Cognitive/Behavioral Treatment

The Cognitive/Behavioral Treatment recommendation has been downgraded one level because of inconsistent evidence.

One high quality (Riddle 2019) and one moderate quality study (Cai 2018) met inclusion criteria. Multiple studies of CBT are present in the orthopaedic literature; however, the lack of randomization and robust data analysis limit the current analysis to two studies. Furthermore, the various methods of CBT available and different methods of delivery make interpretation of the literature challenging.

One high quality study (Riddle 2019) demonstrated no differences in WOMAC scores among patients undergoing TKA for those who had or who had not received pain coping skills cognitive behavioral interventions.   However, this study included only those patients with moderate to high levels of catastrophizing, an area not routinely measured among those undergoing musculoskeletal surgery.

One moderate quality study (Cai 2018) noted that patients with high levels of kinesiophobia undergoing TKA who were in the intervention arm experienced decreased pain and improved function, but noted decreased kinesiophobia, after surgery.  However, this study is limited in its applicability, given the limitation of the patient population to only those with high levels of kinesiophobia, a characteristic not routinely measured in patients undergoing musculoskeletal surgery. 

Benefits/Harms of Implementation

While cognitive behavioral therapy may be a promising non-pharmacologic modality to improve post-operative pain control and function, there is not enough evidence to recommend its use at this point.  There are limited risks to using CBT, primarily emotional discomfort, although this may be more severe in some patients.  Only one of the studies (Cai 2018) focused on differences in treatment efficacy between genders and found none, and none of the studies specifically evaluated the effect of education level on outcomes.

Cost Effectiveness/Resource Utilization

Costs and resource utilization depend on the method of CBT chosen. In some studies, noted above, CBT is performed by trained clinical psychologists, whereas in others physical therapists are trained in CBT techniques. The costs and use of resources may vary substantially depending on the method of delivery chosen.

If personnel other than behavioral health professionals are performing this intervention they would need to be identified and receive appropriate training.  Presumably, they would be people already working with patients undergoing surgery, without need for additional hires.  The availability and cost of this training is 

not known.  However, once this training is received, this would seem to be a more cost-effective measure than pharmacologic options if training costs were offset by savings in other areas (e.g,, fewer opioids prescriptions, better function resulting in shorter lengths of stay).

Acceptability

CBT is receiving increased attention as a mechanism to improve pain and function.  However, cost, resource utilization, and time management concerns may hinder the delivery of CBT to patients.  The studies available for review were limited in either the patient population included (levels of kinesiophobia or pain catastrophizing) or because they were performed outside of the US.  Given the significant cultural implications of pain expression and opioid use, it is difficult to extrapolate results found among patients in a different culture to patients from the broad range of backgrounds found in the US. 

Feasibility

CBT may not be available to all patients due to limited access to or availability of behavioral health services, non-availability of CBT for outpatient surgical patients, and time constraints. Providing access to physical therapists and/or psychologist with training in CBT related to surgical outcomes may be challenging, especially in rural/frontier or smaller hospitals, where access to mental health services is already limited. While tele-mental health could be utilized for this, half of the US population does not have access to sufficient broad band internet access for this type of patient visit, and future studies would need to assess whether phone consultation in their circumstances is equivalent to in-person or virtual (audio and visual) interactions.

Future Research

Additional research is needed to better determine the impact of CBT on patient function and opioid use after musculoskeletal surgery.  This would seem to be a promising non-pharmacologic intervention, given the significant impact of mental health on the pain experience and opioid use, but there is currently insufficient evidence to recommend its routine use.  In addition, current evidence is limited to specific populations, and the efficacy of CBT has not been established for heterogeneous groups.   While 2 of the included studies found no differences in outcome based on patient sex or gender, future studies should include this as a routine variable.  Further research should investigate the effect of culture, education status, socioeconomic status, sex, gender, and other demographic variables on the efficacy of CBT after orthopaedic surgery. Furthermore, the optimal timing and method of delivery of CBT has not been established and merits further study.