydromorphone .75 mg [1].
3. Procedure
Patients who were scheduled for TKA at one of three collaborat-
ing hospitals were invited to participate in the research. Patients
were informed that the research was concerned with the physical,
psychological and social determinants of recovery following sur-
gery. They were invited to sign a consent form as a condition of
participation. Participants received $25 as compensation for com-
pleting the questionnaires. The research was approved by the
Research Ethics Boards of the McGill University Health Centre,
the Hôpital Maisonneuve-Rosemont and the Capital Health
Authority of Nova Scotia. Participants completed questionnaires
at the time of their pre-surgical evaluation (one day prior to sur-
gery), and at the time of their 6-week post-surgical follow-up.
Surgeries were performed by seven surgeons from three
different hospitals. Surgery was performed under spinal (n = 44)
or general anesthesia (n = 31). Thirty-two patients also received a
femoral block.
The same approach to surgery was used by all surgeons. A mid-
line incision with para-medial arthrotomy was performed. Intra-
medullary alignment guides were used for femoral and tibial cuts.
The posterior cruciate ligament was left or resected at the discre-
tion of the surgeon. Bicondylar femoral and tibial components
were implanted and cemented. Resurfacing of the patellae was at
the discretion of the surgeon. A polyethylene liner was inserted be-
tween the metallic femoral and tibial prostheses. Post-operatively,
124 M. Sullivan et al. / PAINÒ
143 (2009) 123–129

4. patients were given systemic prophylactic antibiotics and prophy-
lactic anticoagulant to decrease deep venous thrombosis risk.
Anterior–posterior (AP) and lateral knee radiographs were taken
and reviewed before patient was transferred to a floor for contin-
ued care. The radiographs were reviewed to ensure that the pros-
thesis was inserted properly and that alignment was correct.
Compression dressings were removed the day after surgery and
continued passive range of motion was applied. Patients were in-
structed to weight bear as tolerated.
At 6-week follow-up, radiographic analysis indicated that all
implants were in good mechanical alignment (2–7° of femoral-tib-
ial valgus) with satisfactory implant placement. None of the study
patients had evidence of ligament instability on follow-up exami-
nation. By clinical standards, all patients in the study sample were
considered surgical successes.
3.1. Data analytic approach
Initial analyses addressed whether scores on predictor variables
or outcome variables varied as a function of surgeon or hospital.
No significant differences were found. As such, surgeon and hospital
are not includedin the predictive analyses. No significantdifferences
on outcome measures were found as a function of type of anesthesia.
One patient developed infection post-surgery. Analyses were con-
ducted with and without this patient. The pattern of results was
not affected and the patient was retained in the predictive analyses.
Descriptive statistics were computed on sample characteristics
and questionnaire scores. Pearson correlations were used to assess
the concurrent and prospective relations among study variables.
Bonferroni correction was used to control for alpha inflation. Mul-
tiple regression analyses were used to assess the value of pre-sur-
gical psychological variables in predicting post-surgical pain and
function. In predictive analyses, initial scores on measures of pain
and function were used as covariates. In the regression results re-
ported, all tolerance coefficients were greater than .60 such that no
problem of multicollinearity was indicated.
4. Results
4.1. Sample characteristics
As shown in Table 1, age distribution, BMI and WOMAC pain
and function scores were similar to those reported in previous re-
search on patients undergoing TKA [7,56]. The average patient re-
ported having two co-morbid health conditions. The most
frequently reported co-morbid health conditions were high blood
pressure (71%), back pain (50%), and heart disease (15%). The pres-
ence or absence of high blood pressure and heart disease did not
influence scores on post-operative pain and function. The presence
of back pain was associated with more impaired post-operative
function, t(73) = 2.0, p < .05, but was unrelated to post-operative
knee pain.
PCS scores were higher than those that have been reported in
previous studies of patients undergoing TKA [64]. The distribution
of depression scores suggests that the average patient was experi-
encing mild symptoms of depression. According to the suggested
cut-off for clinically meaningful depressive symptomatology (e.g.,
PHQ-9 > 15), 4/75 patients scored in the moderate-severe range
of depression.
As expected, there were significant decreases in pain (À13.3),
t(74) = 7.2, p < .001, and functional difficulties (À20.0), t(74) =
11.7, p < .001 from the pre-surgical to post-surgical evaluation.
4.2. Concurrent relations among psychological variables, pain and
function: pre-surgery
Table 2 presents the pre-surgical concurrent relations between
psychological variables and health status variables. In order to con-
trol for alpha inflation, Bonferonni corrected alpha was set at .005.
Consistent with previous research in individuals with arthritic
conditions, measures of pain catastrophizing, pain-related fears,
and depression were significantly correlated with measures of pain
and function [33,38,42,64]. In addition to the correlations pre-
sented in Table 2, age was inversely correlated with pre-surgical
pain, r = À.38, p < .01, and BMI, r = À.46, p < .01.
4.3. Prospectiverelations between pre-surgical psychological variables
and post-surgical outcomes
Table 3 presents the correlations between pre-surgical psycho-
logical measures and post-surgical measures of pain and function.
Bonferonni corrected alpha was set at .005. Pre-surgical scores on
measures of pain catastrophizing, pain-related fears, and depres-
sion were significantly correlated with post-surgical measures of
pain and function. Of the three PCS subscales, the magnification
subscale showed the highest correlations with post-surgical pain
and function. As expected, post-surgical measures of pain and
function were also significantly correlated with pre-surgical mea-
sures of pain and function. BMI, number of co-morbidities, dura-
Table 1
Sample characteristics.
Women Men p Total
Age 68.1 (10.2) 69.5 (9.2) ns 68.6 (9.6)
BMI 30.5 (5.7) 29.0 (4.5) ns 29.7 (5.2)
Comorbid 2.4 (1.2) 2.5 (1.2) ns 2.4 (1.2)
Surgery duration 95.5 (12.2) 101.3 (16.1) ns 97.7 (14.0)
48 h Aspirin eq 529.27 (2433.8) 5226.6 (2165.7) ns 5267.1 (2319.0)
48 h Morphine eq 44.4 (19.0) 42.0 (16.7) ns 43.4 (18.1)
Pain Pre 60.9 (13.9) 58.5 (13.7) ns 59.9 (13.7)
Function Pre 66.0 (12.1) 64.2 (10.6) ns 65.1 (11.6)
Pain Post 44.1 (14.0) 50.8 (18.1) ns 46.6 (15.8)
Function Post 44.2 (13.7) 46.4 (12.9) ns 45.0 (13.3)
PCS 15.4 (12.5) 18.0 (11.0) ns 16.2 (11.9)
TSK 29.2 (9.1) 28.5 (7.0) ns 29.0 (8.3)
PHQ-9 5.6 (4.4) 4.2 (4.3) ns 5.0 (4.4)
Note: N = 75. BMI = body mass index; Comorbid = number of comorbid health
conditions; 48 h Aspirin eq = analgesic consumption first 48 hours post-op, aspirin
equivalent mgs; 48 h Morphine eq = analgesic consumption first 48 hours post-op,
morphine equivalent mgs; Pain Pre = WOMAC Pain Score, pre-surgery; Function
Pre = WOMAC Physical Function Score, pre-surgery; Pain Post = WOMAC Pain Score,
post-surgery; Function Post = WOMAC Physical Function Score, post-surgery;
PCS = Pain Catastrophizing Scale; TSK = Tampa Scale for Kinesiophobia; PHQ-
9 = Patient Health Questionnaire-9.
Table 2
Concurrent relations among pre-surgical variables.
1 2 3 4 5 6 7
1. Pain Pre
2. Function Pre .67**
3. TSK .32**
.37**
4. PHQ-9 .48**
.49**
.44**
5. PCS tot .44**
.49**
.50**
.45**
6. PCS rumin .40**
.40**
.46**
.36**
.90**
7. PCS magni .40**
.44*
.46**
.43**
.88**
.69**
8. PCS helps .42**
.55**
.58**
.53**
.96**
.78**
.82**
Note: N = 75. Pain Pre = WOMAC Pain Score, pre-surgery; Function Pre = WOMAC
Physical Function Score, pre-surgery; Pain Post = WOMAC Pain Score, post-surgery;
Function Post = WOMAC Physical Function Score, post-surgery; TSK = Tampa Scale
for Kinesiophobia; PHQ-9 = Patient Health Questionnaire-9; PCS tot = Pain Catas-
trophizing Scale Total Score; PCS rumin = rumination subscale of the PCS; PCS
magni = magnification subscale of the PCS; PCS helps = helplessness subscale of the
PCS.
**
p < .005.
M. Sullivan et al. / PAINÒ
143 (2009) 123–129 125

5. tion of surgery, and post-surgical analgesic intake were not signif-
icantly correlated with post-operative pain and function.
4.4. Predicting post-surgical pain and function
Separate hierarchical regressions were computed to assess the
value of pre-surgical measures of catastrophizing, pain-related
fears, and depression in the prediction of post-surgical pain and
function. In each regression, age and sex were entered in the first
step. In the second step of the analyses, the pre-surgical score on
the dependent variable (i.e. pain or function) was entered. In the
third step of the analyses, co-morbid back pain (absent, present)
was entered. Finally, the three psychological variables were
entered.
As shown in Table 4, age and sex were entered in the first step
of the analysis but the contribution of this step failed to attain sta-
tistical significance (p = .07). However, in the final regression equa-
tion, sex did emerge as a significant predictor of post-surgical pain
where women reported more intense pain than men. Pre-surgical
pain accounted for 17% of the variance in post-surgical pain, before
entering the psychological variables. Co-morbid back pain did not
contribute to the prediction of post-operative knee pain. The PCS,
TSK and PHQ-9 were entered in the final step of the regression
and contributed significant variance to the prediction of post-sur-
gical pain beyond the variance accounted for by age, sex and pre-
surgical knee and back pain. Examination of the beta weights from
the final regression equation indicated that, of the three psycholog-
ical variables, only the PCS (beta = .28, p < .05) contributed signifi-
cant unique variance to the prediction of post-surgical pain.
Controlling for all other variables in the regression equation, sex,
pre-surgical knee pain and pain catastrophizing accounted for 4%,
8% and 8% of the variance in post-surgical pain, respectively.
Table 5 shows the results of the regression analysis for the pre-
diction of post-surgical function. Pre-surgical WOMAC function
scores accounted for 7% of the variance in post-surgical WOMAC
function scores. Co-morbid back pain accounted for 5% of the var-
iance in post-surgical WOMAC function scores. The three psycho-
logical variables were entered in the final step of the analysis but
failed to contribute significantly to the prediction of post-surgical
WOMAC function scores. Examination of the beta weights for the
final regression equation revealed that the predictive value of the
TSK was marginally significant, p = .06.
5. Discussion
The present findings add to a growing body of literature sug-
gesting that certain psychological variables might predispose indi-
viduals to adverse pain-related outcomes following surgical
intervention. The results of the present research are consistent
with previous studies showing that higher levels of pre-surgical
pain and functional difficulties predict post-surgical pain and func-
tional difficulties [26,31]. The results are also consistent with
previous research showing that women experience more intense
post-surgical pain than men [25,61]. The present research extends
previous findings in showing that pain catastrophizing predicts
post-surgical pain to the same degree as pre-surgical pain. Further-
more, the contribution of pain catastrophizing to the prediction of
post-surgical pain was independent of the contribution of pre-sur-
gical pain. Pain-related fears made a near-zero contribution to the
prediction of post-surgical pain. Pain-related fears of movement
were found to predict post-surgical functional difficulties following
TKA in univariate but not multivariate analyses.
From a theoretical perspective, the findings are consistent with
cognitive behavioural models of pain that suggest that negative
appraisals (e.g., catastrophic thinking) of pain will influence the
intensity and persistence of pain experience. Pain catastrophizing
has been construed as a multidimensional construct comprising
Table 3
Prospective relations between pre-surgical and post-surgical variables.
Pain Post Function Post
Pain Pre .43**
.37**
Function Pre .30 .29
PCS tot .46**
.32
PCS rumin .38**
.17
PCS magni .47**
.37**
PCS helps .42**
.35**
TSK .31 .38**
PHQ-9 .26 .24
BMI .05 .16
Co-morbidities .11 .05
Surgery duration (min) .05 .04
48 h Aspirin À.13 .08
48 h Morphine .06 .01
Note: N = 75. Pain Pre = WOMAC Pain Score, pre-surgery; Function Pre = WOMAC
Physical Function Score, pre-surgery; Pain Post = WOMAC Pain Score, post-surgery;
Function Post = WOMAC Physical Function Score, post-surgery; PCS tot = Pain
Catastrophizing Scale Total Score; PCS rumin = rumination subscale of the PCS; PCS
magni = magnification subscale of the PCS; PCS helps = helplessness subscale of the
PCS; TSK = Tampa Scale for Kinesiophobia; PHQ-9 = Patient Health Questionnaire-9;
48 h Aspirin eq = analgesic consumption first 48 hours post-op, aspirin equivalent
mgs; 48 h Morphine eq = analgesic consumption first 48 hours post-op, morphine
equivalent mgs.
**
p < .005.
Table 4
Regression analysis predicting post-surgical pain severity (WOMAC pain).
Beta R2
change Fchange
Step 1
Age .01
Sex .20*
.06 2.3 (2,72)
Step 2
Pain Pre .28*
.17 16.5 (1,71)**
Step 3
Back pain .11 .01 .7 (1,70)
Step 4
PCS .28*
TSK .07
PHQ-9 .01 .08 2.8 (3,67)*
Note: N = 75. Pain Pre = WOMAC Pain Score, pre-surgery; PCS = Pain Catastrophizing
Scale; TSK = Tampa Scale for Kinesiophobia; PHQ-9 = Patient Health Questionnaire-
9. Values in parentheses are degrees of freedom. Beta weights are from the final
regression equation.
*
p < .05.
**
p < .01.
Table 5
Regression analysis predicting post-surgical physical function (WOMAC function).
Beta R2
change Fchange
Step 1
Age .09
Sex .09 .02 1.0 (2,72)
Step 2
Function Pre .13 .07 6.1 (1,71)**
Step 3
Back pain .23*
.05 4.2 (1,70)*
Step 4
PCS .12
TSK .24
PHQ-9 .04 .09 2.5 (3,68)
Note: N = 75. Function Pre = WOMAC Physical Function Score, pre-surgery;
PCS = Pain Catastrophizing Scale; TSK = Tampa Scale for Kinesiophobia; PHQ-
9 = Patient Health Questionnaire-9. Values in parentheses are degrees of freedom.
Beta weights are from the final regression equation.
p = .06.
*
p < .05.
**
p < .01.
126 M. Sullivan et al. / PAINÒ
143 (2009) 123–129

6. elements of rumination (i.e. excessive focus on pain sensations),
magnification (i.e. heightened perception of the threat value of
pain symptoms) and helplessness (i.e., beliefs that the control of
pain is beyond one’s ability) [75]. In previous research, each of
these dimensions has been shown to have an adverse impact on
pain experience [11,21,79].
In addition to the psychological processes that link catastro-
phizing to adverse pain outcomes, there are indications that catas-
trophizing might also influence neurophysiological processes
involved in pain modulation. High levels of pain catastrophizing
have been associated with poorer response to opioids for both clin-
ical and experimental pain [24,32,35]. It has been suggested that
pain catastrophizing might interfere with descending pain-inhibi-
tory systems and might facilitate neuroplastic changes in the
spinal cord during repeated painful stimulation, subsequently pro-
moting sensitization in the CNS [28].
The findings are also partially consistent with fear-avoidance
models that have been developed to account for the development
of pain-related disability. According to fear-avoidance models,
pain-related fears will lead to activity avoidance or escape, and
in turn, contribute to functional disability. Prolonged periods of
inactivity then compound disability through deconditioning and
heightened risk of developing co-morbidities (e.g., obesity and dia-
betes) [33].
The results of the present research highlight the importance of
examining psychological predictors of post-surgical outcomes
from a multivariate perspective. Like previous research, the pres-
ent study revealed significant variance overlap among measures
of catastrophic thinking, pain-related fears and depressive symp-
toms (20–25% shared variance). In spite of this degree of shared
variance, the findings suggest that pain catastrophizing and pain-
related fears of movement are differentially associated with post-
surgical pain and function. Not only do these findings support
the conceptual distinctiveness of pain catastrophizing and pain-re-
lated fears of movement, but they also have implications for the
nature of interventions that might be considered for individuals
scheduled for TKA.
Many individuals with OA will continue to experience debilitat-
ing symptoms of pain following surgery. In the present study, at
6 weeks post-surgery, 30% of patients reported their pain at rest
to be moderate or severe. Research suggests that approximately
half of these patients might go on to develop chronic pain condi-
tions [31,43,44]. Once symptoms of pain become chronic, available
methods of managing pain, whether pharmacological or psycho-
logical, have only modest impact on suffering and function. Persis-
tent pain symptoms have been identified as central determinants
of disability, both pre- and post-TKA [26,52,78]. Persistent pain
symptoms following TKA can contribute to a trajectory increasing
distress and disability associated with discontinuation of life role
activities, progressive decline toward a sedentary lifestyle, and so-
cial isolation [12,39].
If individuals at risk for post-surgical pain and disability can be
identified before the problem becomes chronic, individual’s suffer-
ing might be prevented or reduced to a significant degree. The re-
sults of the present study suggest that measures of pain
catastrophizing and pain-related fears of movement might be con-
sidered as screening measures for identifying patients at risk for
problematic outcomes following TKA. Individuals identified at risk
might then be considered for targeted interventions that might
prevent the development of persistent pain and disability follow-
ing surgery.
Research suggests that pain catastrophizing and pain-related
fears of movement can best be construed as modifiable risk factors
for problematic health outcomes. Although pain catastrophizing
and pain-related fears of movement have been shown to be stable
in the absence of intervention, both variables have been shown to
decrease in response to intervention [71,74]. Although compara-
tive studies have yet to be conducted, there are data to suggest that
cognitive techniques might be most effective in reducing pain
catastrophizing while behavioural (e.g., exposure) techniques
might be most effective in reducing pain-related fears of move-
ment [76,83]. The present research suggests that interventions that
specifically target pain catastrophizing and pain-related fears of
movement could be adapted for patients scheduled for TKA, and
hold promise of reducing the degree to which patients will con-
tinue to experience significant pain and disability post-surgery.
To date, preventative psychosocial interventions for OA patients
have primarily taken the form of broad-based educational pro-
grams. Since education programs do not select individuals at risk,
nor do they target specific prognostic factors for pain and disabil-
ity, it is not surprising that they have yielded only modest impact
on surgical outcomes [53].
There have been previous reports suggesting that depression
might contribute to poor TKA outcomes, defined either in terms
of pain, function or quality of life indices [25,26]. For example, Fall-
er et al. [22] reported that pre-operative depression scores pre-
dicted post-operative scores of a measure of functional
difficulties at 3 months and 12 months following TKA. In the latter
study, the unique contributions of pain catastrophizing and pain-
related fears of movement were not simultaneously assessed. In
the present study, depression was associated with pain and func-
tion scores in univariate analyses (but not when correlations were
Bonferonni corrected), and not in the multivariate analyses.
Although the negative impact of depression needs to be considered
in the treatment of all debilitating health conditions, depression
might not make a unique contribution to problematic health out-
comes following TKA.
Roth et al. [64] recently reported the results of a study examin-
ing predictors of post-surgical pain in a sample of patients having
undergone TKA. Cross-sectional analyses revealed significant rela-
tions between pain intensity and pain catastrophizing, but pro-
spective analyses failed to show significant predictive value of
pre-operative pain or pre-operative pain catastrophizing. A num-
ber of factors might account for these inconsistent findings. First,
the level of catastrophizing of patients in the Roth et al. sample
(Total PCS = 4.7) was considerably lower than that in the present
study (Total PCS = 16.2). It is possible that high scores on pain
catastrophizing were insufficiently represented in the Roth et al.
study to reveal a prospective relation with post-surgical outcomes.
Roth et al. also assessed pain in the first three days following TKA
while the present study assessed TKA outcomes at 6-weeks post-
surgery. It is possible that due to higher medication intake during
the days immediately following surgery, relations between pain
catastrophizing and pain intensity might have been obscured.
More research is needed to specify the conditions that determine
whether or not prospective relations between psychological vari-
ables and post-surgical outcomes will be observed.
Caution must be exercised in the interpretation of the present
findings. It is important to consider that cross-study discrepancies
provide grounds for questioning the reliability or robustness of the
findings. Sample sizes have been modest in most studies con-
ducted to date on the psychological predictors of post-surgical out-
comes. Confidence in the reliability of the findings awaits
replication with a larger sample size. In addition, the present sam-
ple was followed up for only 6 weeks. While the findings point to
the influence of catastrophic thinking and pain-related fears of
movement on pain and function at 6 weeks post-surgery, it is un-
clear whether these relations would persist over a longer period of
time. In many studies of orthopedic surgery outcomes, follow-up
periods might be as long as two years. Since psychological factors
likely have a dynamic relation with changing health status over
time, longer follow-up periods might be needed to provide a
M. Sullivan et al. / PAINÒ
143 (2009) 123–129 127

7. clearer portrait of the manner, and the time frame within which
pre-surgical psychological variables might impact on orthopedic
post-surgical outcomes.
In spite of these limitations, the results of the present study
showed that pre-surgical levels of pain catastrophizing and pain-
related fears of movement predicted post-surgical pain and func-
tional difficulties, respectively. Research has highlighted that the
prevalence of problematic outcomes following TKA is alarmingly
high, in spite of indicators of surgical success. The findings of the
present study suggest that psychological variables might be play-
ing an important role as determinants of problematic health out-
comes following TKA. These findings might be important to
consider in implementing screening procedures to identify individ-
uals at risk for problematic outcomes and for developing risk-fac-
tor targeted interventions aimed at preventing problematic
outcomes following TKA.
Conflict of interest
None of the authors has any financial interests in the findings of
the present study.
Acknowledgements
This research was supported by a grant from the Canadian Insti-
tutes of Health Research (CIHR). The authors thank Karen Smith,
Donalda Dickey, Allan Hennigar, Kory Arsenault and Anne-Marie
Laliberté for their assistance in participant recruitment and data
collection.
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