Norwegian
version of this page
The MultiKnee Trial
A multidisciplinary intervention in total knee arthroplasty – a multicenter, randomized controlled trial in osteoarthritis patients (MultiKnee trial).
Publications
-
-
-
Kise, Nina Jullum; Eliassen, Siri Marie M; Furnes, Ove Nord; Gay, Caryl; Heir, Stig & Lerdal, Anners
[Show all 10 contributors for this article]
(2025).
Fear avoidance and catastrophizing are associated with both knee awareness and quality of life in knee osteoarthritis patients: a secondary report of a cross-sectional study
| Acta Orthopaedica.
Acta Orthopaedica.
ISSN 1745-3674.
96,
p. 920–926.
doi:
10.2340/17453674.2025.45070.
Full text in Research Archive
Show summary
Background and purpose: In patients with knee osteoarthritis (OA), psychological factors (anxiety, depression, and pain-related catastrophizing) are associated with more pain and worse physical function. Low knee awareness and high knee-related quality of life (QoL) are key indicators of a well-functioning knee. The objective of our study was to evaluate associations between psychological factors and knee awareness and knee-related QoL in patients with knee OA.
Methods: In this Norwegian cross-sectional study of 653 patients with knee OA, 4 psychological factors were assessed: anxiety, depression, pain-related catastrophizing, and fear avoidance of physical activity. Associations between these factors and knee awareness and knee-related QoL were examined in unadjusted and adjusted regression models, controlling for age, sex, BMI, pain, and whether patients accepted or declined inclusion in a randomized controlled trial (ClinicalTrials.gov: NCT03771430). Regression coefficients with values below zero indicate negative associations between the independent and dependent factors and values above zero indicate positive associations.
Results: Worse scores on all 4 psychological measures were associated with higher knee awareness and poorer knee-related QoL in unadjusted analyses. Standardized estimates (βs) ranged from –0.38 (95% confidence intervals [CI] –0.45 to –0.31) to –0.16 (CI –0.23 to –0.08). In adjusted analyses, pain catastrophizing (β –0.07, CI –0.14 to –0.01) and fear-avoidance (β –0.11, CI –0.18 to –0.05) remained associated with higher knee awareness, whereas poorer knee-related QoL remained associated with more anxiety (β –0.10, CI –0.16 to –0.03) and depression (β –0.14, CI –0.20 to –0.08), as well as more pain catastrophizing (β –0.19, CI –0.26 to –0.12) and fear-avoidance (β –0.19, CI –0.25 to –0.13).
Conclusion: Higher fear avoidance of physical activity and more pain catastrophizing had the strongest associations with higher knee awareness and poorer knee-related QoL.
-
Bergvad, Ingvild Buset; Kottorp, Anders; Aamodt, Arild; Lerdal, Anners; Skou, Søren Thorgaard & Lindberg, Maren Falch
(2025).
Cross-cultural adaptation and validation of a Norwegian version of the Goodman Satisfaction Score (GSS-NO) for patients with total hip and knee arthroplasty.
Acta Orthopaedica.
ISSN 1745-3674.
96,
p. 52–58.
doi:
10.2340/17453674.2024.42703.
Full text in Research Archive
Show summary
Background and purpose: Measuring patient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is important. We aimed to cross-culturally adapt and examine the psychometric properties of the self-reported Goodman Satisfaction Score (GSS) in a sample of Norwegian patients following primary THA and TKA.
Methods: The GSS was translated and adapted into Norwegian (GSS-NO) following standard guidelines. 800 patients from the Norwegian Arthroplasty Register who had undergone surgery 6–11 months prior were invited to complete GSS-NO and questions on sociodemographic factors, pain, and function in a cross-sectional study. We examined validity in relation to internal structure, response processes, and precision using Rasch analysis, relationships between the GSS-NO and pain and function using Pearson’s correlation coefficients, and test–retest reliability using linear weighted kappa statistics.
Results: The GSS-NO was adapted with few challenges. 404 patients (49% THA, 51% TKA) returned complete answers. The GSS-NO met all criteria regarding the rating scale functioning. Local independence among items and unidimensionality was supported and there was acceptable goodness-of-fit. The internal consistency was 0.94. We found no systematic differential item functioning by age, sex, work status, education, cohabitation status, or hip or knee surgery. The correlation coefficients between GSS-NO and pain and function outcomes were 0.79 (95% confidence interval [CI] 0.76–0.82) and 0.79 (CI 0.76–0.82), respectively. Test–retest reliability with weighted kappa ranged from 0.43–0.55 for THA and 0.54–0.81 for TKA.
Conclusion: The cross-cultural adaptation of GSS-NO proved to be a valid and reliable measure for use in Norwegian-speaking patients following primary THA and TKA.
-
Olsen, Unni Solveig Johansen; Sellevold, Vibeke Bull; Gay, Caryl; Aamodt, Arild; Lerdal, Anners & Småstuen, Milada Cvancarova
[Show all 8 contributors for this article]
(2024).
Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study.
BMC Musculoskeletal Disorders.
25(1).
doi:
10.1186/s12891-023-07125-y.
Full text in Research Archive
Show summary
Background Few studies have evaluated the associations between preoperative factors and pain and physical function outcomes after total knee arthroplasty (TKA) from a mid-term perspective. Identification of such factors is important for optimizing outcomes following surgery. Thus, we examined the associations between selected preoperative factors and moderate to severe pain and pain-related functional impairment as measured using the Brief Pain Inventory (BPI), five years after TKA in patients with knee osteoarthritis. Methods In this prospective observational study, all patients scheduled for primary unilateral TKA for osteoarthritis were consecutively recruited. Preoperative factors identified from previous meta-analyses were included to assess their associations with pain severity and pain-related functional impairment five years after TKA. Pain severity was the primary outcome, while pain-related functional impairment was the secondary outcome. The BPI was used to evaluate outcomes five years post-TKA. Statistically significant factors from univariate regressions were entered into a multiple logistic regression model to identify those with the strongest associations with pain severity or pain-related functional impairment five years after TKA. Results A total of 136 patients were included, with a mean age of 67.7 years (SD 9.2) and a majority being female (68%). More severe preoperative pain (OR = 1.34, 95% CI [1.03 to 1.74]), more painful sites (OR = 1.28., 95% CI [1.01 to 1.63]), and more severe anxiety symptoms (OR = 1.14., 95% CI [1.01 to 1.28]) were associated with increased likelihood of moderate to severe pain five years after TKA surgery, while more severe osteoarthritis (OR = 0.13, 95% CI [0.03 to 0.61]) was associated with reduced likelihood of moderate to severe pain five years after TKA. More severe anxiety symptoms (OR = 1.25, 95% CI [1.08 to 1.46]) were also associated with increased likelihood of moderate to severe pain- related functional impairment five years after surgery, while male sex (OR = 0.23, 95% CI [0.05 to 0.98]) was associated with reduced likelihood of pain-related functional impairment five years after surgery. Conclusion The identified preoperative factors should be included in larger prognostic studies evaluating the associations between preoperative factors and mid-term pain severity and physical function outcomes after TKA surgery.
-
Rognsvåg, Turid; Bergvad, Ingvild Buset; Furnes, Ove Nord; Indrekvam, Kari; Lerdal, Anners & Lindberg, Maren Falch
[Show all 9 contributors for this article]
(2024).
Exercise therapy, education, and cognitive behavioral therapy alone, or in combination with total knee arthroplasty, in patients with knee osteoarthritis: a randomized feasibility study.
Pilot and Feasibility Studies.
10.
doi:
10.1186/s40814-024-01470-y.
Full text in Research Archive
Show summary
Background: One in five patients experience chronic pain 1 year after total knee arthroplasty (TKA), highlighting the need for enhanced treatment strategies to improve outcomes. This feasibility trial aimed to optimize the content and delivery of a complex intervention tailored to osteoarthritis (OA) patients at risk of poor outcome after TKA and assess the feasibility of initiating a full-scale multicenter randomized controlled trial (RCT). Methods: Patients scheduled for TKA were included between August 2019 and June 2020 and block-randomized into one of three groups: (a) 12-week exercise therapy and education (ExE) and 10-module internet-delivered cognitive behavioral therapy (iCBT), (b) TKA followed by ExE and iCBT and (c) TKA and standard postoperative care. Outcomes were (i) recruitment and retention rate, (ii) compliance to the intervention and follow-up, (iii) crossover, and (iv) adverse events, reported by descriptive statistics. Results: Fifteen patients were included in the study. Only 1 out of 146 patients screened for eligibility was included during the first 4 months. During the next 3 months, 117 patients were not included since they lived too far from the hospital. To increase the recruitment rate, we made three amendments to the inclusion criteria; (1) at-risk screening of poor TKA outcome was removed as an eligibility criterion, (2) patients across the country could be included in the study and (3) physiotherapists without specific certification were included, receiving thorough information and support. No patients withdrew from the study or crossed over to surgery during the first year. Nine out of 10 patients completed the ExE program and six out of 10 completed the iCBT program. Fourteen out of 15 patients completed the 1-year follow-up. One minor adverse event was registered. Conclusions: Except for recruitment and compliance to iCBT, feasibility was demonstrated. The initial recruitment process was challenging, and necessary changes were made to increase the recruitment rate. The findings informed how a definitive RCT should be undertaken to test the effectiveness of the complex intervention.
-
Enbakom, Mestawet Getachew; Lerdal, Anners; Småstuen, Milada Cvancarova; Eshete, Million Tesfaye; Desta, Tilahun & Lindberg, Maren Falch
(2023).
Modifiable factors associated with a consistently high acute pain trajectory after surgical treatment of traumatic fractures in Ethiopia: a multi-center prospective cohort study.
Journal of Orthopaedic Surgery and Research.
18(1).
doi:
10.1186/s13018-023-03770-0.
Full text in Research Archive
Show summary
Background In Ethiopia, little is known about postoperative pain trajectories and possible predictive factors associated with them in patients undergoing surgery following traumatic fractures. Methods This multi-center prospective observational cohort study included surgical candidates for traumatic fractures (n = 218). Worst pain intensity was measured with an 11-point numeric rating scale on the first 4 postoperative days and day of hospital discharge. Growth mixture modeling was used to identify subgroups of patients based on their pain trajectories, and logistic regression models to quantify associations between pain trajectories and demographic, clinical, psychological, and life style factors. Results Two postoperative pain trajectory subgroups were identified: rapid pain relief (48% of included individuals) and consistently high pain (52% of included individuals). Sub-analysis stratified by cause of injury demonstrated that higher preoperative pain was an independent risk factor for consistently high postoperative pain regardless of the patient’s injury type: traffic accident (OR = 1.48, 95% CI 1.23–1.79), machine/tool injury or conflict (OR = 1.58, 95% CI 1.11–2.26), or fall (OR = 1.47, 95% CI 1.08–1.99). Moreover, longer surgical time was a risk factor for consistently high postoperative pain among patients who had a fall-related injury (OR = 1.02, 95% CI 1.00–1.03). In contrast, among patients with a traffic-related injury, receiving a nerve block was a protective factor (OR = 0.19, 95% CI 0.04–0.87) compared with general anesthesia. Conclusion Higher preoperative pain and longer surgical time were associated with a consistently high acute postoperative pain trajectory. Clinicians may use these potentially modifiable factors to identify patients at risk for consistently high pain during the early postoperative period.
-
Olsen, Unni; Lindberg, Maren Falch; Rose, Christopher James; Denison, Eva Marie-Louise; Gay, Caryl & Aamodt, Arild
[Show all 11 contributors for this article]
(2023).
Factors correlated with pain after total knee arthroplasty: A systematic review and meta-analysis.
PLOS ONE.
18(3).
doi:
10.1371/journal.pone.0283446.
Full text in Research Archive
Show summary
Main objective: Systematically review and synthesize preoperative and intraoperative factors associated with pain after total knee arthroplasty (TKA) in patients with osteoarthritis. Methods: Based on a peer-reviewed protocol, we searched Medline, Embase, CINAHL, Cochrane Library, and PEDro for prospective observational studies (January 2000 to February 2023) investigating factors associated with pain after TKA. The primary outcome was pain twelve months after TKA. Pain at three and six months were secondary outcomes. Multivariate random-effects meta-analyses were used to estimate mean correlation (95% CIs) between factors and pain. Sensitivity analysis was performed for each risk of bias domain and certainty of evidence was assessed. Results: Of 13,640 studies, 29 reports of 10,360 patients and 61 factors were analysed. The mean correlation between preoperative factors and more severe pain at twelve months was estimated to be 0.36 (95% CI, 0.24, 0.47; P < .000; moderate-certainty evidence) for more catastrophizing, 0.15 (95% CI; 0.08, 0.23; P < .001; moderate-certainty evidence) for more symptomatic joints, 0.13 (95% CI, 0.06, 0.19; P < .001; very low-certainty evidence) for more preoperative pain. Mean correlation between more severe radiographic osteoarthritis and less pain was -0.15 (95% CI; -0.23, -0.08; P < .001; low-certainty evidence). In sensitivity analysis, the estimated correlation coefficient for pain catastrophizing factor increased to 0.38 (95% CI 0.04, 0.64). At six and three months, more severe preoperative pain was associated with more pain. Better preoperative mental health was associated with less pain at six months. Conclusion and relevance: More pain catastrophizing, more symptomatic joints and more pain preoperatively were correlated with more pain, while more severe osteoarthritis was correlated with less pain one year after TKA. More preoperative pain was correlated with more pain, and better mental health with less pain at six and three months. These findings should be further tested in predictive models to gain knowledge which may improve TKA outcomes.
-
Sellevold, Vibeke Bull; Olsen, Unni; Lindberg, Maren Falch; Steindal, Simen Alexander; Aamodt, Arild & Lerdal, Anners
[Show all 7 contributors for this article]
(2023).
“I am accustomed to something in my body causing pain”: A qualitative study of knee replacement non-improvers’ stories of previous painful and stressful experiences.
BMC Musculoskeletal Disorders.
24(1).
doi:
10.1186/s12891-023-06423-9.
Full text in Research Archive
Show summary
Background: Approximately 20% of total knee arthroplasty patients experience persistent postsurgical pain one year after surgery. No qualitative studies have explored previous stories of painful or stressful life experiences in patients experiencing persistent postsurgical pain after total knee replacement. This study aimed to explore stories of previous painful or stressful experiences in life in a cohort of patients that reported no improvement in pain one year after total knee arthroplasty. Methods: The study employed an explorative-descriptive qualitative design. Data was collected through semistructured interviews five to seven years after surgery, with patients who reported no improvement in pain-related interference with walking 12 months after total knee replacement. The data was analyzed using qualitative content analysis. Results: The sample consisted of 13 women and 10 men with a median age of 67 years at the time of surgery. Prior to surgery, six reported having at least one chronic illness and 16 reported having two or more painful sites. Two main themes were identified in the data analysis: Painful years - the burden of living with long lasting pain, and the burden of living with psychological distress. Conclusions: The participants had severe longlasting knee pain as well as longlasting pain in other locations, in addition to experiences of psychologically stressful life events before surgery. Health personnel needs to address the experience and perception of pain and psychological struggles, and how it influences patients’ everyday life including sleeping routines, work- and family life as well as to identify possible vulnerability for persistent postsurgical pain. Identifying and assessing the challenges enables personalized care and support, such as advice on pain management, cognitive support, guided rehabilitation, and coping strategies both pre-and post-surgery.
-
Sellevold, Vibeke Bull; Steindal, Simen Alexander; Lindberg, Maren Falch; Småstuen, Milada Cvancarova; Aamodt, Arild & Lerdal, Anners
[Show all 7 contributors for this article]
(2022).
Many Patients with Persistent Pain One Year After TKA Report Improvement by 5-7 years: A Mixed Methods Study.
Clinical Orthopaedics and Related Research.
ISSN 0009-921X.
480(11),
p. 2075–2088.
doi:
10.1097/CORR.0000000000002183.
Full text in Research Archive
Show summary
Background: Approximately 20% of patients report pain 12 months after TKA. No studies have investigated patients’ experiences of living with persistent postsurgical pain 5 to 7 years after TKA by combining a qualitative and quantitative methodology. Question/purpose: In a mixed-methods study, we explored patients’ experiences of living with persistent pain up to 7 years after primary TKA. We asked: In a subgroup analysis of patients who reported persistent pain 1 year after TKA surgery, how do patients live with persistent pain at the 5- to 7-year postoperative timepoint? Methods: This follow-up study was part of a longitudinal study of pain, symptoms, and health-related quality of life in patients who underwent TKA for osteoarthritis. The present study targeted a subgroup of patients (22% [45 of 202]) identified in the longitudinal study who reported no improvement in pain interference with walking at 12 months after surgery. Inclusion criteria were: all 31 patients in this subgroup who attended their 5-year follow-up at the hospital and lived within a 2-hour drive from the hospital. Eight patients declined or were unable to participate due to illness or death. Hence, the final sample consisted of 23 patients (13 women and 10 men). The participants’ mean age at surgery was 66 6 10 years. There were no differences in sociodemographic baseline data between the 23 included and the 22 excluded participants. A mixed-methods approach was employed, in which the quantitative data were followed up and investigated with qualitative interviews. Instruments used were the Brief Pain Inventory preoperatively, 12 months, and 5 years after surgery, as well as a semistructured interview guide. The individual interviews were conducted at one timepoint 5 to 7 years postsurgery to capture how pain was experienced at that timepoint. The interviews were audiorecorded, transcribed, and analyzed using qualitative content analysis. Meaning units were identified, condensed, and sorted into subthemes that were interpreted and abstracted into themes, guided by the research question. With a small sample, the quantitative analysis focused on descriptive statistics and nonparametric statistics when comparing demographics of included and nonincluded patients. In addition, two multivariate mixed models for repeated measures were employed to estimate within‐patient and between‐patient variations as well as to assess the effect of time on the pain outcomes. Results: Pain with walking decreased from 12 months to 5 years postoperatively (estimated mean score 7 versus 4, difference of means -3 [95% CI -5 to -2]; p < 0.001). Pain with daily activity decreased from 12 months to 5 years postoperatively (estimated mean score 6 versus 3, difference of means -3 [95% CI -4 to -1]; p < 0.001). Pain intensity (average pain) decreased from 12 months to 5 years postoperatively (estimated mean score 5 versus 4, difference of means -1 [95% CI -3 to 0]; p = 0.03). The results are presented as point estimates rounded up to whole numbers. The qualitative data analysis yielded three themes: persistent limitations after TKA, regained wellness over time, and complexity in physical challenges. Intermittent pain with certain movements resulted in limitations with some activities in everyday life and seemed to persist beyond 5 years. Multiple painful body sites and presence of comorbidities seemed to interfere with regained wellness over time. Conclusion: In this subgroup of patients experiencing postsurgical persistent pain 12 months after primary TKA, persistent postsurgical pain still limited certain activities for the participants, although pain seemed to be less influential in their everyday lives after 5 years to 7 years. Clinicians may use these findings to inform and guide patients with delayed improvements in pain into more realistic expectations for recovery, rehabilitation, and strategies for coping with pain and impaired function. However, it is imperative to rule out other reasons for pain in patients reporting pain 12 months and longer after surgery and to be attentive of possible changes in pain over time.
-
Getachew, Mestawet; Lerdal, Anners; Småstuen, Milada Cvancarova; Gay, Caryl; Aamodt, Arild & Tesfaye, Million
[Show all 7 contributors for this article]
(2022).
Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after total knee arthroplasty - a longitudinal study.
Scandinavian Journal of Pain.
ISSN 1877-8860.
doi:
10.1515/sjpain-2022-0007.
Full text in Research Archive
Show summary
Objectives: There are several known predictors of pain after total knee arthroplasty (TKA). However, it is unclear whether acute postoperative pain intensity and postoperative opioid intake are associated with pain 12 months after TKA. Thus, the aim of this study was to assess whether worst pain intensity and opioid intake during the early postoperative period are associated with moderate-severe pain 12 months after TKA. Methods: A total of 202 patients undergoing primary TKA between October 2012 and September 2014 were prospectively enrolled. Age, sex, contralateral knee pain, BMI, physical status and opioid intake were collected preoperatively. Ketamine and daily opioid intake were collected on postoperative days (POD) 0–3. Using the Brief Pain Inventory, patients’ “worst pain intensity” was measured pre-operatively, on POD 0–4, and 12 months after TKA. Two logistic regression models evaluated the independent association of early postoperative pain intensity (model 1) and postoperative opioid intake (model 2) with moderate-severe pain 12 months after TKA, adjusting for possible confounders. Results: In total, 187 patients with data at the 12 month postoperative follow-up were included in this analysis. Pain intensity on POD2 and POD3, as well as preoperative pain and BMI, were significantly associated with pain at 12 months in univariate models. However, in multivariable models adjusted for preoperative pain and BMI, neither pain intensity on POD 0–4 (model 1) nor opioid intake on POD 0–3 (model 2) were associated with pain at 12 months. Preoperative pain was still significant in both models, but BMI remained significant only in model 2. Conclusions: Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after TKA when controlling for potential confounders. More research is needed to confirm these findings.
-
Olsen, Unni; Lindberg, Maren Falch; Rose, Christopher James; Denison, Eva Marie-Louise; Gay, Caryl & Aamodt, Arild
[Show all 11 contributors for this article]
(2022).
Factors Correlated with Physical Function 1 Year after Total Knee Arthroplasty in Patients with Knee Osteoarthritis: A Systematic Review and Meta-analysis.
JAMA Network Open.
5(7),
p. 1–15.
doi:
10.1001/jamanetworkopen.2022.19636.
Full text in Research Archive
Show summary
Importance: More than 1 in 5 patients do not experience improved physical function after total knee arthroplasty (TKA). Identification of factors associated with physical function may be warranted to improve outcomes in these patients. Objective: To identify preoperative and intraoperative factors associated with physical function at 12 months after TKA in a systematic review and meta-analysis. Data Sources: Data from January 2000 to October 2021 were searched in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Physiotherapy Evidence Database (PEDro). No language restrictions were applied. Study Selection: Prospective observational studies or randomized clinical trials on factors associated with physical function after TKA in adult patients with osteoarthritis were selected. A prespecified peer-reviewed protocol was followed. Data Extraction and Synthesis: Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline, 2 reviewers independently screened titles and abstracts and judged risk of bias using Quality in Prognosis Studies (QUIPS). Multivariate random-effects meta-analyses were performed to estimate mean correlations between factors and physical function with 95% CIs. Sensitivity analyses were conducted for each QUIPS domain. Certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Main Outcomes and Measures: The primary outcome was physical function 12 months after TKA. Secondary outcomes were physical function 3 and 6 months after TKA. All estimates are mean correlations between factors and postoperative function. Positive correlations correspond to better function. Results: Among 12 052 articles, 20 studies (including 11 317 patients and 37 factors) were analyzed. Mean correlation with higher BMI was estimated to be −0.15 (95% CI, −0.24 to −0.05; P = .33; moderate-certainty evidence), while mean correlation with better physical function was estimated to be 0.14 (95% CI, 0.02 to 0.26; P = .03; low-certainty evidence) and mean correlation with more severe osteoarthritis was estimated to be 0.10 (95% CI, 0.01 to 0.19; P = .17; high-certainty evidence). In sensitivity analyses, mean correlation with better physical function was estimated to be 0.20 (95% CI, 0.04 to 0.36; P = .02), and so perhaps a larger coefficient than in the main analysis, while mean correlations were estimated to be similar for other factors (BMI: –0.17; 95% CI, –0.28 to –0.06; P < .001; osteoarthritis severity: 0.10; 95% CI, −0.01 to 0.20; P = .05). Conclusions and Relevance: This study found that higher presurgical BMI was correlated with worse physical function (with moderate certainty) and that better physical function (low certainty) and osteoarthritis severity (high certainty) were correlated with better physical function after TKA. These findings suggest that these factors should be included when testing predictive models of TKA outcomes.
-
Rognsvåg, Turid; Lindberg, Maren Falch; Lerdal, Anners; Stubberud, Jan Egil; Furnes, Ove Nord & Holm, Inger
[Show all 11 contributors for this article]
(2021).
Development of an internet-delivered cognitive behavioral therapy program for use in combination with exercise therapy and education by patients at increased risk of chronic pain following total knee arthroplasty.
BMC Health Services Research.
21(1),
p. 1–14.
doi:
10.1186/s12913-021-07177-7.
Full text in Research Archive
Show summary
Background: Approximately 20% of patients experience chronic pain after total knee arthroplasty (TKA). Due to the growing number of TKA procedures, this will affect an increasing number of people worldwide. Catastrophic thinking, dysfunctional illness perception, poor mental health, anxiety and depression characterize these non-improvers, and indicate that these patients may need individualized treatment using a treatment approach based on the bio-psycho-social health model. The present study developed an internet-delivered cognitive behavioral therapy (iCBT) program to be combined with exercise therapy and education for patients with knee osteoarthritis (OA) at increased risk of chronic pain after TKA. Methods: The development process followed the first two phases of the UK Medical Research Council framework for complex interventions. In the development phase, the first prototype of the iCBT program was developed based on literature review, established iCBT programs and multidisciplinary workshops. The feasibility phase consisted of testing the program, interviewing users, condensing the program, and tailoring it to the patient group. A physiotherapist manual was developed and adapted to physiotherapists who will serve as mentors. Results: The development process resulted in an iCBT program consisting of 10 modules with educational texts, videos and exercises related to relevant topics such as goalsetting, stress and pain, lifestyle, automatic thoughts, mindfulness, selective attention, worry and rumination. A physiotherapist manual was developed to guide the physiotherapists in supporting the patients through the program and to optimize adherence to the program. Conclusions: The iCBT program is tailored to patients at risk of chronic pain following TKA, and may be useful as a supplement to surgery and/or exercise therapy. A multicentre RCT will evaluate the iCBT program in combination with an exercise therapy and education program. This novel intervention may be a valuable contribution to the treatment of OA patients at risk of chronic pain after TKA.
-
Lindberg, Maren Falch; Aamodt, Arild; Badawy, Mona; Bergvad, Ingvild Buset; Borchgrevink, Petter Chr. & Furnes, Ove Nord
[Show all 21 contributors for this article]
(2021).
The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis – study protocol for the MultiKnee trial.
BMC Musculoskeletal Disorders.
22:1054,
p. 1–14.
doi:
10.1186/s12891-021-04924-z.
Full text in Research Archive
Show summary
Background
One in five patients report chronic pain following total knee arthroplasty (TKA) and are considered non-improvers. Psychological interventions such as cognitive behavioral therapy (CBT), combined with exercise therapy and education may contribute to reduced pain an improved function both for patients with OA or after TKA surgery, but the evidence for the effectiveness of such interventions is scarce. This randomized controlled trial with three arms will compare the clinical effectiveness of patient education and exercise therapy combined with internet-delivered CBT (iCBT), evaluated either as a non-surgical treatment choice or in combination with TKA, in comparison to usual treatment with TKA in patients with knee OA who are considered candidates for TKA surgery.
Methods
The study, conducted in three orthopaedic centers in Norway will include 282 patients between ages 18 and 80, eligible for TKA. Patients will be randomized to receive the exercise therapy + iCBT, either alone or in combination with TKA, or to a control group who will undergo conventional TKA and usual care physiotherapy following surgery. The exercise therapy will include 24 one hour sessions over 12 weeks led by a physiotherapist. The iCBT program will be delivered in ten modules. The physiotherapists will receive theoretical and practical training to advise and mentor the patients during the iCBT program. The primary outcome will be change from baseline to 12 months on the pain sub-scale from the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcomes include the remaining 4 sub-scales from the KOOS (symptoms, function in daily living, function in sports and recreation, and knee-related quality of life), EQ-5D-5L, the Pain Catastrophizing Scale, the 30-s sit-to-stand test, 40-m walking test and ActiGraph activity measures. A cost-utility analysis will be performed using QALYs derived from the EQ-5D-5L and registry data.
Discussion
This is the first randomized controlled trial to investigate the effectiveness of exercise therapy and iCBT with or without TKA, to optimize outcomes for TKA patients. Findings from this trial will contribute to evidence-based ersonalized treatment recommendations for a large proportion of OA patients who currently lack an effective treatment option.
Trial registration Clinicaltrials.gov: NCT03771430. Registered: Dec 11, 2018.
-
Olsen, Unni Solveig Johansen; Lindberg, Maren Falch; Denison, Eva Marie-Louise; Rose, Christopher James; Gay, Caryl & Aamodt, Arild
[Show all 11 contributors for this article]
(2020).
Predictors of chronic pain and level of physical function in total knee arthroplasty: a protocol for a systematic review and meta-analysis.
BMJ Open.
10,
p. 1–9.
doi:
10.1136/bmjopen-2020-037674.
Full text in Research Archive
Show summary
Abstract
Introduction One in five patients undergoing total knee arthroplasty (TKA) experience unchanged or worse pain and physical function 1 year after surgery. Identifying risk factors for unfavourable outcomes is necessary to develop tailored interventions to minimise risk. There is a need to review more current literature with updated methodology that addresses the limitations of earlier systematic reviews and meta-analyses. We present a Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of predictors of chronic pain and impaired function after TKA.
Methods and analysis This review will include prospective longitudinal observational studies, or randomised trials (including cluster and crossover designs) that report arm-wise predictors of chronic postsurgical pain or impaired physical function at 3 months, 6 months or 12 months. A comprehensive literature search of studies published between 2000 and 2019 will be performed in Medline, Embase, CINAHL, Cochrane Library and PEDro. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction and assessment of bias risk (Quality in Prognosis Studies tool). The co-primary outcomes, pain and impaired function, at 12 months after TKA will be analysed separately. Estimates of association between each outcome and any preoperative or intraoperative factor that may predict chronic pain or impaired physical function will be extracted from the included studies, where possible. For randomised studies, results will only be extracted from TKA arms (or the first period of crossover trials). Estimates of association from the primary evidence will be synthesised narratively, and quantitatively using multivariate meta-analysis to provide ‘pooled’ estimates of association. Subgroup and sensitivity analyses will be performed. Certainty of evidence for each predictor will be derived from the Grading of Recommendations Assessment, Development and Evaluation framework.
Ethics and dissemination No ethical issues are associated with this project. The results from this review will be published in peer-reviewed journals and presented at international conferences.
-
Enbakom, Mestawet Getachew; Lerdal, Anners; Småstuen, Milada Cvancarova; Gay, Caryl; Aamodt, Arild & Tesfaye, Million
[Show all 7 contributors for this article]
(2020).
High levels of preoperative pain and fatigue are red flags
for moderate‐severe pain 12 months after total knee
arthroplasty—A longitudinal cohort study.
Musculoskeletal Care.
ISSN 1478-2189.
p. 1–7.
doi:
10.1002/msc.1522.
Full text in Research Archive
Show summary
Background: Moderate/severe pain after total knee arthroplasty (TKA) is a poor surgical outcome. Many studies have identified preoperative risk factors of painafter TKA, but studies of the joint contributions of co-occurring symptoms arelacking.
Methods: Patients undergoing primary TKA (n=202) were enrolled in a longitu-dinal cohort study. Preoperatively, patients completed questionnaires measuring demographics and symptoms (pain, fatigue, sleep problems and depression). Painwas re-assessed 12 months after TKA. Logistic regression analysis was used to compute the probabilities of moderate-severe pain at 12 months based on preoperative symptom levels, and results were combined into a risk matrix.
Results: More than one-third (40%) of patients (n=187) reported moderate-severepain after TKA. Among preoperative risk factors included in the logistic regressionanalyses were age, sex, pain, fatigue, sleep problems and depression. Adjusting forpossible confounders, fatigue (p=0.02) and pain (p=0.01) were significant riskfactors for moderate-severe pain at 12-months follow-up and were retained in the final risk matrix. The co-occurrence of high-preoperative fatigue and pain scores resulted in 57% estimated probability of moderate-severe pain at 12 months.Similarly, the co-occurrence of low-preoperative fatigue and pain scores resulted in14% estimated probability of moderate-severe pain 12 months after TKA.
Conclusion: The combination of high fatigue and pain scores prior to surgery was akey risk factor for moderate-severe pain 12 months after TKA. Mapping of these factors could be used preoperatively to identify patients who are at risk to expe-rience a poor outcome of TKA.
-
Lindberg, Maren Falch; Miaskowski, Christine; Rustøen, Tone; Cooper, Bruce A.; Aamodt, Arild & Lerdal, Anners
(2020).
Preoperative risk factors associated with chronic pain profiles following total knee arthroplasty.
European Journal of Pain.
ISSN 1090-3801.
p. 1–13.
doi:
10.1002/ejp.1703.
Full text in Research Archive
Show summary
Background One in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person‐centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles. Methods On the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified. Results Patients in the “lower average” and “lower worst” pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the “higher average” and “higher worst” pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes. Conclusions These risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients’ outcomes after TKA. Significance statement The present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.
-
Bragstad, Line Kildal; Lerdal, Anners Vetle; Gay, Caryl L.; Kirkevold, Marit; Lee, Kathryn A. & Lindberg, Maren Falch
[Show all 10 contributors for this article]
(2020).
Psychometric properties of a short version of Lee Fatigue Scale used as a generic PROM in persons with stroke or osteoarthritis: assessment using a Rasch analysis approach.
Health and Quality of Life Outcomes.
18,
p. 1–8.
doi:
10.1186/s12955-020-01419-8.
Full text in Research Archive
Show summary
Background: Fatigue is a common symptom associated with a wide range of diseases and needs to be more thoroughly studied. To minimise patient burden and to enhance response rates in research studies, patientreported outcome measures (PROM) need to be as short as possible, without sacrificing reliability and validity. It is also important to have a generic measure that can be used for comparisons across different patient populations. Thus, the aim of this secondary analysis was to evaluate the psychometric properties of the Norwegian 5-item version of the Lee Fatigue Scale (LFS) in two distinct patient populations. Methods: The sample was obtained from two different Norwegian studies and included patients 4–6weeks after stroke (n =322) and patients with osteoarthritis on a waiting list for total knee arthroplasty (n =203). Fatigue severity was rated by five items from the Norwegian version of the LFS, rating each item on a numeric rating scale from 1 to 10. Rasch analysis was used to evaluate the psychometric properties of the 5-item scale across the two patient samples. Results: Three of the five LFS items (“tired”, “fatigued” and “worn out”) showed acceptable internal scale validity as they met the set criterion for goodness-of-fit after removal of two items with unacceptable goodness-of-fit to the Rasch model. The 3-item LFS explained 81.6% of the variance, demonstrated acceptable unidimensionality, could separate the fatigue responses into three distinct severity groups and had no differential functioning with regard to disease group. The 3-item version of the LFS had a higher separation index and better internal consistency reliability than the 5-item version. Conclusions: A 3-item version of the LFS demonstrated acceptable psychometric properties in two distinct samples of patients, suggesting it may be useful as a brief generic measure of fatigue severity. Trial registration: Clinicaltrials.gov: NCT02338869; registered 10/04/2014 (stroke study).
-
Rehman, Yasser; Lindberg, Maren Falch; Arnljot, Kristine; Gay, Caryl; Lerdal, Anners & Aamodt, Arild
(2020).
More severe radiographic osteoarthritis is associated with increased improvements in patients' health state following a total knee arthroplasty.
Journal of Arthroplasty.
ISSN 0883-5403.
35(11).
doi:
10.1016/j.arth.2020.06.025.
Full text in Research Archive
Show summary
Background
To assess whether preoperative radiological severity of osteoarthritis (OA) is related to the level of improvement in patients’ health state measured 1 year after total knee arthroplasty (TKA).
Methods
Radiographic severity of OA was graded using the Kellgren-Lawrence (KL) classification. Two independent observers were blinded to patients’ outcome scores. Health-related quality of life was measured using EQ-5D-3L preoperatively and at 12-month follow-up. The 5 dimensions of the EQ-5D were converted into a health state index score. The association between KL grade and improvement in health state score was analyzed using multiple linear regression.
Results
Among 156 consecutive patients (68% females, mean age 69 years) who underwent primary TKA, 3 knees (2%) were classified as KL grade 2, 115 as KL grade 3 (74%), and 38 as KL grade 4 (24%). Follow-up rate was 77%. There was substantial intra-rater and inter-rater agreement (Cohen’s kappa = 0.80 and 0.79). Most patients (64%) had clinically significant improvement in their health state score 1 year after TKA. However, after adjusting for relevant covariates, patients with severe OA (KL grade 4) were found to have significantly more improvement in their health state score than patients with mild or moderate OA (KL grade 2 or 3, respectively). Separate analysis of the 5 EQ-5D dimensions showed that the KL group differences were most evident in the “usual activities” and “pain/discomfort” dimensions.
Conclusion
Patients with severe OA have significantly more improvement in their usual activities and pain/discomfort 1 year after TKA than patients with less severe OA.
-
Lindberg, Maren Falch; Schweitz, Turid Undebakke; Aamodt, Arild; Gay, Caryl & Lerdal, Anners
(2020).
High pre- and postoperative symptom burden in non-responders to total knee arthroplasty.
PLOS ONE.
15(5)(5),
p. 1–14.
doi:
10.1371/journal.pone.0233347.
Full text in Research Archive
Show summary
Objectives
One in five patients does not improve in pain with walking (non-responders) 12 months after
total knee arthroplasty (TKA). This longitudinal study investigated a broad range of symptoms before and after TKA and evaluated possible differences in symptom distress between
responders and non-responders with regards to pain with walking after TKA.
Methods
Prior to TKA surgery, 182 patients completed a demographic questionnaire and the Memorial Symptom Assessment Scale—Short Form (MSAS-SF). The MSAS-SF was repeated 12
months following TKA. Clinical data were extracted from medical records. Patients were categorized as responders or non-responders based on their trajectories of pain with walking
assessed prior to surgery, on postoperative day 4, at 6 weeks, and at 3 and 12 months.
Results
Overall, the most distressful preoperative symptoms were pain, lack of energy, difficulty
sleeping, feeling drowsy, worrying, feeling bloated, and problems with sexual interest or
activity. However, compared with patients classified as responders to TKA, non-responders
had higher total symptom distress scores both preoperatively and 12 months postoperatively. Preoperatively, non-responders scored higher than responders on five of the seven
most distressing symptoms (i.e., all except difficulty sleeping and feeling bloated), and 12
months postoperatively, non-responders scored higher than responders on six of the seven
most distressing symptoms (i.e., all but feeling bloated). In a multivariate analysis, higher
preoperative distress scores for pain and problems with sexual interest or activity were significant predictors of non-response to TKA, controlling for other relevant factors.
Conclusions
Patients’ preoperative symptom burden may be a useful indicator of their risk for nonimprovement following TKA surgery. Future studies need to evaluate the effect of reducing patients’ preoperative symptom burden on TKA outcomes
View all works in NVA
-
-
-
-
-
-
Finstad, Therese Aamli; Larsen, Marie Hamilton; Stubberud, Jan Egil; Lerdal, Anners; Gay, Caryl & Lindberg, Maren Falch
(2025).
Breaking New Ground: Cluster-Based Insights into Digital Health Literacy in KOA Patients.
Full text in Research Archive
-
Lillegård, Julianne Helene Frøyen; Lindberg, Maren Falch; Bergvad, Ingvild Buset; Gay, Caryl & Lerdal, Anners
(2025).
No associations between digital health literacy and adherence to internet-delivered cognitive behavioral therapy in OA patients.
Full text in Research Archive
-
-
-
-
-
-
-
Lerdal, Anners; Gay, Caryl; Rehman, Yasser; Petursson, Gunnar & Lindberg, Maren Falch
(2025).
Preoperative illness perceptions predict pain interference in patients undergoing total knee arthroplasty.
Full text in Research Archive
-
-
Bergvad, Ingvild Buset; Lerdal, Anners & Lindberg, Maren Falch
(2024).
Body mass index and physical activity in
patients undergoing total knee arthroplasty
– a prospective cohort study.
Full text in Research Archive
-
-
-
-
Nordmo, Ingrid Kismul; Lindberg, Maren Falch; Bergvad, Ingvild Buset; Gay, Caryl & Lerdal, Anners
(2024).
Digital health literacy and sociodemographic factors in patients with hip and knee OA.
Full text in Research Archive
-
Bergvad, Ingvild Buset; Kottorp, Anders; Aamodt, Arild; Lerdal, Anners; Skou, Søren Thorgaard & Lindberg, Maren Falch
(2023).
Translation and validation of the Norwegian version of a
brief satisfaction measure for use in patients undergoing
total joint arthroplasty.
Full text in Research Archive
-
Sellevold, Vibeke Bull; Steindal, Simen Alexander; Lindberg, Maren Falch; Småstuen, Milada Cvancarova; Aamodt, Arild & Lerdal, Anners
[Show all 7 contributors for this article]
(2022).
IASP World Congress on Pain, Toronto: Many patients with persistent pain one year after total knee arthroplasty report improvement by 5-7 years.
Full text in Research Archive
-
Rognsvåg, Turid; Lindberg, Maren Falch; Lerdal, Anners; Furnes, Ove Nord; stubberud, jan & Holm, Inger
[Show all 11 contributors for this article]
(2022).
Development of an internet-delivered cognitive behavioral therapy program for use in combination with exercise therapy and education by patients at increased risk of chronic pain following total knee arthroplasty.
Full text in Research Archive
-
-
Schweitz, Turid Undebakke; Lindberg, Maren Falch; Aamodt, Arild; Gay, Caryl & Lerdal, Anners
(2021).
Preoperative symptoms as risk factors for non-response to total knee arthroplasty.
Full text in Research Archive
-
Lindberg, Maren Falch
(2021).
Fra praksissykepleier til forsker i praksis.
In Rustøen, Tone & Lerdal, Anners (Ed.),
Klinisk forskning innen helsefag.
Fagbokforlaget.
ISSN 9788245022926.
p. 141–152.
Full text in Research Archive
-
Lindberg, Maren Falch
(2021).
MAGIC and Lovisenberg. Enhancing the evidence ecosystem, for increased value and reduced waste in health care.
Full text in Research Archive
-
Rehman, Yasser; Lindberg, Maren Falch; Arnljot, Kristine; Gay, Caryl; Lerdal, Anners & Aamodt, Arild
(2021).
More Severe Radiographic Osteoarthritis Is Associated With Increased Improvement in Patients’ Health State Following a Total Knee Arthroplasty.
Full text in Research Archive
-
Lindberg, Maren Falch; Rustøen, Tone; Cooper, Bruce A; Aamodt, Arild & Lerdal, Anners Vetle
(2021).
Authors’ reply to the comment by Riddle et al.
European Journal of Pain.
ISSN 1090-3801.
doi:
10.1002/ejp.1756.
Full text in Research Archive
-
Lindberg, Maren Falch; Miaskowski, Christine; Rustøen, Tone; Cooper, Bruce A; Aamodt, Arild & Lerdal, Anners
(2021).
Chronic pain profiles and associated risk factors following total knee arthroplasty - a prospective observational study.
Full text in Research Archive
-
-
-
-
Lau, Bjørn & Stubberud, Jan
(2019).
Kognitivt adferdsterapi knyttet til smerte og bruk av e-CBT program - for fysioterapeuter i MultiKnee studien.
Full text in Research Archive
-
Lindberg, Maren Falch; Witzøe, Andreas & Rognsvåg, Turid
(2018).
Ny studie: Vil se på alternativer til operasjon med kneprotese.
[Journal].
Fysioterapeuten.
Full text in Research Archive
-
-
Lindberg, Maren Falch; Aamodt, Arild & Lerdal, Anners
(2018).
A multidisciplinary intervention in total knee arthroplasty - a multicenter randomized controlled trial in patients on waiting list for TKA (The MULTI-KNEE trial).
Full text in Research Archive
-
-
Rose, Christopher James; Olsen, Unni; Lindberg, Maren Falch; Denison, Eva Marie-Louise; Aamodt, Arild & Lerdal, Anners
(2020).
A new multivariate meta-analysis model for many variates and few studies.
arXiv.
Full text in Research Archive
-
Olsen, Unni Solveig Johansen; Lerdal, Anners; Aamodt, Arild; Brox, Jens Ivar; Furnes, Ove & Denison, Eva Marie-Louise
[Show all 8 contributors for this article]
(2018).
Preoperative and intraoperative predictors of persistent postoperative pain and impaired physical function in total knee arthroplasty - a systematic review of prognostic studies.
PROSPERO, International prospective register of systematic reviews.
Full text in Research Archive
View all works in NVA
Published Mar. 3, 2021 12:11 PM
- Last modified Sep. 19, 2023 9:58 AM
