CORR Insights®: Can Patients Forecast Their Postoperative Disability and Pain?

Where Are We Now?

Alokozai and colleagues [1] conducted a novel prospective study to determine whether patient-forecasted disability and pain are associated with realized disability and pain after discretionary hand surgery. They were also interested in determining the factors associated with accurately predicting realized disability and pain.

The authors found that forecasted postoperative disability was moderately correlated with realized postoperative disability, and 47% of patients correctly predicted their disability within the minimally important clinical difference (MCID) of their realized disability score. Forecasted pain was weakly correlated with realized postoperative pain, and few patients accurately predicted their postoperative pain. Symptoms of depression were associated with greater realized disability. Both symptoms of depression and catastrophic thinking about pain were associated with greater realized pain [1].

Making the decision to undergo discretionary surgery implies a belief in postsurgery reduction of pain and disability. However, results of this study, consistent with prior reports [15], show that, as a group, patients experience minimal postsurgery reduction in disability. This is surprising given the high prevalence of discretionary surgical procedures, general beliefs that these surgeries are effective, and overall high satisfaction with these procedures.

Patients who forecasted lower disability and less pain generally experienced reductions in both. This fits well with both the larger field of expectations and the placebo effect, which specify that patients’ confidence in the effectiveness of the treatment prescribed is an important predictor of outcomes [7]. However, more than half of these patients overestimated the magnitude of postsurgical improvement in both pain and disability. This finding is consistent with affective forecasting, which shows that, as a group, humans tend to underestimate their ability to adapt to stress and adversity, and overestimate how they will feel once stress and adversity are no longer present [2, 5]. Affective forecasting greatly influences decision making [5]. Both providers and patients may justify opting for medical interventions because of an impact biased caused by affective forecasting.

Symptoms of depression before surgery were associated with more pain and disability after surgery. Patients with depression also predicted that they would have less pain after surgery then they actually endorsed. Catastrophic thinking about pain before surgery was also associated with more pain after surgery. Considering what we know about affective forecasting, it seems likely that some patients chose to undergo surgery because they believed they would not be able to cope with symptoms and that they would get much more relief than was realistically possible.

Research within the past decade clearly demonstrated that psychosocial factors are important predictors of pain and disability, and most often explain the lack of association between impairment and disability [8, 10, 13, 14]. Previously published studies have also shown that discretionary orthopaedic surgeries (subacromial decompression, knee arthroscopy, for example) are not as effective as once thought [9, 11]. Although patients continue to ask for surgeries, surgeons continue to perform them, and insurance companies continue to reimburse for them, it is encouraging to see more and more orthopaedic journals publishing psychosocial studies.

Depression, ineffective coping, expectations, and forecasting are likely a function of an underlining construct that drives individuals to seek care and elect surgery for conditions that most individuals can manage on their own. Our disability questionnaires measure these factors, and it is thus not surprising that presurgery disability is the best predictor of postsurgery disability.

Where Do We Need To Go?

The study raises important questions: (1) What is the profile of patients who are, versus those who are not able to accurately forecast their disability and pain? (2) How does forecasting, as conceptualized and measured in this study, fits in within the larger research on human ability to forecast and the growing field of the role of presurgery expectations and the placebo response? Is forecasting increasing our ability to predict success after discretionary surgery over and above presurgery psychosocial factors and disability?

Depression and ineffective coping cannot be fixed by orthopaedic surgery and can result in decisions to have surgery based on inaccurate predictions, as well as an increased likelihood of persistent pain, disability, and clinical dissatisfaction [15]. As such, surgeons need to identify patients with depression and catastrophizing before surgery, educate them on the role of psychosocial factors in their surgical outcome, and facilitate referrals so that patients can improve their coping skills before offering elective surgery.

More research is needed to understand the relationship between forecasting, expectations, placebo, psychosocial factors, pain and disability. For example, it is unclear whether forecasting is a useful construct in predicting realized disability over and above presurgery disability. Further it appears that both expectations and forecasting are driven by psychosocial factors (having positive expectations about a treatment can help, but those with depression tend to have unrealistic expectations and overestimate improvement after surgery). Future prospective studies accounting for presurgery disability, psychosocial factors, forecasted disability/pain and expectations would help clarify which factors drive postsurgery disability and pain.

Forecasting is impacted by contextual factors (information from surgeons, other patients, media) that are difficult to assess and account for. Further, patients’ expectations of treatment can be inadvertently biased toward surgery as the best treatment, one that they have to “work towards”, as they progress through other nonoperative treatments [6]. It is thus unclear how much patients “apply” themselves to these nonoperative treatments versus going through the motions toward what they may ultimately believe to be the best treatment for them [6]. This may be particularly relevant for individuals with depression and ineffective coping strategies. We may have a great opportunity to decrease requests for discretionary surgery and improve outcomes of traditional, nonoperative treatments by addressing symptoms of depression and less-effective coping strategies while simultaneously increasing expectations of success of nonoperative treatments.

How Do We Get There?

The path toward biopsychosocial care in orthopaedics is complicated by established cultural patterns, mental health stigma, a lack of training and sophistication among orthopaedic surgeons on topics related to patients’ psychological well-being, misconceptions about pain, disability and the role of surgery, and challenges with current health care reimbursements that make it easy to get surgery and hard to access psychosocial care. The need and strategies to develop comprehensive health care models have been previously described [12, 16]. Furthermore, we need to conduct clinical trials to test whether psychosocial interventions that effectively treat depression and ineffective coping in other populations, can be successfully tailored for orthopaedic patients to sustainably improve disability. There is promising evidence that such interventions can be helpful to orthopaedic patients, but fully powered clinical trials are lacking [3, 4].

It has been my experience that, until recently, federal agencies have been reluctant to fund psychosocial trials in orthopaedic settings. This may have been in part due to similar misconceptions we see in our patients—that surgeries are required to improve outcomes. Driven by funding sources, psychologists have been focused primarily on treatments for patients with persistent pain in primary care or pain clinic settings. Moving forward, we need to engage psychologists, surgeons, and federal funding agencies to conduct rigorous clinical trials to provide evidence of efficacy of skills interventions in improving outcomes in patients in orthopaedic surgery practices. Such studies are desperately needed to move the care of orthopaedic patients toward a true biopsychosocial model.