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British Journal of Pain logoLink to British Journal of Pain
. 2021 Nov 15;15(4):486–496. doi: 10.1177/20494637211005803

The association between sleep quality, preoperative risk factors for chronic postoperative pain and postoperative pain intensity 12 months after knee and hip arthroplasty

Dennis Boye Larsen 1,2, Mogens Laursen 3, Ole Simonsen 3, Lars Arendt-Nielsen 1,2, Kristian Kjær Petersen 1,2,✉
PMCID: PMC8611299  PMID: 34840796

Abstract

Background:

Chronic postoperative pain following total joint replacement (TJA) is a substantial clinical problem, and poor sleep may affect predictive factors for postoperative pain, such as pain catastrophizing. However, the magnitude of these associations is currently unknown. This exploratory study investigated (1) the relationship between preoperative sleep quality, clinical pain intensity, pain catastrophizing, anxiety, and depression and (2) their associations with chronic postoperative pain following TJA.

Methods:

This secondary analysis from a larger randomized controlled trial included rest pain intensity (preoperative and 12 months postoperative; visual analogue scale, VAS), preoperative Pittsburgh Sleep Quality Index (PSQI), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS) data from 74 knee and 89 hip osteoarthritis (OA) patients scheduled for TJA. Poor sleepers were identified based on preoperative PSQI scores higher than 5.

Results:

Poor sleepers demonstrated higher preoperative VAS, pain catastrophizing, anxiety, and depression compared with good sleepers (all p < 0.003). Preoperative PSQI (β = 0.23, p = 0.006), PCS (β = 0.44, p < 0.005), and anxiety (β = 0.18, p = 0.036) were independent factors for preoperative VAS. Preoperative VAS (β = 0.32, p < 0.005), but not preoperative sleep quality (β = −0.06, p = 0.5), was an independent factor for postoperative VAS.

Conclusion:

The OA patients reporting poor preoperative sleep quality show higher preoperative pain, pain catastrophizing, anxiety, and depression. High preoperative pain intensity, but not poor sleep quality, was associated with higher chronic postoperative pain intensity. Future studies are encouraged to explore associations between sleep and chronic postoperative pain.

Keywords: Sleep quality, preoperative risk factors, total knee and hip arthroplasty, postoperative pain, pain catastrophizing, depression

Introduction

Knee and hip osteoarthritis (OA) are highly prevalent musculoskeletal disorders that affect the elder population. 1 The treatment for end-stage OA is total joint replacement (total knee or hip replacement: TKA and THA, respectively); however, it is well established that an approximate 20% of patients following TKA and 10% of patients following THA will report chronic postoperative pain. 2

Preoperative pain intensity 3 and cognitive factors such as high preoperative pain catastrophizing predict the presence of chronic postoperative pain 6 and 24 months after TKA.4–8 Furthermore, a recent study demonstrated that preoperative sleep parameters such as Pittsburgh Sleep Quality Index (PSQI) and daily sleepiness were associated with acute postoperative pain after TKA and THA. 9 Sleep may therefore play an important role in maintaining, for example, neural mechanisms such as descending pain inhibitory control 10 and possibly the prevention of, for example, depression 11 known to predict chronic postoperative pain.3,12,13 Furthermore, in a smaller cohort of 18 knee and hip OA patients, Roehrs and Roth 14 reported that simply extending sleep by approximately 1 hour improved early postoperative outcomes. These lines of evidence may suggest an interplay between cognitive factors such as depression, sleep, and postoperative pain. However, no evidence is currently available on how preoperative poor sleep is associated with preoperative risk factors pain catastrophizing, depression, anxiety, or chronic postoperative pain 12 months after TKA and THA.

The aims of the present exploratory study were to (1) assess the association between preoperative sleep quality and preoperative clinical pain intensity, pain catastrophizing, anxiety, and depression and (2) explore the associations between preoperative sleep quality, pain intensity, pain catastrophizing, depression, and anxiety and chronic postoperative pain intensity 12 months after total joint replacement in patients with OA.

Methods

Patients

A total of 185 knee OA patients (82 men and 103 women; mean age ± SD: 68.8 ± 8.92 years) and 189 hip OA patients (120 men and 69 women; mean age ± SD: 66.93 ± 13.75 years) scheduled for TKA or THA were enrolled. The patients took part in a large randomized controlled trial assessing the effect of acute and 7-day postoperative administration of the muscle relaxant chlorzoxazone on postoperative pain (12 months after TKA or THA). Chlorzoxazone is believed to enhance acute postoperative pain recovery, 15 which may improve postoperative pain, 16 but the study demonstrated no effect of chlorzoxazone on acute and chronic postoperative pain compared with placebo. 17 Therefore, these exploratory analyses were carried out. Patients were assessed for eligibility at a prescheduled hospital visit preceding admission for surgery between September 2015 and September 2016, and a follow-up was conducted 12 months post-surgery (2017).

Exclusion criteria involved use of gabapentinoids, glucocorticoids, opioids, anxiolytics, antiepileptics or antidepressants; alcohol abuse; other pain treatments outside of standard care; malignant conditions; pregnancy; BMI > 40 kg/m2; suffering from other peripheral or central acting diseases; allergy towards chlorzoxazone; perioperative complications (e.g. fractures) and liver diseases. All patients signed an informed consent prior to inclusion. The study was approved by the National Medicine Agency, the local ethics committee (VN-20150024) and National Data Protection Agency, preregistered at Clinicaltrials.gov (identifier number: NCT02405104) and conducted in accordance to the Declaration of Helsinki.

Sleep quality

Sleep quality was assessed preoperatively using the PSQI. The PSQI measures sleep quality and disturbances over 1-month intervals using 19 items, including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, sleep medication usage and daytime dysfunction, and is assessed on a 0- to 21-point scale. 18 A PSQI measure >5 indicates poor sleep, with reported sensitivity of ~90% when distinguishing good from poor sleepers. 18

Pain Catastrophizing Scale

The Pain Catastrophizing Scale (PCS) 19 was administered preoperatively to assess pain catastrophizing. The PCS scores range from 0 to 52 across three subscales (rumination, magnification, and helplessness) based on 13 items (each scored from 0 to 4) reflecting the frequency of catastrophizing cognitions. The PCS is validated in chronic pain patients, pain-free subjects,20,21 and the Danish version in clinical and non-clinical cohorts. 22 The total PCS score was calculated and used for further analysis.

Anxiety and depression

The Hospital Anxiety and Depression Scale (HADS) is considered part of the (British) National Institute for Health and Care Excellence (NICE) recommendation for diagnosis of depression and anxiety 23 and was employed to determine the level of preoperative anxiety and depression. The scale consists of 14 questions, of which 7 items assess anxiety and 7 items assess depression. 24 Each item is evaluated by a score from 0 to 3 and summated to give a separate score for anxiety and depression. Cut-off values for anxiety and depression scores are 8 or above, which yield good specificity and sensitivity. 25

Pain intensity measures

Clinical pain intensity was defined as pain after 20 minutes of rest and was rated on a visual analogue scale (VAS; 0–10 cm; referred to as pain from hereon). Both pre- and 12-month postoperative clinical pain intensity were obtained.

Statistics

First, the potential effect of chlorzoxazone on the study parameters was tested in a multivariate analysis of co-variance (MANCOVA), with fixed factor randomization (chlorzoxazone or placebo).

Patients (TKA and THA pooled) were grouped based on sleep quality into good or poor sleepers defined as PSQI > 5. Independent-samples t tests were conducted between the two subgroups to explore whether the two groups differed. Chi-square tests on proportions were used to test differences in proportions of gender and surgery type between good and poor sleepers. Linear regression analyses were conducted on postoperative pain intensity 12 months after surgery with independent preoperative factors pain, PSQI, PCS, anxiety, and depression, and on preoperative pain intensity with independent preoperative factors PSQI, PCS, depression, and anxiety. In addition, a linear regression was conducted for preoperative PSQI with independent preoperative factors pain, PCS, anxiety, and depression. All collinearity tolerance and variance inflation factor (VIF) levels were above 0.1 and below 10, 26 respectively, indicating no collinearity or multicollinearity among the independent variables. Since TKA and THA patients may differ in aetiology and experience of pain, associations within the TKA and the THA group were tested separately with Pearson’s product moment correlation tests. A p-value below 0.05 was set to determine statistical significance. Bonferroni correction was applied to correct for multiple comparisons (0.05 / 5 = 0.01). All statistical analyses were performed in Statistical Package for Social Sciences (SPSS; version 26, IBM). Data are reported as mean ± standard error of the mean (SEM) unless otherwise stated.

Results

A total of 163 patients all had preoperative and postoperative data available (41.48% of all participants in the primary trial) and were included for further analysis (CONSORT diagram, Figure 1). The excluded patient group displayed a significantly higher proportion of females (62.8%) compared with included patients (37.2%, p = 0.03), but otherwise no significant differences were found for age (t(372) = 1.68, p = 0.09), PCS (t(328) = 0.89, p = 0.4), PSQI (t(230) = −0.54, p = 0.6), anxiety (t(295) = 0.31, p = 0.76), or depression (t(291) = 1.1, p = 0.28). Demographics for the included patients can be seen in Table 1. The MANCOVA demonstrated that randomization (chlorzoxazone or placebo) did not impact preoperative pain (F(1,161) = 1.74, p = 0.19), postoperative pain (F(1,161) = 0.87, p = 0.35), PCS (F(1,161) = 0.14, p = 0.71), PSQI (F(1,161) = 0.39, p = 0.53), anxiety (F(1,161) = 0.41, p = 0.52), or depression (F(1,161) = 2.15, p = 0.14).

Figure 1.

Figure 1.

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CONSORT diagram.

TKA: total knee arthroplasty, THA: total hip arthroplasty.

Flow of patients throughout the trial and the secondary analysis conducted in the current study.

Table 1.

Demographics and descriptives of the patient cohort (N = 163).

Age (years) (mean ± SD) 66.71 ± 13.63
Gender (n (%)) 99 males (60.74%); 64 females (39.26%)
Surgical procedure (TKA/THA), n (%) 74 (45.4%)/89 (54.6%)
Preoperative pain intensity (0–10) (mean ± SD) 3.55 ± 2.3
PCS (0–52) (mean ± SD) 17.79 ± 12.25
PSQI (0–21) (mean ± SD) 7.91 ± 4.61
HADS (Anxiety; 0–21) (mean ± SD) 3.96 ± 3.36
HADS (Depression; 0–21) (mean ± SD) 2.31 ± 2.64
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SD: standard deviation; TKA: total knee arthroplasty, THA: total hip arthroplasty; PCS: Pain Catastrophizing Scale; PSQI: Pittsburgh Sleep Quality Index; HADS: Hospital Anxiety and Depression Scale.

The impact of sleep quality on psychological factors

The good sleepers were older than the poor sleepers (t(151) = −0.25, p = 0.02). In addition, a higher proportion of females were found in the poor sleepers’ group (poor sleepers = 50 males/44 females; good sleepers = 41 males/18 females) (χ2 = 3.9, p = 0.046). No difference was observed for proportion of surgery type in the subgroups (χ2 = 3.7, p = 0.055) (see Table 2).

Table 2.

Differences in main comparisons.

Good sleepers Poor sleepers t test
Age (years) (mean ± SD) 70.47 ± 15.8 64.27 ± 11.47 t(161) = −2.9, p = 0.004
Gender (M/F) (n) 45/19 54/45 χ 2 = 4.05, p = 0.044
Surgical procedure (TKA/THA) (n) 35/29 39/60 χ2 = 3.7, p = 0.055
Preoperative pain intensity (0–10) (mean ± SD) 2.76 ± 2.11 4.06 ± 2.29 t(161) = 3.62, p < 0.001
PCS (0–52) (mean ± SD) 12.39 ± 8.85 21.29 ± 12.89 t(160.38) = 5.22, p < 0.001
HADS (Anxiety; 0–21) (mean ± SD) 2.39 ± 2.26 4.97 ± 3.57 t(160.96) = 5.64, p < 0.001
HADS (Depression; 0–21) (mean ± SD) 1.28 ± 1.67 2.98 ± 2.92 t(158.79) = 4.71, p < 0.001
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TKA: total knee arthroplasty, THA: total hip arthroplasty; PCS: Pain Catastrophizing Scale, PSQI: Pittsburgh Sleep Quality Index, HADS: Hospital Anxiety and Depression Scale.

Good sleepers were significantly older, were represented by less women, and had lower preoperative pain, lower PCS, lower depression, and lower anxiety than the poor sleepers.Boldfaced values represent significant findings (P < 0.05).

The poor sleepers reported significantly increased preoperative pain intensity (t(151) = 3.06, p = 0.003; Figure 2(a)), higher pain catastrophizing thoughts (t(149.16) = 4.96, p < 0.001; Figure 2(b)), higher anxiety scores (t(150.88) = 5.32, p< 0.001; Figure 2(c)), and higher depression scores (t(150.51) = 4.5, p < 0.001; Figure 2(d)) compared with the good sleepers.

Figure 2.

Figure 2.

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Differences between OA patients suffering from poor sleep versus good sleep (median ± interquartile ranges). Poor sleepers reported (a) significantly higher pain, (b) pain catastrophizing thoughts, (c) anxiety, and (d) depression.

PCS: Pain Catastrophizing Scale; Anxiety/Depression: Hospital Anxiety and Depression Scale.

Associations between preoperative sleep, preoperative pain intensity and preoperative cognitive factors

For preoperative pain, the linear regression model was significant (F(4,158) = 13.71, p < 0.005) with independent preoperative factors PSQI (β = 0.23, p = 0.006), PCS (β = 0.44, p < 0.005), and anxiety (β = 0.18, p = 0.036) explaining 23.9% of the variance (R2 = 0.239) in preoperative pain. Pre-operative depression was not a significantly independent predictor for preoperative pain (β < 0.005, p = 0.99). For preoperative PSQI, the linear regression model was significant (F(4,158) = 21.26, p < 0.005) with independent preoperative factors pain (β = 0.201, p = 0.006), PCS (β = 0.177, p = 0.044), anxiety (β = 0.18, p = 0.036), and depression (β = 0.23, p = 0.005) explaining 33.3% of the variance (R2 = 0.333) in preoperative PSQI.

Associations between preoperative sleep quality, pain intensity, cognitive factors and postoperative pain intensity 12 months after surgery

For postoperative pain intensity 12 months after surgery, the linear regression model was significant (F(5,157) = 4.25, p = 0.001) and explained 9.1% of the variance (R2 = 0.091) with independent preoperative factor pain (β = 0.32, p < 0.005). Preoperative PCS (β = 0.091, p = 0.38), anxiety (β = −0.137, p = 0.18), depression (β = 0.036, p = 0.72), and PSQI (β = −0.06, p = 0.5) were not independent factors for postoperative pain intensity 12 months after surgery.

Associations within subgroups of OA patients undergoing TKA or THA

Both the TKA and THA subgroup showed significant correlations between preoperative PSQI and PCS with preoperative pain (all r > 0.325, all p < 0.005; similar to the full cohort). Only the TKA group demonstrated associations between preoperative pain and preoperative PCS and postoperative pain 12 months after surgery (r = 0.507 and 0.286, both p < 0.013), whereas the THA group did not (r = 0.085 and −0.019, respectively, p = 0.428). Only the THA group showed an association between preoperative pain and preoperative depression (r = 0.285, p = 0.007). All subgroup correlations are shown in Table 3.

Table 3.

Correlation analyses within each subgroup of OA patients.

TKA only THA only Full cohort
Preoperative PSQI & preoperative pain r = 0.325, p = 0.005 r = 0.393, p < 0.001 r = 0.36, p < 0.001
Preoperative pain and preoperative PCS r = 0.419, p < 0.001 r = 0.489, p < 0.001 r = 0.46, p < 0.001
Preoperative pain and preoperative depression r = 0.132, p = 0.263 r = 0.285, p = 0.007 r = 0.23, p = 0.004
Preoperative pain and preoperative anxiety r = 0.09, p = 0.43 r = 0.202, p = 0.057 r = 0.16, p = 0.12
Preoperative pain and postoperative pain r = 0.507, p < 0.001 r = 0.085, p = 0.428 r = 0.32, p < 0.001
Postoperative pain and preoperative PCS r = 0.286, p = 0.013 r = −0.019, p = 0.86 r = 0.15, p = 0.057
Postoperative pain and preoperative anxiety r = −0.123, p = 0.298 r = 0.106, p = 0.323 r = −0.045, p = 0.57
Postoperative pain and preoperative depression r = 0.094, p = 0.427 r = 0.07, p = 0.513 r = 0.042, p = 0.59
Postoperative pain and preoperative PSQI r = 0.116, p = 0.325 r = 0.048, p = 0.654 r = 0.05, p = 0.52
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TKA: total knee arthroplasty, THA: total hip arthroplasty; PCS: Pain Catastrophizing Scale, PSQI: Pittsburgh Sleep Quality Index.

Preoperative pain was significantly correlated with preoperative PSQI and PCS in each group. For the TKA group, both preoperative pain and preoperative PCS were associated with postoperative pain intensity 12 months after surgery, whereas preoperative depression was associated with preoperative pain within the THA group.Boldfaced values represent significant findings (P < 0.05).

Discussion

The current study aimed to assess the association between poor sleep quality, preoperative factors known to influence postoperative pain and pain intensity 12 months after surgery. The results show that poor sleepers demonstrate higher preoperative pain intensity, higher levels of pain catastrophizing thoughts and higher levels of anxiety and depression. Finally, higher preoperative pain intensity, but not preoperative sleep quality, was an independent factor for higher pain intensity 12 months after surgery.

Sleep quality, its impact on preoperative pain and relation to chronic postoperative pain

Up to 50% of chronic pain patients report poor sleep, 27 and 1-month postoperative sleep disruption may mediate the association between pain and functional limitations reported 1 and 3 months after surgery, respectively. 28 A recent systematic review and meta-analysis identified sleep difficulties as a strong preoperative predictor of poor postoperative pain control; however, this was only based on two studies. 29 In addition, Mamie et al. 30 showed preoperative chronic sleep difficulties increased the risk of severe acute postoperative pain following intraperitoneal or orthopaedic surgery. A recent study reported that preoperative PSQI and daily sleepiness were associated with acute postoperative pain, up to 3 months and 3 days after TKA and THA, respectively. 9 The current study extends these findings by demonstrating that patients who are considered poor sleepers, based on the PSQI cut-off value, also report higher preoperative pain, pain catastrophizing, anxiety, and depression. Conversely, no significant association between preoperative sleep quality and pain intensity 12 months after surgery was found. It is worth nothing that the primary trial did not aim to assess the association(s) between sleep quality and pain after surgery, and therefore also present with large attrition which will be further discussed in the limitations. These considerations should be factored in when comparing the current findings with those of Luo et al. 9 Nonetheless, there may be an association between poor sleep quality preoperatively and pain after surgery; however, the timeline of which this remains relevant and the underlying mechanisms should be elucidated in future studies. In healthy participants, partial and total sleep deprivation have shown to affect both peripheral10,31 and central facilitatory and inhibitory pain mechanisms.10,32 These pain mechanisms are also altered in chronic pain patients suffering from, for example, fibromyalgia or knee OA12,33–35 and may predict the analgesic response to standard pain treatment in OA36,37 and reports of chronic postoperative pain following TKA12,13,38–41 and THA.42,43 Together with the current findings, these studies indicate that OA patients reporting poor sleep also suffer from higher preoperative pain which is predictive of chronic postoperative pain. 3 Interestingly, the subgroup correlations provided in the current report may suggest that preoperative pain intensity is associated with pain intensity 12 months after surgery only in TKA patients. Future studies may investigate whether such difference exists in a design specifically aimed towards this. In a randomized controlled feasibility trial, Roehrs and Roth 14 demonstrated, in a cohort of 18 knee and hip OA patients scheduled for TKA or THA, that extending sleep by approximately 1 hour yielded an improvement in acute postoperative pain and opiate use, indicating that improving sleep might yield better postoperative outcomes for patients. Of note, earlier large-scale studies,44,45 albeit not related to postoperative pain, have demonstrated associations between sleep quality and sleep duration, however, often of low-to-moderate strength. Therefore, sleep quality and sleep duration should not be considered synonymous parameters and should be considered in the present discussion and future studies on the relationship between sleep parameters and pre- and postoperative measures of pain. Since the current study found a difference in age between those patients who sleep poorly compared with those who sleep well, the possible effect of age on postoperative pain should be considered, despite the availability of contrasting evidence on the association between age and postoperative pain after various surgical procedures. 46 The risk of postoperative pain may decline as a linear function of age per decade increase, across a large variety of different surgical procedures, including TKA and THA. 47 In the current study, this may partially explain why the preoperative pain intensity was higher in the younger poor sleep group and may have indirectly influenced postoperative pain intensity due to the well-established association between pre- and postoperative pain (see, for example, Lewis et al. 3 ). However, this remains a speculation as of now and requires further investigation. Furthermore, a larger proportion of women was found in the poor sleep group, and women, in general, report higher preoperative pain intensity 48 and more frequently develop chronic postoperative pain.49,50 It is worth noting that our findings are in line with earlier epidemiological studies investigating the differences in, for example, sleep quality, where a larger proportion of women report poor sleep quality among other sleep parameters compared with men. 51 This study cannot rule out a possible influence of the difference in proportion of females in the poor sleepers group when comparing, for example, preoperative pain intensity, but it is acknowledged and should be controlled in future studies.

Sleep quality and its relation to anxiety, depression and pain catastrophizing

Sleep abnormalities have been associated with high risk of depression,52,53 anxiety, 11 and pain catastrophizing. 54 For instance, depression was shown to be independently associated with sleep problems in rheumatoid arthritis patients, 55 however, the direction in which insomnia, depression, and even chronic pain interact remains elusive. 56 In temporomandibular disorder patients, sleep disturbance was shown to exert a mediating role on pain catastrophizing. 57 In support, indirect evidence for the role of sleep on pain catastrophizing was shown in another study, where cognitive behavioural therapy for insomnia in knee OA patients reduced pain catastrophizing. 58

These studies support early interventions aimed at managing depression, anxiety, and pain catastrophizing, since they, especially the latter, are known to predict chronic postoperative pain,4,5 and this exploratory study extends these findings by showing higher levels of pain catastrophizing in knee OA patients who report poor sleep prior to TKA and THA. A recent multi-site randomized clinical trial was performed to lower catastrophizing thoughts in TKA patients but showed no effect on the incidence of chronic postoperative pain. 59 Therefore, future studies may explore the possibility of managing this triad of cognitive impairment through, for instance, sleep therapy or cognitive behavioural therapy, to evaluate its effect on chronic postoperative pain.

Cognitive factors and their relation to chronic postoperative pain

A systematic review and meta-analysis showed that preoperative anxiety and pain catastrophizing hold predictive value for chronic postoperative pain 3–12 months after various surgeries. 60 Another study reported that patients enrolled for abdominal surgery who underwent a preoperative pain management intervention for understanding and managing chronic postoperative pain exhibited lower preoperative anxiety and pain attitude and, importantly, reported lower acute pain intensity up to 24 hours after surgery. 61 In knee OA, preoperative anxiety and depression was shown to be associated with chronic postoperative pain 6 62 and 12 months after TKA. 63 Furthermore, in TKA patients, pain intensity and pain-related distress may be associated with anxiety, depression, and pain catastrophizing. 64 In addition, preoperative pain catastrophizing has been demonstrated to predict chronic postoperative pain 6 4 and 24 months 5 after TKA, albeit contradictory evidence exist. 65 In this respect, the association between pain and functional limitation 1 and 3 months after surgery, respectively, may be mediated by reported sleep disruption 1 month after TKA. 28 Furthermore, depression has been shown to predict higher postoperative pain, whereas catastrophizing was shown to be a unique predictor of higher postoperative night-time pain. 66 In populations suffering from sleep-related disorders such as sleep apnea, the prevalence of depression and anxiety is more pronounced when compared with a non-apnea group. 67 The current exploratory study adds to this growing body of evidence by showing that hip and knee OA patients reporting poor sleep exhibit higher preoperative anxiety, depression, and pain catastrophizing levels. In a 12-month longitudinal study, Scott et al. 68 demonstrated that following a telecare intervention optimizing pain monitoring and analgesic management, improvements in depression, pain catastrophizing, and anxiety predicted better pain outcomes. Therefore, these factors may play a direct or an indirect role in chronic postoperative pain, and further research similar to the study by Riddle et al. 59 is needed to further our understanding of preoperative interventions on cognitive factors associated with postoperative pain.

Limitations

Several limitations should be considered for this study. Large attrition from the primary trial (i.e. only 41.48% of the participants of the original trial 17 were included in this report, due to a lack of pre- or post-measures of the included variables) may introduce issues with both external and internal validity; hence, we opted to demonstrate that baseline values for the included cohort did not differ significantly compared with the excluded patients. However, this does not conclusively demonstrate that the included cohort is representative for the full population of TKA and THA patients from which they originated from, and the results should be interpreted with care. Since a larger proportion of females were found in the excluded and poor sleepers’ groups, and that females are known to report higher anxiety, 69 higher preoperative pain intensity, 48 and more frequently develop chronic postoperative pain,49,50 this should be considered when interpreting the current findings. Furthermore, since the current study investigated preoperative depression and anxiety, it is important to highlight that the primary trial excluded patients based on the use of antidepressants and anxiolytics within the past 4 weeks. 17 As such, the prevalence (~20% for both types of OA)70,71 or severity of depression or anxiety symptoms in the patient cohort may be underrepresented compared with the general TKA or THA population undergoing surgery. No exclusion criteria on common sleep disturbances such as obstructive sleep apnea were implemented in the primary trial, and since no predictive value of the PSQI has been shown for sleep disturbances such as obstructive sleep apnea 72 or other sleep behaviour disorders, 73 this study cannot rule out that other underlying sleep disorders were present in the cohort.

Conclusion

This study investigated associations between preoperative quality of sleep, preoperative risk factors for chronic postoperative pain and pain intensity 12 months after TKA and THA. The results showed that OA patients with poor preoperative sleep have higher preoperative pain intensities and higher levels of pain catastrophizing, anxiety, and depression compared with patients who sleep well. Preoperative pain intensity, but not sleep quality, was an independent factor for pain intensity 12 months after total knee and hip arthroplasty. As such, the present findings do not support an association between preoperative sleep quality and postoperative pain intensity 12 months after surgery, but that differences may exist in preoperative measures important to resolve pain after surgery based on sleep quality.

Footnotes

Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Contributorship: K.K.P., M.L., O.S., and L.A.-N. contributed to the conceptual development of the study. Data were collected by M.L. and O.S. and analysed by D.B.L. All authors interpreted and discussed the data. D.B.L. wrote the first draft, which was critically revised by K.K.P., L.A.-N., O.S., and M.L. All authors approved the final version.

Data availability: Data are available upon request from the author.

Ethical approval: Ethical approval for this study was obtained from the Northern Jutland Scientific Ethics Committee (VN-20150024).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the University Talent Management Programme (J. No. 771126), the Shionogi Science Program, and the TaNeDS Europe grant. None of the funders had any role in the study other than to provide funding. K.K.P. received a grant from the Ministry of Higher Education and Science in collaboration with Cortex Technology Aps to develop the cuff algometer. Center for Neuroplasticity and Pain (CNAP) is supported by the National Research Foundation (DNRF121).

Guarantor: K.K.P. is the guarantor of this article.

Informed consent: Written informed consent was obtained from all subjects before the study.

Trial registration: Clinicaltrials.gov (identifier number: NCT02405104)

ORCID iD: Dennis Boye Larsen Inline graphic https://orcid.org/0000-0002-2844-7408

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