Pathways Through Care for Long‐Term Pain After Knee Replacement: A Qualitative Study With Healthcare Professionals

MacKichan, Fiona; Wylde, Vikki; Gooberman-Hill, Rachael

doi:10.1002/msc.1093

Cited by 14 publications

(23 citation statements)

References 35 publications

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“… 35 Barriers to healthcare professionals providing healthcare to patients with chronic pain after TKA include complexities in assessment and management and a lack of explicit access points to services. 98 …”

Section: Treatment and Managementmentioning

confidence: 99%

“…There is acknowledgement among orthopaedic healthcare professionals that a multidisciplinary approach with a focus on stratification is needed. 84 , 98 , 103 Stratified care is a way of ensuring that resources are targeted towards those who are in most need and likely to benefit. It has been argued that we do not need new interventions for pain, and that what is needed is improved access to existing treatments with combination treatments matched to patient characteristics.…”

Section: Treatment and Managementmentioning

confidence: 99%

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Chronic pain after total knee arthroplasty

Wylde¹,

et al. 2018

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Despite a good outcome for many patients, approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA).Chronic pain after TKA can affect all dimensions of health-related quality of life, and is associated with functional limitations, pain-related distress, depression, poorer general health and social isolation.In both clinical and research settings, the approach to assessing chronic pain after TKA needs to be in-depth and multidimensional to understand the characteristics and impact of this pain. Assessment of this pain has been inadequate in the past, but there are encouraging trends for increased use of validated patient-reported outcome measures.Risk factors for chronic pain after TKA can be considered as those present before surgery, intraoperatively or in the acute postoperative period. Knowledge of risk factors is important to guide the development of interventions and to help to target care. Evaluations of preoperative interventions which optimize pain management and general health around the time of surgery are needed.The causes of chronic pain after TKA are not yet fully understood, although research interest is growing and it is evident that this pain has a multifactorial aetiology, with a wide range of possible biological, surgical and psychosocial factors that can influence pain outcomes.Treatment of chronic pain after TKA is challenging, and evaluation of combined treatments and individually targeted treatments matched to patient characteristics is advocated. To ensure that optimal care is provided to patients, the clinical- and cost-effectiveness of multidisciplinary and individualized interventions should be evaluated.Cite this article: EFORT Open Rev 2018;3:461-470. DOI: 10.1302/2058-5241.3.180004

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Section: Treatment and Managementmentioning

confidence: 99%

Section: Treatment and Managementmentioning

confidence: 99%

Chronic pain after total knee arthroplasty

Wylde¹,

et al. 2018

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“… 8 Provision of services for patients with chronic pain after TKR is patchy and inconsistent, 9 with a lack of explicit access points. 10 A systematic review identified that only one intervention has been evaluated for the management of this condition: a single intra-articular botulinum toxin injection. 11 …”

Section: Introductionmentioning

confidence: 99%

Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review

Wylde¹,

Beswick²,

Dennis³

et al. 2017

BMJ Open

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ObjectiveTo identify postoperative patient-related risk factors for chronic pain after total knee replacement (TKR).DesignThe systematic review protocol was registered on the International Prospective Register of Systematic Reviews (CRD42016041374). MEDLINE, Embase and PsycINFO were searched from inception to October 2016 with no language restrictions. Key articles were also tracked in the Institute for Scientific Information (ISI) Web of Science. Cohort studies evaluating the association between patient-related factors in the first 3 months postoperatively and pain at 6 months or longer after primary TKR surgery were included. Screening, data extraction and assessment of methodological quality were undertaken by two reviewers. The primary outcome was pain severity in the replaced knee measured with a patient-reported outcome measure at 6 months or longer after TKR. Secondary outcomes included adverse events and other aspects of pain recommended by the core outcome set for chronic pain after TKR.ResultsAfter removal of duplicates, 16 430 articles were screened, of which 805 were considered potentially relevant. After detailed evaluation of full-text articles, 14 studies with data from 1168 participants were included. Postoperative patient-related factors included acute pain (eight studies), function (five studies) and psychosocial factors (four studies). The included studies had diverse methods for assessment of potential risk factors and outcomes, and therefore narrative synthesis was conducted. For all postoperative factors, there was insufficient evidence to draw firm conclusions about the association with chronic pain after TKR. Selection bias was a potential risk for all studies, as none were reported to be conducted at multiple centres.ConclusionThis systematic review found insufficient evidence to draw firm conclusions about the association between any postoperative patient-related factors and chronic pain after TKR. Further high-quality research is required to provide a robust evidence base on postoperative risk factors, and inform the development and evaluation of targeted interventions to optimise patients’ outcomes after TKR.

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“…Currently there is a lack of clear pathways and referral processes for patients with chronic pain after knee replacement [ 7 ]. These are considered to be integral aspects of good care for chronic pain [ 10 ] and their absence hinders patients’ access to targeted and individualised care [ 13 ] indicating a pressing need for the development of new models of care delivery for this population.…”

Section: Introductionmentioning

confidence: 99%

“…The intervention aims to enable appropriate onwards referral to existing services to ensure that underlying reasons for chronic pain are considered and that treatment is targeted at these to improve pain management and to reduce the impact of pain. The initial design of this intervention was informed by a systematic review which evaluated the existing evidence for the management of chronic pain after total knee replacement [ 8 ], a survey of NHS service provision [ 7 ], qualitative work with health professionals [ 13 ], consensus meetings with pain experts, and patient and public involvement activities with a musculoskeletal forum [ 14 ]. Taken together, this background research informed the initial design of the STAR trial intervention.…”

Section: Introductionmentioning

confidence: 99%

Development of a complex intervention for people with chronic pain after knee replacement: the STAR care pathway

Wylde

Howells

Bertram

et al. 2018

Trials

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BackgroundApproximately 20% of people who have total knee replacement experience chronic pain afterwards, but there is little evidence about effective interventions for managing this type of pain. This article describes the systematic development and refinement of a complex intervention for people with chronic pain after knee replacement. The intervention is a care pathway involving an assessment clinic and onward referral, with telephone follow-up as required. In the design of this multistage study, we chose to focus on ensuring that the intervention was deliverable, implementable and acceptable.MethodsIn line with the UK Medical Research Council’s recommendations for comprehensive development of complex interventions, multiple phases of work were undertaken. Following on from initial development work to design the intervention, the draft intervention content was refined through consensus questionnaires with 22 health professionals and discussion at meetings with 18 healthcare professionals. Testing of intervention delivery and acceptability to patients was undertaken by two health professionals delivering the assessment clinic to ten patients. Views about future implementation within the context of a randomised trial were evaluated through a questionnaire based on the Normalisation Measure Development (NoMAD) instrument with ten health professional stakeholders.ResultsConsensus work with health professionals ensured the components of the intervention were appropriate and informed a number of substantive changes to improve the intervention. Testing of intervention delivery identified a number of logistical issues that were then addressed in the development of a comprehensive intervention training manual. Engagement with stakeholders indicated that the intervention could be successfully implemented in a clinical setting for evaluation in a randomised trial.ConclusionsThis work has informed the development and refinement of a complex intervention for people with chronic pain after knee replacement. The next stage is to evaluate the clinical and cost-effectiveness of the STAR care pathway in a multicentre randomised trial.Electronic supplementary materialThe online version of this article (10.1186/s13063-017-2391-8) contains supplementary material, which is available to authorized users.

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Pathways Through Care for Long‐Term Pain After Knee Replacement: A Qualitative Study With Healthcare Professionals

Cited by 14 publications

References 35 publications

Chronic pain after total knee arthroplasty

Chronic pain after total knee arthroplasty

Post-operative patient-related risk factors for chronic pain after total knee replacement: a systematic review

Development of a complex intervention for people with chronic pain after knee replacement: the STAR care pathway

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