Date Presented 04/03/2022

OTs play an important role in total joint presurgical education by improving patient competence in daily activities and adherence to precautions. This short course will describe the efficacy of a brief preoperative behavioral intervention to reduce pain, medication use, and anxiety while improving overall function in the population with total knee arthroplasty.

Primary Author and Speaker: Vanessa Meyer

Contributing Authors: Nicole Goble, Michelle M. Hunter

Preoperative education has been shown to improve total joint arthroplasty (TJA) patient satisfaction and decrease length of hospital stay (Novikov, Bosco & Iorio, 2018). In the Military Health System occupational therapy (OT) is part of the multi-disciplinary preoperative TJA education team. The prevalence of total knee arthroplasty is increasing with estimates nearing 3.5 million procedures by 2040 (Singh, J. A., Yu, S., Chen, L., & Cleveland, J. D. 2019).The purpose of this study it to determine the effectiveness of including a cognitive-behavioral psychoeducation (CBE) to the OT curriculum on improving pain, opioid medication use, anxiety and function in the total knee arthroplasty (TKA) population. This randomized controlled trial consisted of 36 Department of Defense beneficiaries awaiting preoperative education for TKA. The standard of care group (SOC) received information from OT to include home safety, adaptive equipment, and postoperative precautions. Cognitive-behavioral psychoeducation (CBE) added information on the healing process, the effects of stress on healing and recommendations on optimizing healing and health through breathing techniques, proper sleep hygiene, anti-inflammatory nutrition, realistic goal setting and use of a mental imagery script. Pain, anxiety and function were measured at 5 varying intervals: consent, education, post-op day 0 or 1, at the three week and at the three months orthopedic follow up. Pain was measured using the Defense and Veterans Pain Rating Scale (DVPRS) with supplemental questions: pain overall, with use, affecting sleep, affecting mood, and affecting stress. Participants were also asked to complete an opioid medication log. Anxiety was scored using the General Anxiety Disorder (GAD-7) Scale and heartrate variability was evaluated using an emwave2 unit. Function was measured by scores from the Knee Outcome Survey Activity of Daily Living Scale (KOS-ADL), the modified Functional Independence Measure (FIM), the Global Rate of Change Scale (GRC) and knee active range of motion. Findings of this study demonstrate significant improvement in overall pain from 4.5/10 to .6/10 in the CBE group compared to 4.9/10 to 2.4/10 in the SOC. Similarly, significant improvements were found in pain with activity, and pain affecting sleep. Opioid medication use was significantly lower within the CBE group with an average of 347 morphine milligram equivalent (MME) when compared to 821 MME for SOC. Post-operative anxiety decreased significantly according to GAD-7 scores for the CBE group by 2.1 points compared to an increase by .2 points in SOC, with similar findings in high heart-rate coherence. Functional improvement was recognized with an increase in KOS-ADL scores by 45.75% in the CBE group compared to 18.08% in SOC, and GRC data showed a change of +4.5 in the CBE compared to +2.5 with SOC. FIM scores were negligible in dressing, transfers and bed mobility but found to be one grade higher in toileting with CBE. Knee motion was greater in the CBE group with an increase of 27.2 degrees compared to 16.05 with SOC. Of significance, twice as many participants in the CBE group were discharged on same day of surgery and a majority of these participants continued to use health promoting habits at the three month follow up. In this randomized-control trial, the inclusion of a brief cognitive-behavioral intervention to the OT total joint curriculum improved postoperative pain, opioid medication use, anxiety and function. Positive outcome of this study reinforces the value of OT’s role in pre-surgical education and encourages further exploration of OT wellness education in surgical settings and throughout rehabilitation to optimize healthcare outcomes.


Novikov, D., Bosco, J. A., & Iorio, R. (2018, January 24). The 7 pillars of value-based care in total joint arthroplasty. International Congress for Joint Reconstruction. 2018, January 24; 340

Singh, J. A., Yu, S., Chen, L., & Cleveland, J. D. Rates of total joint replacement in the 329 United States: Future projections to 2020-2040 using the national inpatient sample. The Journal of Rheumatology, 2019; 46(9), 1134-1140.