Here’s the research I’ve been waiting for to disprove the hype around the idea that “catastrophizing leads to more pain and worse outcomes”. In this study, they expected to get results confirming this “catastrophizing hypothesis“, but they found no such thing.
They did find that when patients’ pain was relieved after successful knee replacement (80% success rate), their catastrophizing score was also dramatically reduced, regardless of which trial arm they were in.
This is contradictory to many less rigorous studies that showed catastrophizing leading to worse outcomes. But this prospective randomized study shows what pain patients have always known:
When pain is relieved, so is catastrophizing.
A high level of pain catastrophizing prior to scheduled knee arthroplasty is not, as previously thought, a harbinger of poor outcomes, and affected patients don’t benefit from cognitive-behavioral therapy–based training in pain coping skills, Daniel L. Riddle, PhD, reported at the OARSI 2019 World Congress.
“The take-home message for us is knee arthroplasty is incredibly effective and there really is no reason to do pain coping skills training in these high–pain catastrophizing patients because the great majority of them have such good outcomes,” said Dr. Riddle, professor of physical therapy at Virginia Commonwealth University, Richmond
“The other clear message from our trial is that, when you have pain-catastrophizing patients and you lower their pain, their catastrophizing is also lowered.
So pain catastrophizing is clearly a response to pain and not a personality trait per se,” he said at the meeting sponsored by the Osteoarthritis Research Society International.
Thank you, Dr. Riddle, for finally stating the obvious and for daring to go against the current hype that blames catastrophizing for chronic pain and worse outcomes after other (less effective) interventions.
He presented the results of a 402-patient, randomized, three-arm, single-blind trial conducted at five U.S. medical centers.
All participants were scheduled for knee arthroplasty for osteoarthritis, and all had moderate- to high-level pain catastrophizing as reflected in the group’s average Pain Catastrophizing Score of 30.
They were assigned to
- an arthritis education active control group,
- usual care, or
- an intervention developed specifically for this study: a cognitive-behavioral therapy–based training program for pain coping skills.
Similar pain coping skills training interventions have been shown to be beneficial in patients with medically treated knee OA but hadn’t previously been evaluated in surgically treated patients.
So actually this study also hints that “medically treated OA” doesn’t cause the extreme lowering of catastrophizing because “medically treated OA” simply doesn’t relieve pain significantly.
The primary study endpoint was change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale at 2, 6, and 12 months after surgery.
The improvement in WOMAC pain in the three study arms was virtually superimposable, going from an average pain score of about 12 preoperatively to 2 postoperatively.
So, the pre-operative counseling intended to lower catastrophizing had zero effect on the outcomes when pain was significantly reduced.
“This was a clear no-effect trial,” Dr. Riddle observed. “These are patients we thought to be at increased risk for poor outcome, but indeed they’re not.”
It’s amazing that this study was even presented while so many are not published when they find no benefit from the “alternative” (non-opioid) treatment they are studying.
Pain Catastrophizing Scores improved from 30 preoperatively to roughly 7 at 1 year. “We’ve never seen pain catastrophizing improvements of this magnitude,” the researcher commented.
It seems pretty clear that the reduction of pain “caused” the reduction of catastrophizing. My experience with pain makes me believe that these results are representative of reality.
I think previous studies didn’t see such dramatic improvements in catastrophizing because they didn’t try out any method of pain relief that was effective enough to see this result.
Of note, even with the impressively large improvements in knee pain, function, and other secondary endpoints in the study group as a whole, roughly 20% of study participants experienced essentially no improvement in their function-limiting knee pain during the first year after arthroplasty.
These nonresponders were spread equally across all three study arms. Further research will be needed to develop interventions to help this challenging patient subgroup.
So a poor outcome of surgery was not correlated to catastrophizing.
Dr. Riddle reported having no financial conflicts regarding the National Institutes of Health-funded study, the full details of which have been published (J Bone Joint Surg Am. 2019 Feb 6;101:218-227).
Below are parts of the abstract of the actual study:
Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty.
Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty.
The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education.
Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care.
So, catastrophizing before surgery had NO effect on the outcomes of total knee replacement surgery (TKA).
Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain. […and the catastrophzing that comes with such disabling pain]