What did I do?

I investigated the relationship between psychological health before total knee arthroplasty (TKA) and health service outcomes after TKA. I developed a psychologically informed physiotherapy intervention for patients before TKA, and pilot tested this intervention, evaluating patient outcomes, health service outcomes and implementation outcomes. I developed and tested a training intervention to upskill physiotherapists in key aspects of this psychologically informed physiotherapy intervention.

Why did I do it?

My clinical experience in a socially disadvantaged context was that patients with psychological symptoms recovered slowly and had longer hospital stays after TKA. This delayed patient flow through the hospital which impacted costs and patient care. However, little evidence explored these relationships, nor potential solutions. Understanding who is at risk for longer hospital stays, and interventions to minimise this risk, are important to empower clinicians to meet the needs of these patients, and for patients, carers and healthcare providers to have realistic expectations of recovery and hospital stays. There is greater urgency to understand this now as enhanced recovery pathways for TKA are implemented rapidly following COVID-19 disruptions to elective surgery, with pressure to provide a high volume of procedures in a short period of time.

Musculoskeletal research and practice has acknowledged the value of a biopsychosocial approach to patient assessment,1 particularly for chronic pain, which is relevant to people undergoing TKA. However, TKA pathways are focused on biomedical assessment, and I sought to understand how a holistic, biopsychosocial approach could be applied to TKA care.

How did I do it?

Study 1 was a systematic review that explored the association between preoperative psychological health and hospital length of stay after TKA.2

Study 2 was a real-world observational study and explored associations between preoperative psychological health and acute hospital length of stay after TKA. Resilience is the ability to ‘bounce back from stress’,3 and this was the first study to explore resilience and hospital length of stay after TKA.4

In study 3, I developed a novel preoperative physiotherapy intervention named KOMPACT-P: Knee Osteoarthritis Management with Physiotherapy informed by Acceptance and Commitment Therapy. My pilot randomised trial assessed safety, acceptability and feasibility of the intervention as well as effectiveness outcomes.5

In study 4, I designed and tested an implementation strategy to upskill musculoskeletal physiotherapists in key areas of a psychologically informed approach, using Acceptance and Commitment Therapy as an operational framework. We explored knowledge and confidence in learning outcomes and implementation outcomes.6

What did I find?

The systematic review found a likely association between the presence of psychological symptoms before TKA and longer hospital stays after TKA; however, high variation in reporting of psychological health and length of stay approaches limited meta-analysis.2 The observational study demonstrated that our group experiencing depression, anxiety and stress above a ‘mild’ symptom threshold before TKA had a longer hospital stay compared with our symptom-free group.4 Resilience scores before TKA were not associated with hospital length of stay.4 Multivariate analysis demonstrated that only fatigue and anaesthetic risk (ASA) score predicted length of stay, and socioeconomic and psychological factors did not predict length of stay.4

The pilot randomised controlled trial5 started recruitment, however, was impacted by COVID-19 restrictions. Preliminary results indicate that the intervention was safe, feasible, delivered with high fidelity and was acceptable to participants. We used randomisation with stratification for sex, site and psychological status, to ensure the treatment group was experiencing psychological symptoms and had potential to benefit from the intervention. Baseline results showed that the treatment group had multiple risk factors for prolonged length of stay including high ASA scores, high body mass index (>40) and higher pain scores.

The final study6 demonstrated that our intervention led to increased physiotherapist confidence in patient-centred care skills immediately after implementation and at 6-week follow-up.6 Participants had high behaviour intention and high implementation scores, indicating sustained translation of skills to clinical practice.6 This was particularly important given our participants were early career and culturally diverse.

What is the most important clinical impact?

Depression, Anxiety and Stress Scale-21 scores before TKA were associated with longer hospital stays after TKA. Valid and reliable psychological outcome measures need to be adopted into routine preoperative assessments before TKA. This would help to identify patients at risk of long hospital stays, and health services to implement tailored management for physical and psychosocial concerns before and after TKA. Health funding models also need to reflect psychosocial complexity. Current preoperative services often include standardised exercise and/or education, despite little evidence of efficacy for most people undergoing TKA.7 8 We recommend that preoperative interventions include both physical and psychosocial approaches and that these interventions be tailored and targeted towards patients at higher risk of longer hospital stays.

There are few professional development opportunities for physiotherapists to improve their skills in psychologically informed care. New opportunities need to be developed that include opportunities for safe and effective practice, such as simulated patients and role play, as these provide an effective and authentic learning experience.