CORR Insights®: What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

Where Are We Now?

The understanding of pain and disability experienced by people with knee osteoarthritis (OA) has traditionally been seen through a biomedical, predominantly biology-based perspective, similar to many chronic conditions [12], in which pain is thought to be a direct product of a noxious stimulus activating a dedicated neural pathway. In 1977, Engel [4] was one of the pioneers to introduce a more comprehensive approach to understanding chronic pain and disability through a biopsychosocial lens. Since then, research in this area has shown that psychosocial factors are substantial predictors of disability, and that they play an important role in the transition from acute to chronic pain [17].

In this issue of Clinical Orthopaedics and Related Research®, Jayakumar et al. [8] present a cross-sectional study analyzing mental health constructs (mood and pain coping) and their association with capability in knee and hip OA. They found that pain coping and capability had the strongest association. Mood and pain coping are part of a broader suite of psychological factors that can effect outcomes. Melzack and Casey’s [11] multidimensional model of pain suggest that there are three broad categories: sensory-discriminatory (such as pain sensitization), cognitive-evaluation (such as kinesiophobia or catastrophizing), and the affective-motivation (such as depression or anxiety).

Symptoms of depression and anxiety (sometimes characterized as “mood”, as in the paper by Jayakumar et al. [8]) are known to worsen pain [5], and pain and disability are more severe in patients who display cognitive-affective pain responses that make coping more difficult, like catastrophizing or kinesiophobia. Those entities are related, but they differ in important ways. Pain catastrophizing is defined as an exaggerated and negative appraisal of pain that occurs in response to actual or anticipated pain experiences, whereas kinesiophobia refers to an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability because of a painful injury or reinjury [19].

The finding by Jayakumar et al. [8] that pain coping and symptoms of anxiety and depression were most important to a patient’s experience of pain and disability, and of the two, pain coping was more important, has immediate, practical implications. Armed with this awareness, surgeons should consider incorporating some form of screening that covers both mood and, in particular, pain coping domains during their clinical consults to explore and address these psychological factors with their patients where possible. This can be in the form of a short screening questionnaire, like the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag (OSPRO-YF) used in this study. In more complex situations, a multidisciplinary team approach, potentially alongside psychologists or social workers, may be necessary to achieve the optimal outcome.

Where Do We Need to Go?

Psychological factors can often be viewed as “fuzzy” and sometimes lacking clear definitions despite efforts to classify them; however, it is important that we do not view psychological factors in isolation as they often interact interchangeably with each other to influence a wide range of outcomes [1]. Of note, the 10-item OSPRO-YF used in the study by Jayakumar et al. [8] is a multidimensional psychological tool that was developed and streamlined from existing questionnaires, and it has been shown to predict pain intensity, disability, and quality of life [2]. Beyond just psychological factors, incorporating the social elements would be important as part of a comprehensive biopsychosocial understanding and its impact in a variety of settings [7]. Future studies should ideally incorporate a broad suite of social factors, guided by frameworks like the PROGRESS-PLUS framework, which clearly defines social factors that stratify health opportunities and outcomes for clinical research [9].

Based on the timeframe between exposure and outcome, psychosocial factors can act as predisposing, precipitating, and maintaining factors [3]. We need studies to track changes in psychosocial factors over time, uncovering the relationships between each other and exploring the underlying factors that predict these changes and how they influence outcome. Exploring whether psychosocial factors serve as predictors, mediators, or moderators of outcomes and whether these relationships are bidirectional will help support development of clinically relevant and practical frameworks to untangle these complex relationships. In addition, the same psychosocial factors can have different interpretations and applications depending upon the cultural context [14, 21]. Population-specific research, across broad community types to help improve understanding of these psychosocial factors and ultimately the quality of care delivered to their local communities, are needed.

Psychosocial phenotyping has increasingly become a powerful tool to help craft personalized self-management interventions for people with chronic diseases, and it has been shown to be effective in many other conditions [10]. Previous efforts have been made to incorporate psychological factors through deep phenotyping to better understand pain in OA [15]. Psychosocial phenotyping through the identification of the key psychosocial predictive factors may allow for the practice of precision medicine. For example, high-risk knee OA subpopulations could be identified with targeted approaches to improve nonsurgical treatment, promote physical activity, maximize functional outcomes, and reduce/delay the need for expensive/risky surgery, and ultimately, embracing the concept of value-based care.

How Do We Get There?

Going beyond cross-sectional studies, conducting high-quality longitudinal studies on psychosocial factors that identify their impact on a range of clinical outcomes and health utilization and that are done in different geographical and cultural settings is key to building a strong foundation on these important topics. Not to be confused with the PROGRESS-PLUS framework mentioned earlier, the PROGRESS framework (PROGnosis RESearch Strategy) is a methodological framework that highlights best practice guidelines for the different types of prognostic research ranging from prognostic factors to prognostic model research [6]. Existing large, international cohort studies focus primarily on biological factors such as radiographic imaging and biomarkers [13, 16]. Recent efforts have started to lay the groundwork for large longitudinal cohorts focusing on psychosocial factors [18].

Beyond generating high-quality research, translating the data into clinical practice for practical implementation is critical. A key barrier to this is the mountain of information that clinicians must manage and digest meaningfully in a short space of time during each consultation. Clinical decision support (CDS) tools can be important aids. These CDS tools should be (1) validated, ideally in combination between content experts and individuals with lived experiences; (2) culturally contextualized, that is easily understood by the local population of interest; and (3) feasible to be used in a busy, routine, clinical setting that is ideally linked to the electronic medical health records. Artificial intelligence and machine learning are powerful tools that if used correctly, can complement this effort by processing large volumes of high-quality data [3] to develop predictive algorithms. These algorithms must be rigorously tested and validated in local populations through the use of training and validation datasets, with their performance evaluated continuously through their real-world implementation.

We are in an exciting time as we seek to transform the model of care from a biomedical model to a biopsychosocial one. Coming together as a community, through interdisciplinary organizations and research collaboratives such as the International Musculoskeletal Mental and Social Health Consortium (I-MESH) [20], in partnership with clinicians and clinical groups will be critical to support high-quality cross-disciplinary, transnational research and drive clinical translation and implementation for the betterment of all our patients.

Read This Next

Two interesting articles might be of interest:

• A recent qualitative study investigated Asian perspectives on psychosocial factors in knee OA. The results suggested that there may be specific factors, such as chronic illness shame or family support networks, that may play a different role in predominantly collectivist Asian societies, highlighting the importance of culturally contextualizing psychosocial factors [21].

• In this paper about psychosocial phenotyping as a personalization strategy for chronic disease self-management interventions, the authors reviewed the evidence, discussed the theoretical underpinnings, and proposed a research agenda moving forward that could potentially transform the way care is delivered [10].