Physiological Indices of Stress Prior to and Following Total Knee Arthroplasty Predict the Occurrence of Severe Post-Operative Pain

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Objective. The severe pain and disability associated with osteoarthritis often motivate individuals to undergo arthroplastic surgery. However, a significant number of surgical patients continue to experience pain following surgery. Prior research has implicated both the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) in the sensitization of pain receptors and chronic pain conditions. This study uses a prospective, observational, cohort design to examine whether physiological stress responses before and after surgery could predict post-operative pain severity.

Subjects. Participants included 110 patients undergoing total knee arthroplasty.

Methods. Physiological indices of stress included the measurement of catecholamine and cortisol levels in 15-hour urine samples collected prior to and 1 month following surgery, as well as in-hospital heart rate and blood pressure (before and after surgery), which were abstracted from medical records. Patients completed the pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [Bellamy et al., J Orthop Rheumatol1, 95 (1988)] 2.5 weeks prior to surgery and at a 3-month follow-up.

Results. Contrary to expectations, lower stress hormone levels at baseline were related to more severe post-operative pain. Data at later time points, however, supported our hypothesis: cardiovascular tone shortly before surgery and urinary levels of epinephrine 1 month following surgery were positively related to pain severity 3 months later.

Conclusion. Results suggest that the occurrence of post-operative pain can be predicted on the basis of stress physiology prior to and following arthroplastic surgery.

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