Pain coping skills training doesn’t improve knee arthroplasty outcomes– by Bruce Jancin – June 2019
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[3]:218-227).
Below are parts of the abstract of the actual study:
Background
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.
Conclusions
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]
EDS and Chronic Pain News & Info 
NOT being an MD or PhD, I can not relate to the “science” of pain management. What I can relate to is the human suffering when pain is prevalent in the thought process, continuously, to a level that is consistent with torture all while knowing that pain management with opiate medication IS effective! I have had 25 years to meditate, read, consider, and practice all “alternative” forms of pain reduction but I am yet to find any pain management therapy, effective pain management therapy that is as beneficial, effective, as pain management with opiate medication. However when an “expert” that is not experiencing constant, inhuman levels of pain attempts to measure with science what “should” be adequate as far as medication be it non opiate medication or treatment with an opiate medication , the result is more than obvious. opiate medication…..works. A tailored to the patient dosage for many millions of patients IS the only way to manage pain so intense that possibly suicided is recognized by the patient as the ONLY way to stop the pain. Even VERY religious portions of the populous whom in their religious beliefs truly believe that suicide will result in the loss of the immortal soul, still choose do the deed to escape constant, “over the top”, unbearable…..pain. Is this fact…significant or do the “experts” STILL believe that the pain management patient, all of us are in the end simply just “addicts”?
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The pain psychologists have been profiting from the catasptrophizing false narrative, https://www.psychiatryadvisor.com/home/topics/anxiety/dr-beth-darnall-on-treating-catastrophizing-for-pain-relief/
Catastrophizing is more important than the pain itself. https://med.stanford.edu/news/all-news/2016/09/5-questions-beth-darnall-on-opioids-and-pain-management.html
It is most certainly profitable. Just one more of the lies, propaganda, and misinformation tactics, the industries came up with. Industry friendly researchers created a term, that denies the existence or importance of pain. If we ask, Who benefits, firstly the researchers who come up with industry friendly doubt, and confusion. The insurers, They can deny diagnosis and treatment, now described as dangerous. The pharma industry, they can sell expensive but useless alternatives and blame the patients when they don’t work. The healthcare industry, they can deny treatment or diagnosis, because it could lead to opioid addiction or catastrophizing. The industry needed a cover for failed surgeries, multiple appointments, misdiagnosed injuries, and even failed back surgeries.
They had to come up with a false narrative about pain. After all is main reason people even seek medical care. People can ignore all kinds of other symptoms, but pain nags at people. The US has a two tiered health industry, one for the wealthier with good insurance and another for low income people. They had to come up with a false narrative to deny medical care to millions of people. When one of these people has cancer, for example, and turns to a physician, it the main reason they saw the physician is pain, they can be ignored. No research has been done on how often this has happened. They had to come up with a good reason to deny the existence of pain.
Doctors would much rather deal with catastrophization with denial, and platitudes, than to diagnose or treat pain. Treating pain can be dangerous for physicians, as they watch their colleagues who did treat pain with compassion and empathy go to prison or lose their livelihoods. The so called pain psychologists/marketers are propagandists repeating a lie so often it became the “truth.” The industries needed a convenient lie in order to increase profits, deny care and avoid any accountability.
The NIH chose to fund the researchers who came up with convenient denial.
https://med.stanford.edu/news/all-news/2016/09/5-questions-beth-darnall-on-opioids-and-pain-management.html Notice the lies, misreported science and alternate facts, this researcher presents. She made an awful lot of money, gained prestige and created an alternate fact narrative about pain. https://www.practicalpainmanagement.com/resources/practice-management/letters-word-catastrophizing-aipm-ceases-operations-patient-questions
Here she tries to back-peddle the lies, and propaganda that was repeated so often it is now considered fact. https://www.nature.com/articles/d41586-018-04994-5 I need to remind everyone that the reason there is no long term research, is because they chose not to do it. That kind of research is inconvenient and unprofitable. It would be relatively easy to find a cohort of long term patients considering all of the data they have been selectively collecting, such as the prescription monitoring database. By the way, we have no idea what they are doing with that data, or who has access to it. They very clearly did not use any of this data as it was intended.
We thought the internet would bring in the “Free exchange of ideas” instead we see how the data, has been used against all of us. Self described researchers, that are good marketers and built a strong social media presence, by appealing to the industries are amplified. The facts and real research are buried if they conflict with the popular false narrative.
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I’ve been finding studies and articles that debunk catastrophizing ever since I first heard about it:
(You can find more of them using the tag: https://edsinfo.wordpress.com/tag/catastrophizing)
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Thank You Zyp! You were among the first and only online. Other sites reported on catastrophizing as if it were based on facts or science. Lots of newspaper articles written by journalists with no science background referred to catastrophizing too. After all if Stanford, was studying it, it must be real. It is another fairy tale, like Opioid Induced Hyperalgia. What is really disturbing is how quickly an imaginary thing can be presented enough times that it becomes real.
What I could not figure out was how they knew, when mice and rats were catastrophizing. I did , have a poodle once that would fake an injury, if it meant she would get a treat, or if she was in trouble for some kind of mischief.
Check this out. https://twitter.com/CHOIRCare Stanford Pain is peddling this.
https://choir.stanford.edu/
https://choir.stanford.edu/publications/
Now they don’t even have to meet the patient before denying them pain care, treatment or a diagnosis. It is just like the Wallet Biopsy!
“This requires large amounts of data and requires substantial cognitive load for information processing. What CHOIR enables clinicians to do is to begin a basic multidisciplinary assessment of the patient before even meeting him or her. 53% of patients are completing the surveys at home, vs 47% in clinic. CHOIR then displays this information in a logical, easy-to-read format. Domains presented for clinician review include Education, Occupation, Adverse Childhood Experiences, and Substance History. As an example of a small portion of this computer-assisted documentation, on the left is the Social History of a simulated patient profile.”
This sounds really sciency, but there are very likely a lot of data points they won’t collect.
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Yikes – this is all a bit too “A.I.” for me – they’re all after our data, which can be processed, mined, and redeployed as desired to turn us into submissive “consumers of healthcare goods and services”.
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Really glad there is more proof about catastrophizing NOT being indicative of poorer outcomes.
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Yes Zyp, Just imagine how they can monetize this data, and how they can cross pollinate it with insurance information, employment history, and social media activity.
https://www.bloomberg.com/features/2018-palantir-peter-thiel/ This corporation has access to Medicare, prescription drug databases, insurance claims, state welfare agencies, hospitals, social media, banks and cell phones. The comb social media posts, private emails and cell phone conversations for key words for their clients, which includes the federal government.
The CEO is one spooky character, with millions in federal contracts. He is also involved in healthcare, he was offshoring vaccine trials. He has a lot of pull with 45, and is a top supporter. Palantir perfected it’s data tracking overseas, tracking terrorists, and then turned it on us. The big corporations have accesses to this data, and it is pretty clear they are already using it in nefarious ways.
Tracking down immigrants and their family members is just the beginning for these ghouls,
https://www.theverge.com/2016/12/21/14012534/palantir-peter-thiel-trump-immigrant-extreme-vetting https://www.vice.com/en_us/article/9kx4z8/revealed-this-is-palantirs-top-secret-user-manual-for-cops They brag about accessing data across all of these platforms. Healthcare data is more valuable for corporate propaganda and deceptive advertising, that it is for benefiting patients.
These companies are so powerful that if they want to acquire new data sets they just buy the company. Facebook graciously allowed states to hold “Opioid Conferences” on their platform, then used the data from Patients, people with addiction, and desperate family members to market expensive treatment centers. There was enough data available, on participants income and insurance for them to target the marketing.
We should be really suspicious of these clinical trials, and academic institutions too. They have access to a lot of data directly from patients, yet we have not seen any improvement in healthcare. The only improvement is in the marketing. The highly watched preferred advertising slots on TV are full of pharma ads. Healthcare costs have gone up exponentially, and outcomes are no better than they were 30 years ago, except for very specific circumstances. Researchers are studying moods and mindset, rather than study quantifiable measures.
I think that we are all in trouble, all of this big data is being used for lies, propaganda, and marketing. We can look at the so called opioid crisis, after all of these years. There was no way to regulate the big pharma companies, and to distract form the real root causes they went after pain patients, and the overdoses went up. They are able to count every pill these companies sold, but instead of regulation them they went after patients and ruined lives, because it was profitable. People who were addicted died, while they were more concerned with corporate profits. They are still not really researching pain, or the root causes, they are studying people’s reaction to pain, in order to blame the patient, not the broken healthcare system.
We live in Interesting Times, an ancient Chinese Curse. Our goofball politicians still won’t regulate big tech, the pharma industry or anything else that is negatively impacting our country. Sick people were a good target to place the blame on, to stigmatize and lie about. It is all about the money, and they use lies and propaganda to maintain their profitability. Try to find any information on outcomes for pain patients in any of the research, there are none. The corporations have taken over, and they will use Big Data against us all, as they are already doing.
https://www.reuters.com/article/us-palantir-merck-kgaa-jv-idUSKCN1NO1KH
http://med.stanford.edu/pain/snapl/completed-research.html
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I certainly hope you’re wrong… and I’ll bet you do too.
To me, it looks like our civilization has passed its prime and is heading downhill, but then I remind myself how many of my previous predictions of gloom and doom didn’t happen, so maybe I’m wrong this time too.
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