Published 6/20/2024
Leah Lawrence

Research Shows Patient Mental Health Is an Important Aspect of Orthopaedic Outcomes

Research has shown that patients with untreated mental disorders can have worse outcomes following orthopaedic surgery, including decreased function, increased chronic pain, and decreased quality of life, explained Anna N. Miller, MD, FACS, vice chair and chief of orthopaedic trauma at Washington University in St. Louis. At the 2024 AAOS Annual Meeting, Dr. Miller moderated an Instructional Course Lecture (ICL) titled “Integrating Mental and Social Health in Orthopaedic Practice: The Time Is Now.” This issue has gotten increased attention in orthopaedics as clinicians have progressively increased tracking of Patient-Reported Outcomes Measurement Information System (PROMIS) scores, a set of metrics that measure and monitor physical, mental, and social health.

“Many providers may wonder though, ‘What do these numbers even mean?’” Dr. Miller said. “They may ask, ‘What if I see a problem but don’t have the resources to help these patients?’” In this ICL, experts discussed the importance of these psychological factors and provided guidance on navigating these concerns in their daily practice.

Why care about mental health outcomes?
The course’s first presenter, Prakash Jayakumar, MD, PhD, assistant professor of surgery and perioperative care and director of value-based healthcare and outcome measurement innovations at the University of Texas at Austin Dell Medical School, discussed why orthopaedic surgeons should care about the biopsychosocial model of health. “Musculoskeletal populations are diverse, with about two-thirds of patients experiencing substantial mental, social, and lifestyle concerns,” Dr. Jayakumar said. Despite this, treatment strategies remain focused more on procedures and less on therapies, self-management, and whole-person care, with only 30 percent of care teams estimated to have access to a range of evidence-based nonoperative strategies.

The biopsychosocial model of health understands that health is multidimensional and involves interactions among impairments, activity limitations, participation restrictions, and contextual factors. Not spending time understanding and responding to aspects of mental health is a missed opportunity, Dr. Jayakumar explained.

As an example, Dr. Jayakumar and colleagues studied associations among impairment, sociodemographic and psychosocial factors, and symptom duration. They found that mindset had a greater association with level of capability than objective pathophysiology. Other research has demonstrated that feelings of distress and unhelpful thoughts play large roles in influencing incapability.

“Change is coming,” Dr. Jayakumar said. “[The Centers for Medicare & Medicaid Services] has started mandating patient-reported outcomes for total hip and total knee, some of which include mental health subscales.”

More than a measurement
Although more surgeons are beginning to recognize psychological and social concerns, many do not feel comfortable talking about them, and fewer still are likely to screen and refer for evaluation. The second speaker, David Ring, MD, PhD, associate dean for comprehensive care at Dell Medical School, talked about how to identify and interact with patients in the face of psychological distress and unmet social needs.

“We know orthopaedic specialists are aware of catastrophic or distorted thinking,” Dr. Ring said. “A common example is misinterpreting painful movement as harmful when, in fact, sometimes the only way to get better is to do painful stretches.”

Dr. Ring encouraged orthopaedic surgeons to regularly discuss this type of distress with their patients. However, PROMIS Depression scores or screening questionnaires cannot be relied upon alone. “You can also hear it in a person’s words and when they talk about simple daily tasks,” Dr. Ring said. If patients used extreme words like “excruciating” or “unbearable,” it indicates that to the patient, the pain or distress may feel like a crisis.

Studies have shown that greater symptoms of distress and unhelpful thinking are linked with worse recovery trajectories. In certain cases, Dr. Ring said that surgeons may have to explain that the physical injury has healed and that the patient may have to look beyond the physical to feel fully recovered.

Having these conversations can be difficult because of stigmas associated with mental illness. “Give yourself space to learn and grow as a communicator,” Dr. Ring said. “What patients really want is for you to see them and appreciate them for who and where they are.”

Comprehensive approach
To really see a patient, orthopaedic surgeons may have to look beyond the obvious, according to Chad Mather III, MD, MBA, chief medical officer for specialty care at Optum and clinical associate professor of orthopaedic surgery at Duke University. Pain-related psychological distress goes beyond mood disorders (e.g., depression, anxiety) to behaviors and emotions such as negative coping, catastrophizing, and pain anxiety.

Dr. Mather gave an example of two PROMIS scores that told a different story from a Yellow Flag Assessment Tool, a multidimensional screening tool used to assess psychosocial contribution to musculoskeletal pain. One patient with good social support and no significant medical comorbidities had a PROMIS Physical Function score of 52 and a PROMIS Depression score of 48. However, in the Yellow Flag Assessment Tool, the patient responded to “I can’t seem to keep the pain out of my mind” with “to a great degree” and said that it is “never okay” to experience pain. A second patient who failed nonoperative treatment had a PROMIS Physical Function score of 36 and a Depression score of 57, but on the Yellow Flag Screening Tool said that it is “always true” that it is okay to experience pain, and when asked if they would be able to perform therapy no matter how they felt emotionally, the patient responded that they were “certain I can do it.” These two patients require individualized approaches.

Dr. Ring said he has worked to build effective care pathways to better support a comprehensive, evidence-based approach to managing patients with hip and knee osteoarthritis. Condition-based care is provided by a multidisciplinary team and a trained physical therapist, working in a collaborative network. This team provides coordinated treatment and support across the care experience, including nonoperative, perioperative, and postoperative treatments.

“When you have a way to approach these issues, those patients do the best,” Dr. Ring said. “This is a great space to be engaged in it. It makes me a better, happier clinician, and the patients do better.”

Leah Lawrence is a freelance medical writer for AAOS Now.


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