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Published 10/1/2015

Effects of Behavioral Health Issues on Orthopaedic Outcomes

Do behavioral health issues have an impact on outcomes after elective orthopaedic procedures? If so, are there steps orthopaedic surgeons can take to address those issues and improve outcomes?

Recently, Eeric Truumees, MD, editor-in-chief of AAOS Now, spoke with David C. Flanigan, MD, a sports medicine specialist; Joshua S. Everhart, MD, MPH, an orthopaedic resident; and Andrew H. Glassman, MD, an adult reconstruction specialist and chairman of the department of orthopaedic surgery at Ohio State University. The three authors of “Psychological Factors Affecting Rehabilitation and Outcomes Following Elective Orthopaedic Surgery” in the September 2015 issue of the Journal of the American Academy of Orthopaedic Surgeons, shared their findings and the impact this information has had on their patient selection, counseling, and treatment pathways.

Dr. Truumees: How did you get interested in this area?

Dr. Flanigan: For me, it was talking with my patients and seeing what affected their outcomes after surgery. I primarily perform ligament reconstruction and simple procedures like meniscectomy, but also more complex cartilage restorative procedures. I found that issues such as a patient’s motivation, his or her outlook on life, and fears all played a role in the return to sport or other activities.

Dr. Everhart: I’ve been working in this area with Dr. Flanigan since I was a medical student. I like being able to risk-stratify patients preoperatively to minimize complications. We spent a lot of time focusing on the medical aspect of how to do that. But the patient’s psyche, other behavioral or social issues, and even some unrelated comorbidities play a role in outcomes.

Dr. Glassman: We all know that some patients are going to do better than others following surgery, but we’re just not sure why. The work that Drs. Flanigan and Everhart have done adds a structure to analyzing these patients. Even patients who are not ideal candidates generally acknowledge that they experience significant improvement after primary joint replacement.

In my university setting, half of my patients are second-opinions and often revision patients. These patients have been to good doctors and have no apparent reason to be unhappy. In my opinion, we really need to pay attention to these patients, because, as I tell them, “More surgery can certainly make you different; I’m not sure it will make you better.”

I also deal with patients with obvious problems such as a loose implant, an infection, or instability. The challenge with them is restoring their confidence. For better or worse, primary total joint replacement is often portrayed as a miraculous operation from which patients can expect to bounce back and return to doing things like when they were kids. So when a total joint replacement fails, patients are often very disillusioned. As surgeons, we must point out why their first joint didn’t do well and how we intend to make it better and provide clear expectations about what they will be required to do to rehabilitate it.

Dr. Truumees: I recall as a resident seeing total knee replacement patients who just weren’t bending their knees after surgery. Is any work being done that looks at anxiety, fear of motion, and loss of motion after total joint surgery?

Dr. Glassman: For most patients, stiffness is often physiologic and probably genetic; in many patients, adhesions generally respond very nicely and quickly to closed manipulation. But in a subgroup of people, that is ineffective, and I think these patients have a definite psychologic profile.

Dr. Everhart: Some types of patients struggle with rehabilitation, regardless of their actual orthopaedic complaint. I think it’s going to become more relevant, and I want to continue researching this topic.

Dr. Truumees: Surgeons are increasingly being graded on outcomes. Do you think we will someday have a system that will enable us to risk-stratify these patients and report our outcomes using a variable that identifies patients with psychological impediments to improvement, as we might differentiate a revision from a primary surgery?

Dr. Everhart: It is feasible, but we are not there yet. No single instrument or scale is available now, but we’re heading in that general direction.

Dr. Flanigan: I agree—this is where we want to go. These psychological issues are real and can play a role in our outcomes. At OSU, we are looking into what the best indicators of these issues are and how to measure them. I anticipate someday having appropriate screening tools that will enable us to better identify and stratify patients with these psychological issues. We’ll then be able to tell those patients, “You’re going to have more of a struggle with this type of procedure because of a long rehabilitation process, and these are the tools or resources that you’ll need to have a successful outcome.” For example, in sports it may involve working with a sports psychologist.

Dr. Truumees: Is this a research issue only today or are you administering screening tests to your patients?

Dr. Flanigan: We are currently conducting a prospective study in sports medicine, in conjunction with our psychology department, that examines a wide battery of measures. Our primary goal is to create an easily validated patient form that will address many of these issues. It is only a research study, but it’s been implemented with everyone undergoing surgery.

Dr. Glassman: Currently, we are not incorporating this into our routine screening. We are working on a very vigorous risk-stratification algorithm, and Dr. Everhart is very involved in risk-stratification for periprosthetic infection. But I foresee us incorporating a psychological component into that algorithm.

Dr. Truumees: Your paper focuses on the impact of certain psychological factors on a patient’s ability to undergo rehabilitation. Wouldn’t these factors also be helpful in more straightforward and simpler procedures that are less rehabilitation-driven?

Dr. Flanigan: My honest bias is that they will not play much of a role in simple procedures. For example, I don’t see where a patient’s self-efficacy or optimism makes too much of a difference if the patient has a locked knee. Psychological issues play more of a role in procedures such as ACL reconstruction, total joint replacement, and spine surgery that involve a longer rehabilitative process with its inevitable ups and downs.

Dr. Glassman: I think that the key is expectations—we need to make sure our patients’ expectations are realistic. Unfortunately, a lot of misinformation is available through the media and Internet as well as some self-promotion activities by some surgeons, leading patients to expect an almost immediate recovery.

It’s up to us as surgeons to educate people. A patient’s treatment may not require the acute care setting of a hospital, but you still can’t fool Mother Nature. Knees and hips—particularly knees—will continue to improve for at least a year following total joint arthroplasty and we need to emphasize that with our patients. But we also need a way to better identify patients who have psychological issues that may hinder their rehabilitation and put them at risk for less successful outcomes.

Dr. Truumees: Are these problems becoming more common, or are we getting better at identifying these patients?

Dr. Everhart: During the literature review, I didn’t see any difference in the prevalence or incidence of depression or anxiety in general orthopaedic populations. As we focus more on identifying higher risk patients or those who might potentially have problems after surgery, I believe we’re uncovering an issue that’s always been there.

Dr. Truumees: Many of our readers are acquainted with screening tools for anxiety and depression. For those who are less familiar with low self-efficacy or fear avoidance, how would you describe those behaviors and how do you pick up on them clinically?

Dr. Everhart: Self-efficacy can be a bit tricky; I don’t think it can be adequately assessed in a normal clinic evaluation or conversation. However, there are some pretty good scales specific to orthopaedics or rehabilitation. One is a knee self-efficacy scale and another is for rehabilitation tasks.

Patients who have experienced an injury or live with a chronic pain often feel anxious about the painful stimulus returning. Some will completely avoid the activity that leads to pain, or they aren’t convinced that surgery will correct it; others are afraid of sustaining reinjury during rehabilitation. In very pronounced cases, these fear avoidance behavior patterns (pain catastrophizing and kinesiophobia) can be identified in the clinical setting. Some good short scales are also available, such as an abbreviated pain catastrophizing scale developed by David C. Ring, MD, and the Tampa Scale for Kinesiophobia.

Dr. Truumees: So, if a patient is exhibiting these behaviors, you might consider using one of those tools or refer them for further assessment?

Dr. Flanigan: The first thing we do for athletes who sustain an acute injury is get them into therapy. At that point, we can begin to see how well they are motivated to doing what is necessary to recover, and we may start seeing some of these traits. However, it is very difficult to pick up these traits preoperatively 100 percent of the time. For example, we can’t really determine from one or two encounters whether the patient is an optimist or a pessimist—which are traits that many times go hand in hand with self-efficacy. We often encounter low self-efficacy postoperatively and that is when we look to other resources, such as a sports psychologist. Similarly, the first thing we do for patients with kinesiophobia is to acknowledge their fear and let them know that we have ways to deal with it.

Dr. Truumees: Your paper provides recommendations about canceling versus delaying procedures in patients with active psychosocial issues (Table 1). What’s your experience with patients who have been sent for intervention? What happens when they return?

Dr. Flanigan: For patients who exhibit psychosocial issues, I usually employ our therapist to help gauge beforehand how compliant the patient will be with the rehabilitation process. If the patient is having major fear issues, I’ll quickly involve our sports psychologist.

For the most part, patients are very receptive to honest and fruitful discussions about their issues. As with anything in medicine, it’s the delivery that’s most important. You don’t want to accuse patients of having a major mental issue, but instead point out that what they are feeling is normal for many people and yet it can affect their outcomes. That’s our major goal, for our patients to have good outcomes.

Dr. Glassman: The situation is different for a person with arthritis. When I sense reticence on the part of the patient to undergo a primary joint replacement or, in many instances, revision surgery, I try to emphasize that the procedure is rarely an emergency. It’s not like cancer or heart disease. If they have any misgivings about the procedure, I give them some informational materials and tell them to go home and think about it. That helps relieve their anxiety and reinforces that the decision to move forward with surgery is completely theirs.

I think the biggest challenge for most orthopaedic surgeons will be developing a level of comfort in broaching the subject and incorporating it into their preoperative assessments. We need to learn to be sensitive to certain clues and cues that identify when we’re dealing with a patient who might benefit from an open and transparent discussion on the subject.


  1. Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385-401.
  2. Adogwa O, Parker SL, Shau DN, et al: Preoperative Zung depression scale predicts patient satisfaction independent of the extent of improvement after revision lumbar surgery. Spine J 2013;13(5):501-506.