BACKGROUND: Physical outcomes following surgery for degenerative spine disease have been well studied. It is only relatively recently however that the importance of psychological factors in determining outcome from spine surgery has been addressed. Previous studies suggest that pre-operative psychological distress is a predictor of poor outcome. In the drive to identify patients who will not benefit from spine surgery these patients may in future be denied surgery. AIM: The aim of the current study was to examine the relationship between the severity of physical symptoms, levels of pre-operative psychological distress and out-come in patients with degenerative spine disease undergoing elective spinal surgery. PATIENTS & METHODS: The study was a prospective cohort study. Health status and psychological distress were measured pre-operatively and at 12 months or more post-operatively using the Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS). We compared levels of physical disability (SF-36 physical domain scores) and psychological distress (HADS scores) before and after surgery in this group. Comparisons of pre- and post-operative scores were made using the Kruskal-Wallis, Wilcoxon Signed Rank Test and Mann Whitney U tests as appropriate. RESULTS: A total of 333 patients were included (178 men, 155 women, mean age 54y). Pre-operatively patients with severe levels of anxiety and depression (higher HADS score) had worse (lower) SF-36 physical domain (SF-36 PD) scores compared to those with normal HADS scores (median 181.5 vs 109, p< 0.0001). Both HADS and SF-36 PD scores improved post-operatively (HADS 13 vs 6 p< 0.0001; SF-36 PD 134 vs 250.5 p< 0.0001). Greater reduction in HADS score was observed in patients with severe pre-operative HADS scores compared to those with normal pre-operative HADS scores (p< 0.0001). Patients with severe HADS scores also had greater improvement in SF36 PD scores when compared to patients with normal pre-operative HADS scores (77.24 vs 53.87 p=0.03). CONCLUSION: Poor physical function pre-operatively correlates with severe psychological distress. Both physical and psychological symptoms improve after surgery. Severe levels of anxiety and depression pre-operatively are associated with the greatest symptomatic improvement and psychological morbidity does not worsen outcome

Compare the prevalence of psychological distress in claustrophobic patients compared with a non-affected group, together with determination of presenting disability and overall intervention rates. Retrospective case notes review. 33 patients (13 males) all requiring MRI scan under sedation for claustrophobia (Group 1) were compared with an age and sex matched cohort that had MRI without sedation (Group 2). Both groups were drawn from the same chronic back clinic. Average age in both groups was 54 years (range 27-79 years). Both groups had standard conservative therapy, together with psychometric evaluation. Primary: Zung Depression Index (ZDI), Modified Somatic Perception Questionnaire (MSPQ). Secondary: Oswestry Disability Index (ODI), intervention rates (surgery, injections and physiotherapy sessions). Comparison of means -. 22 patients (66.7%) in Group 1 were discharged after their MRI with no intervention compared to 7 patients (21.2%) in Group 2. Claustrophobic patients with back pain showed higher levels of depression than non-claustrophobic patients, with a greater prevalence of psychological distress. Disability however was the same. The majority of claustrophobic patients had no intervention, with a lower rate than their non-claustrophobic peers. Claustrophobia is a proxy for psychological distress and should be considered in the overall evaluation of chronic back patients

Background: It has been demonstrated that a relationship exists between pro-inflammatory cytokine levels and psychological distress. Psychological distress commonly co-exists with back pain and may be detrimental to rehabilitation in such patients undergoing surgery. We aim to establish whether a link exists between psychological distress and increased levels of Interleukin- 6 (IL-6) and it’s soluble receptor (sIL-6r) in patients undergoing surgery for low back pain. Methods: All individuals selected for spinal fusion or stabilisation surgery, in whom low back pain was the predominant feature, were eligible for inclusion. Participants completed both the Distress and Risk Assessment Method (DRAM) and Hospital Anxiety and Depression Score (HADS) questionnaires pre-operatively. Blood samples for serum IL-6, sIL-6r and high sensitivity C-Reactive Protein (CRP) levels were extracted at recruitment and results were compared with questionnaire findings. Results: 63 patients were recruited of whom 90.5% had some degree of measurable psychological distress. Patients were divided into two groups based upon the degree of their distress. Mean IL-6 levels were higher in groups of patients with more distress measured by the DRAM and HADS depression component but were lower in patients with more anxiety. IL-6 receptor levels were higher in patients with raised DRAM and HADS anxiety scores. No significant correlation between questionnaire responses and cytokine levels was found. A correlation exists between IL-6 and CRP levels even at normal levels of CRP. Conclusion: There does not appear to be a significant relationship between IL-6 and sIL-6r levels and psychological distress in back pain patients

Aims: This is a prospective study that evaluates the impact of psychological disturbance upon symptoms, self-reported disability and surgical outcome in patients with carpal tunnel syndrome. Methods: We recruited a consecutive series of 84 patients with a clinical diagnosis of carpal tunnel syndrome. Symptom severity and disability were assessed using the Boston carpal tunnel questionnaire (Levine et al 1993). Psychological distress was assessed using the Hospital Anxiety and Depression Scale (Zigmond & Snaith 1983). Questionnaires were administered before and six-weeks after open carpal tunnel decompression. Complete pre and postoperative data were available for 69/84 patients (82%). A statistical correlation of psychological distress with symptoms, self reported disability and surgical outcome was performed. Results: There was a signiþcant correlation between the psychological disturbance (the HAD score) and the pre-operative symptom severity (correlation coefþcient = 0.37, p < 0.04) and function scales (correlation coefþcient = 0.55, p < 0.0001) of the Boston carpal tunnel score. Self reported symptoms improved following surgery in 65/69 patients (94%). The mean symptom score improved from 3.01 pre-op to 1.69 post-op (p < 0.0001). Function and psychological distress improved signiþcantly following surgery. Conclusions: There was no signiþcant correlation between pre-operative psychological distress and the outcome of carpal tunnel decompression though there was signiþcant correlation with symptom severity

Background. There are no published studies investigating predictive values of psychological distress on effectiveness of epidural injection. Aims. To evaluate response to epidural injection (EI) in patients with chronic lower back pain (CLBP) with and without psychological distress. Methods. 96 patients with CLBP were recruited to this prospective cohort study. They had preoperative level of distress measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ); back related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal EI comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. Results. There were 62.5% not-distressed patients, 3.1% somatising, 15.6% depressed and 18.8% with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Distress was associated with worse MPQ and ODI. Average VAS and MPQ improved significantly at 6 and 26 weeks. Mean change of ODI was significant but less than MCIC. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was significant predictor of VAS-MCIC at 6 weeks while MZI and MSPQ at 6 months. None could predict this outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC with 53%-sensitivity and 78%-specificity. MZI was significant predictor of ODI-MCIC but not individually.88% patients were satisfied with the treatment at 6 weeks and 63% at 6 months (significantly higher rate if somatising). Conclusions. Early psychological screen was correlated with outcome following epidural injection in CLBP and capable of predicting some response to treatment. Minimal, short-lived improvement of distress was not related to post-treatment CLBP measures

Background: The results after total hip arthroplasty are often excellent, though they can be influenced by multitude of factors. In this study it has been investigated if an association existed between preoperative psychological distress (anxiety and depression) and postoperative functional outcome. Methods: We performed a prospective study of follow-up of a cohort. The inclusion criteria were a clinical and radiological diagnosis of degenerative osteoarthritis of hip. Three functional variables (pain, mobility and functionality) and two psychological variables (anxiety and depression) were evaluated preoperatively and postoperatively in the principal study, being the dementia the principal criterion of exclusion. Results: 91 patients fulfilled the criteria of incorporation (81 primary osteoarthritis, 5 rheumatoid arthritis and 6 osteonecrosis of the femoral head), presenting 9.8 % depression and 12 % anxiety preoperatively, and 2.2 % depression and 3.3 % anxiety postoperatively, finding statistically significant differences in the difference of the functional outcome (p < 0.001) and in the influence of the anxiety (p < 0.02) in them, and not statistically significant in the influence of the depression (p=0.93) in the difference of the functional outcome. Conclusions: Anxiety preoperative influenced the functional outcome one year after the surgical procedure of the patients submitted to hip arthroplasty

The study aims to determine the effects of obesity on the patients’ symptoms and their knee function before knee arthroplasty, as well as their states of anxiety and depression. Ethical approval was obtained before the start of the study. Weights and heights of all patients were measured and BMI calculated on admission. Anxiety and depression states were recorded using the Hospital Anxiety and Depression Scale (HADS). The severity of pain and loss of function of the knees undergoing arthroplasty was measured using the Oxford Knee Score and the American Knee Society Score. All scores were measured per-op and again at 6 weeks post-op. To date, 28 patients were included. The mean body mass index was 28.9. Only six patients had a BMI of < 25. Patients with normal BMI (< 25) had mean anxiety and depression scores of 6.8 and 5.67 respectively. Overweight patients (BMI > 25) had scores of 5.59 and 4.9 respectively. Patients with BMI > 30 had scores of 6.71 (p= 0.22) and 7.0 (p= 0.04) respectively. Patients with BMI > 30 had an improvement in anxiety scores of 1.33 points compared with 0.55 for patients with BMI < 30 (p= 0.3). Depression scores improved by 4 points in the BMI > 30 group compared with 0.67 in the BMI < 30 group (p= 0.03). Improvements in the knee scores were comparable in both groups. Obese patients with BMI of > 30 have higher rates of anxiety and depression pre-operatively. At 6 weeks follow up, there is an improvement in both measures of psychological distress but this is more pronounced for depressive symptoms

Introduction: This study investigates the effect of somatisation on results of lumbar surgery. Methods: Pre- and postoperative data of all primary discectomies and posterior lumbar decompressions was prospectively collected. Pain using the Visual Analogue Score (VAS) and disability using the Oswestry Disability Index (ODI) were measured. Psychological assessment used the Distress Risk Assessment Method (DRAM). Follow-up was at 1 year. Results: There were a total of 320 patients (average age 49.7 years). Preoperatively there were 61 Somatising and 75 psychologically Normal patients. 47 of the pre-operative Somatisers were available for follow-up. All pre-operative parameters were significantly higher compared with the Normal group (back pain VAS 6.3 and 3.8; leg pain VAS 7 and 4.7; ODI 61 and 34.4 respectively). At 1 year follow-up, 23% of the somatising patients became psychologically Normal; 36% became At Risk; 11% became Distressed Depressed; and 30% remained Distressed Somatisers. The postoperative VAS for back and leg pain of the 11 patients who had become psychologically Normal was 3.4 (pre-op 6.8) and 3.2 (pre-op 6.6) respectively. In the 14 patients who remained Distressed Somatisers the corresponding figures were 5.6 (pre-op 7.8) and 6.7 (pre-op 7.0). The postoperative ODI of the 11 patients who had become psychologically Normal was 26.4 (pre-op 55.5). In the 14 patients who remained Distressed Somatisers the corresponding figures were 56.7 (pre-op 61.7). These differences are statistically significant. Discussion: Patients with features of somatisation are severely functionally impaired preoperatively. One year following lumbar spine surgery, 60%(28) had improved psychologically, 23%(11) were defined as psychologically normal. This was associated with a significant improvement in function and back and leg pain. The 14(30%) patients who did not improve psychologically and remained somatisers had a poor functional outcome. Our results demonstrate that psychological distress is not an absolute contraindication to lumbar spinal decompressive surgery

Introduction. Preoperative psychological distress has been reported to predict poor outcome and patient dissatisfaction after total hip replacement (THR). We investigated this relationship in a prospective multi-centre study between January 1999 and January 2002. Methods. We recorded the Oxford Hip Score (OHS) and SF36 score preoperatively and up to five years after surgery and a global satisfaction questionnaire at five year follow up for 1039 patients. We dichotomised the patients into the mentally distressed (Mental Health Scale score - MHS <50) and the not mentally distressed (MHS (50) groups based on their pre-operative MHS of the SF36. 776 (677 not distressed and 99 distressed) out of 1039 patients were followed up at 5 years. Results. Both pre and post-operative OHS and SF-36 scores were significantly worse in the distressed group (both p<0.001). However, both groups experienced statistically significant improvement in OHS and MHS, which was maximal at 1 year after surgery and was maintained over the follow up. The trend in OHS gain was similar in both groups. There was a substantial improvement in mental distress in patients who reported mental distress prior to surgery. The mentally distressed group also reported better mental health gain compared to the non-distressed group. There was no significant difference in patient satisfaction or willingness to have the surgery again at 5 years following surgery between the two groups. Conclusion. Despite having worse absolute values both pre and post operatively, patients with mental distress did not have any less functional gain from THR

Perceived knowledge suggests that patients with Failed Back Surgery and a poor psychological profile would respond poorly to surgical interventions. This comparative study was designed to identify if there was a significant difference in the outcome following endoscopic spinal intervention in patients with Failed Back Surgery when compared to those who had no previous interventions. Between April 1997 and November 1998, 54 patients with failed open back surgery and 85 without previous interventions were included in the study, underwent aware state pain source identification and endoscopic foraminal interventions. Pre- and post-operative assessment at 2 years was made using the Distress and Risk Assessment Method (DRAM), Oswestry Disability Index (ODI) and a Visual Analogue Pain Scale (VAPS). A Mann-Whitney U and Wilcoxon-Signed Rank tests were performed. Patients with failed back surgery demonstrated greater psychological distress, disability (p < 0.05) and pain pre-operatively than those who underwent primary endoscopic interventions. Post-operatively both groups demonstrated significant improvement and no difference was found in the Zung, DRAM, ODI and VAPS scores. With aware state pain source identification, targeted minimal intervention and discrete tissue ablation patients with failed back surgery with associated depression can demonstrate favourable physical and psychometric outcomes

Introduction: Although the functional outcomes after severe lower limb injury ( Gustilo grade IIIb and IIIc ) managed with various surgical techniques is well described in the literature, there is limited information on appearance related psychological impact after complex lower limb reconstruction. We sought to determine the aesthetic problems in patients with open tibial fractures with extensive soft tissue injury.

Materials and methods: Data on patients with open tibial fractures managed with free flaps between 1999–2003 admitted to our trauma unit was collected and analysed. Patients who had finished their treatment at least one year ago with isolated leg injury were identified, patients with surgery related disability were excluded. we used Derriford Scale (DSA24) with additional questionnaire for analysis .

Results: In total 31 patients were contacted out of which 18 provided with completed questionnaires, 14 male and 4 female with mean age of 41.8(17–69) year. Appearance of the leg following surgery significantly effected relationships (3 divorced, 2 split up, 3 worse, 8 same and 2 better). Nine (56.2%) patients experienced poor sexual relationship following surgery and four (22.2%) reported to avoid undressing in front of partners. Five patients (27.7%) requested debunking and two under went surgery. Twelve (66.6%) patients were still taking pain killers. Ten (55.5%) patient complained of donor site weakness or painful scar. Six (33.3%) patients required to change jobs. Thirteen (72.2%) were unconfident in themselves, (66.6%) were distressed to see there legs in mirror. Nine (50%) felt hurt and irritable at home, (61.1%) patients avoided going to beach. Nine (50%) disliked using communal changing areas or even going for shopping and felt closed in a shell. Eight (44.4%) patients felt rejected and chose not to attend social events.

Conclusion: The psychological impact of trauma is generally neglected, sudden and unexpected nature of events and interventions have significant effect on post operative quality of life.

Little is known about the psychological morbidity associated with orthopaedic trauma. Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Little is known about the psychological morbidity associated with orthopaedic trauma.

Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma.

All patients attending ten orthopaedic fracture clinics at three University-affiliated Hospitals were approached for study eligibility. All consenting patients would be requested to complete a baseline assessment form, a 90-item symptom checklist-90R (SCL-90R), and the Short-Form–36. The SCL-90R constitutes nine dimensions (Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism) and three global indices (Global severity index, Positive symptom distress index, positive symptom total). We conducted regression analyses to determine predictors of quality of life among study patients.

Of two hundred and fifteen patients, 59% were male at a mean age of 44.5 years. Over half of patients had lower extremity fractures. Trauma patients experienced greater psychological symptoms than population norms. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Patient functional outcomes were predicted by patient age, ongoing litigation, and Positive Symptom Distress. This model predicted 21% of the variance in patient function. Patient somatization was an important psychological symptom resulting in increasing intensity of symptoms. Smoking, alcohol, open fracture, surgeons’ perception of technical outcome, level of education, and time since injury were not predictive in this model.

Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Funding: This study was funded in part by research grants from AO North America and Regional Medical Associates, McMaster University. Dr. Bhandari was funded, in part, by a 2004 Detweiler Fellowship, Royal Colleges of Physicians and Surgeons of Canada. Dr. Busse is funded by a Canadian Institutes of Health Research Fellowship Award.

Introduction: Little is known about the psychological morbidity associated with orthopaedic trauma.

Purpose: Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma.

Methods: All patients attending 10 orthopaedic fracture clinics at 3 University-affiliated Hospitals were approached for study eligibility. All consenting patients would be requested to complete a baseline assessment form, a 90-item symptom checklist-90R (SCL-90R), and the Short-Form–36. The SCL-90R constitutes 9 dimensions (Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism) and three global indices (Global severity index, Positive symptom distress index, positive symptom total). We conducted regression analyses to determine predictors of quality of life among study patients.

Results: Of 215 patients, 59% were male at a mean age of 44.5 years. Over half of patients had lower extremity fractures. Trauma patients experienced greater psychological symptoms than population norms. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Patient functional outcomes were predicted by patient age, ongoing litigation, and Positive Symptom Distress. This model predicted 21% of the variance in patient function. Patient somatization was an important psychological symptom resulting in increasing intensity of symptoms. Smoking, alcohol, open fracture, surgeons’ perception of technical outcome, level of education, and time since injury were not predictive in this model.

Conclusions: Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Aims. Psychological status may be an important predictor of outcome after periacetabular osteotomy (PAO). The aim of this study was to investigate the influence of psychological distress on postoperative health-related quality of life, joint function, self-assessed pain, and sports ability in patients undergoing PAO. Methods. In all, 202 consecutive patients who underwent PAO for developmental dysplasia of the hip (DDH) at our institution from 2015 to 2017 were included and followed up at 63 months (SD 10) postoperatively. Of these, 101 with complete data sets entered final analysis. Patients were assessed by questionnaire. Psychological status was measured by Brief Symptom Inventory (BSI-18), health-related quality of life was raised with 36-Item Short Form Survey (SF-36), hip functionality was measured by the short version 0f the International Hip Outcome Tool (iHOT-12), Subjective Hip Value (SHV), and Hip Disability and Outcome Score (HOS). Surgery satisfaction and pain were assessed. Dependent variables (endpoints) were postoperative quality of life (SF-36, HOS quality of life (QoL)), joint function (iHOT-12, SHV, HOS), patient satisfaction, and pain. Psychological distress was assessed by the Global Severity Index (GSI), somatization (BSI Soma), depression (BSI Depr), and anxiety (BSI Anx). Influence of psychological status was assessed by means of univariate and multiple multivariate regression analysis. Results. In multiple multivariate regression, postoperative GSI, BSI Soma, and BSI Depr had a negative effect on postoperative SF-36 (e -2.07, -3.05, and -2.67, respectively; p < 0.001), iHOT-12 (e -1.35 and -4.65, respectively; p < 0.001), SHV (e -1.20 and -2.71, respectively; p < 0.001), HOS QoL (e -2.09 and -4.79, respectively; p < 0.001), HOS Function (e -1.00 and -3.94, respectively; p < 0.001), and HOS Sport (e -1.44 and -5.29, respectively; p < 0.001), and had an effect on postoperative pain (e 0.13 and 0.37, respectively; p < 0.001). Conclusion. Psychological distress, depression, and somatization disorders affect health-related quality of life, perceived joint function, and sports ability. Pain perception is significantly increased by somatization. However, patient satisfaction with surgery is not affected. Cite this article: Bone Jt Open 2023;4(10):758–765

Introduction: Sensory hypersensitivity, central hyper-excitability (lowered nociceptive flexion reflex (NFR) thresholds) and psychological distress are features of chronic whiplash. Relationships between these substrates are not clear. The aim of this study was to investigate relationships between psychological factors (distress, catastrophization) and pain threshold responses to sensory stimuli and spinal cord excitability as assessed by the NFR. The former assessments are considered as global pain responses to sensory stimuli as reported by the patient, whereas the latter, an objective measurement for spinal cord excitability to peripheral stimulation. Methods: 30 individuals with chronic (> 3 months) whiplash (Grade II or III; Grade IV were excluded) and 30 asymptomatic controls participated. Pressure pain thresholds (PPTs) and thermal pain thresholds (Thermotest, Somedic AB, Sweden) were measured at the cervical spine, upper and lower limbs. The NFR (intensity of electrical stimulation at the sural nerve required to elicit reflex EMG activity of biceps femoris) was measured as per previous protocols (1). Pain and disability levels (NDI), psychological distress (GHQ-28) and catastrophisation (PCS) were also measured in the whiplash group. Ethical clearance for this study was granted by the Medical Research Ethics Committee of the University of Qld. A MANCOVA was used to determine differences between the whiplash group and controls for sensory measures and the NFR. GHQ-28 and PCS scores were used as covariates in the analysis. Group differences for questionnaire data (GHQ-28 and PCS) were analysed using one way ANOVA. Pearson’s correlation coefficients were used to determine the relationship between the psychological measures (PCS and GHQ-28), pain and disability levels (NDI) and the pain threshold measures (mechanical and thermal) and to determine relationships between the psychological measures, pain and disability measures (NDI) and NFR responses (pain intensity at threshold, threshold). p< 0.05. Results: Whiplash injured participants (23 females, mean (SD) age: 37.7 (11.5) years, NDI: 46.2 (17.6) and VAS scores of pain: 4.2 (2.4)) demonstrated lowered pain thresholds to pressure and cold (p< 0.05); lowered NFR thresholds (p=0.003) and above threshold levels of psychological distress (GHQ-28) compared to controls and levels of catastrophisation comparable to other musculoskeletal conditions. There were no group differences for heat pain thresholds or pain at NFR threshold. In the whiplash group, PCS scores correlated moderately with cold pain threshold (r =0.51, p=0.01). In contrast there were no significant correlations between GHQ-28 scores and pain threshold measures or between psychological factors and NFR responses in whiplash participants. There were no significant correlations between psychological factors and pain thresholds or NFR responses in controls. Discussion: We have demonstrated that psychological factors have some association with sensory hypersensitivity (cold pain threshold measures) in chronic whiplash but do not seem to influence spinal cord excitability. This suggests that psychological disorders are important, but not the only, determinants of central hypersensitivity in whiplash patients. These findings suggest that both physical and psychological factors will need to be addressed in the management of whiplash

Objectives: This study aims to assess the psychological profile of patients prior to total knee replacement, medial unicompartmental knee replacement and patellofemoral joint replacement and determine its effect on outcome. Methods: 113 patients were identified (41 TKR, 37 UKR and 35 PFJR). All patients had mental health assessed preoperatively using SF-12. From the 12 questions a mental and a physical summary score can be calculated (MCS and PCS). The reduced WOMAC score was used pre-operatively to assess knee function and symptoms and then recorded at 8 and 24 months post-operation to assess outcome. Results: 54% of the patients had pre-operative psychological distress. There was no statistically significant difference demonstrated between them mean MCS scores between the three operation groups. Pre-operative MCS had a significant effect such that increasing psychological distress lead to a worse twenty-four month outcome (p = 0.016). The effect of MCS is most marked in postoperative pain levels (p = 0.008) compared to function (p = 0.016). The mean 24-month rWOMAC in the severely distressed group (MCS< 40) was 28.4 compared to 17.4 in the psychologically well group (MCS> 60). Conclusions: Pre-operative mental function prior to knee arthroplasty may provide useful information to guide patients as to their expected outcome in the consent process. Those patients with a very high mental component may be counseled to that although their distress is likely to improve with surgery, their eventual outcome may be worse. The effect of MCS may however only be clinically relevant in those patients with severe mental symptoms

Purpose of the Study: To ascertain the role of Dynesys system (Zimmer Spine, Minneapolis) in the surgical management of chronic low back pain. Methods: 55 patients with persistent low back pain despite conservative measures were treated with Dynesys over a period of two and a half years. Participants either underwent Dynesys procedure alone or in combination with fusion or decompression surgery. Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) and SF-36 questionnaires were completed pre-operatively and at one and two years post-operatively. Pre-operative testing using the Distress and Risk Assessment Method (DRAM) identified psychological distress prior to surgery. Patient Oriented Outcome questionnaires were circulated retrospectively following surgery to obtain data regarding patient’s perceptions and expectations of their outcome. Results: Overall, the mean ODI reduced by 10.23% after one year and 16.15% after two years following surgery. VAS improved by 12mm one year and by 17mm two years after operation. Patients with psychological distress pre-operatively showed less improvement in their ODI and VAS at two-year follow up. The results of fusion were similar to Dynesys alone, and patients who also had decompression had best results. 72.2% patients reported an improvement following their surgery and the same percentage would have the operation again in retrospect. Conclusion: This is the first study exploring clinical outcomes following surgery using Dynesys dynamic stabilization system in patients with disabling low back pain. Previous studies have reported good outcome in the treatment of spinal stenosis. Over 70% patients in our study reported improvement following the procedure but more evidence is needed to determine if it is a viable alternative to spinal fusion

Introduction: We investigated the relationship between psychological distress and outcome after total hip replacement (THR) in the Exeter Primary Outcome Study (EPOS). Materials & Methods: Data were collected from a number of centres across England between January 1999 and January 2002 for patients undergoing primary hip replacement using the cemented Exeter femoral component (Stryker). We recorded the Oxford Hip Score (OHS) for physical function and SF36 questionnaire for both physical and mental domain assessment annually for five years. We dichotomised the patients into the mentally distressed (MHS < 50) and the not mentally distressed (MHS ≥ 50) groups based on their pre-operative Mental Health Score (MHS) from the SF36 score. Results: Complete data were available for 455 (407 not distressed and 48 distressed) patients. Pre-operative OHS and SF-36 score was significantly worse in the distressed group (both p< 0.001). Mean OHS improved from 43 to 20 at 1 year after surgery and remained the same thereafter in the non distressed group. In the mentally distressed group pre-operative mean OHS of 48 improved to 22 at 1 year after surgery. Maximum improvement in OHS occurred in the 1st yr after surgery. Mean MHS improved from 76 to 81 at 1 year after surgery and remained the same thereafter in the non distressed group. Mean MHS improved from 35 to 62 at 1 year after surgery, reaching 65 at 5 years after surgery in the mentally distressed group. The maximum improvement in MHS occurred in the 1st yr after surgery. Conclusion: Pre-operative psychological distress did not compromise functional outcome after hip arthroplasty. There was a substantial improvement in mental distress in patients with mental distress prior to surgery. Both groups of patients experienced improvement in Oxford Hip Score, which was maximal by 1 year after surgery and was maintained over the 5 year follow up

Background: Chronic low back pain (CLBP) is a complex health problem often resulting in difficult consultations for both patients and practitioners. Triggers for consultation may include pain severity, impact of pain on health-related quality of life and troublesomeness of pain. Troublesomeness of CLBP may be influenced by patients’ beliefs about their health, such as beliefs about what is acceptable for their age or lifestyle and their perceptions of risk. Therefore, troublesomeness may be a powerful trigger for consultation for CLBP. Aim: To explore whether troublesomeness of CLBP is associated with consultation. To determine the most powerful predictors of consultation for CLBP from pain severity, troublesomeness, health related quality of life and psychological distress. Method: Postal questionnaire survey to randomly sampled patients registered with 18 MRC General Practice Research Framework general practices (5400 patients) with two reminders. Questionnaire measures persistent pain (presence and location), pain severity (using the Chronic Pain Grade questionnaire), health related quality of life (EQ5D), psychological distress (GHQ12), troublesomeness of pain on a simple five point Likert scale and patient demographics. Chi square tests will be undertaken to explore the relationship between troublesomeness of CLBP and consultations for pain in general and with whether consulted mainstream or complementary practitioners. Multiple logistic regression will be undertaken to explore the most powerful predictors of consultation for CLBP. Results: The survey is ongoing. A full data-set will be available for the presentation. So far 354 questionnaires have been returned, 48% (167/347) of participants report persistent pain of these 62% (104/167) reported at least moderately troublesome CLBP. Of those reporting troublesome CLBP, 74% (76/103) had consulted their GP, 87% (90/103) had consulted other practitioners including physiotherapists, osteopaths and chiropractors, 27% (28/103) had seen a hospital consultant and 17% (18/103) had consulted no one. Conclusions: These data suggest that troublesomeness is a simple way to improve the ability of epidemiological studies of back pain to contribute to health needs assessment

Background: It is universally acknowledged that psychological distress in chronic low back pain (LBP) is commonplace and the early identification of such distress is increasingly being advocated as an important aspect of LBP assessment. The Distress and Risk Assessment Method (DRAM) is a screening tool, using the Modified Zung (MZ) and Modified Somatic Perception Questionnaires (MSPQ), developed to provide a simple classification of patients with LBP. Patients are classified as normal, at risk of developing distress, and those who are distressed (Distressed Depressive {DD} and Distressed-Somatic {DS}). The DRAM was used to screen LBP patients for entrance to an RCT examining different physiotherapy regimes for recurrent LBP. Methods: Patients referred for physiotherapy, at three hospitals within South Birmingham, with a diagnosis of recurrent LBP were screened using the DRAM and Roland Morris Disability Questionnaire (RMDQ). Distressed patients were excluded from the trial as psychological distress has been shown to be associated with an increased risk of poor treatment outcome. Results: 214 patients were screened for entrance to the trial with 69 (31%) excluded on the basis of their DRAM scores (DD=39, DS=30). Excluded (distressed) patients (n=69) had a mean MZ score of 33.30 (SD: 9.28, range= 7 to 56), with patients entered into the trial (non-distressed, n=95) having a mean of 18.12 (SD: 7.83, range=3 to 36). The mean MSPQ score for the distressed patients was 12.70 (SD: 5.69, range=0 to 26), and for the non-distressed patients was 4.37 (SD: 3.67, range= 0 to 22). RMDQ scores (functional disability) were higher for the distressed group (mean 14.09 [SD: 4.80], range=3 to 23) than the non-distressed group (mean 10.52 [SD: 4.22], range= 5 to 21). Conclusions: The results indicate that approximately one third of patients referred for physiotherapy at the units studied exhibited a level of distress that increased their relative risk of poor outcome by 3 to 4 times. The impact of these results has been to slow the recruitment to the ongoing RCT. The clinical implications are that screening this group of patients may indicate when liaison with clinical psychologists is appropriate and possibly identify patients who are too distressed to respond to physiotherapy