The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 14, 2020
REVIEW ARTICLE

Anxiety and Osteoarthritis Disability: Updated Overview and Commentary



Ray Marks1, *
1 Departments of Health and Behavior Studies, Columbia University, Teachers College, New York, USA

Abstract

Introduction:

Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.

Objective:

In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.

Methods:

Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.

Results:

Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.

Conclusion:

This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.

Keywords: Anxiety, Disability, Intervention, Osteoarthritis, Pain, Prevention, Research, Screening, Treatment.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 46
Last Page: 57
Publisher Id: TOORTHJ-14-46
DOI: 10.2174/1874325002014010046

Article History:

Received Date: 31/01/2020
Revision Received Date: 24/03/2020
Acceptance Date: 02/04/2020
Electronic publication date: 15/05/2020
Collection year: 2020

© 2020 Ray Marks

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Health and Behavior Studies, Teachers College, Columbia University, Box 114, 525W, 120th Street, New York, NY 10027, United States. Tel: +1-212-678-3445, Fax: +1-212-678-8259; E-mail: rm226@columbia.edu.





1. INTRODUCTION

Osteoarthritis, the most prevalent musculoskeletal condition affecting older adults commonly produces varying degrees of local pain in and around one or more freely moving joints, such as the hip and knee joints. At the same time, the presence of unrelenting osteoarthritis pain often increases the risk for - or exacerbates concurrently associated chronic health conditions [1Williams A, Kamper SJ, Wiggers JH, et al. Musculoskeletal conditions may increase the risk of chronic disease: a systematic review and meta-analysis of cohort studies. BMC Med 2018; 16(1): 167.
[http://dx.doi.org/10.1186/s12916-018-1151-2] [PMID: 30249247]
], such as obesity, osteoporosis, and depression, while lowering life quality. Its successful remediation or resolution is however, not readily accomplished, despite years of research, and although highly sought, intervening to alleviate osteoarthritis disability or retard its progression remains an extremely challenging undertaking at best. Indeed, despite their overall success rates in ameliorating pain and dysfunction, joint replacement surgeries, as well as selected pharmacologic interventions, which may be helpful, are not universally indicated, or risk free, and do not reverse the disease process, and often do not fully restore function or reduce pain sufficiently and consistently.

In this regard, anxiety, an emotional response to a real or perceived threat, that may also exist independently or concurrently as a prevailing mental state is not only quite prevalent among adults in general, but more so among adults with a variety of medical disorders [2Risal A, Manandhar K, Linde M, Steiner TJ, Holen A. Anxiety and depression in Nepal: prevalence, comorbidity and associations. BMC Psychiatry 2016; 16: 102.
[http://dx.doi.org/10.1186/s12888-016-0810-0] [PMID: 27075664]
], such as osteoarthritis in particular [3Vancampfort D, Koyanagi A, Hallgren M, Probst M, Stubbs B. The relationship between chronic physical conditions, multimorbidity and anxiety in the general population: A global perspective across 42 countries. Gen Hosp Psychiatry 2017; 45: 1-6.
[http://dx.doi.org/10.1016/j.genhosppsych.2016.11.002] [PMID: 28274332]
]. Indeed, increasing research shows that while osteoarthritis is largely considered a biomechanical disease, anxiety may still have a role to play in its pain, disability, and disease progression cycle, even if this not explicitly acknowledged as one of the six osteoarthritis phenotypes recently described [4Dell’Isola A, Allan R, Smith SL, Marreiros SS, Steultjens M. Identification of clinical phenotypes in knee osteoarthritis: a systematic review of the literature. BMC Musculoskelet Disord 2016; 17(1): 425.
[http://dx.doi.org/10.1186/s12891-016-1286-2] [PMID: 27733199]
]. That is, anxiety in its various forms may not only be present in sizeable numbers of cases with osteoarthritis, as this population is usually in their advanced years, but in consideration, that osteoarthritis is the most prevalent disabling musculoskeletal disorder among this population who commonly experience persistent disease associated pain and possibly pain and discomfort from concurrent illnesses. As such, it seems reasonable to suggest that the presence of anxiety, which commonly denotes a state of apprehension and distress, will be quite prevalent in osteoarthritis patients who have advanced mobility and pain problems, especially if efforts to uncover and intervene upon any attendant or inherent proclivity to anxiety are not forthcoming.

To support the above propositions, and in light of the failure of modern medicine to attenuate the personal and societal costs of osteoarthritis in any meaningful way, including the burgeoning use of opiate derivatives, this current review aimed to examine the most recent data concerning this issue. A second goal was to establish the degree of progress in this realm in recent years and whether there is sufficient ongoing support for expanding upon the current research base in this regard, and if so, in what respect. A third goal was to explore whether screening for anxiety is indicated, and if so, what approach might be most practical, along with any definitive intervention approaches that have been proposed to counter anxiety in people with osteoarthritis.

2. METHODS

Since there are several summary reports that discuss this topical theme in the current database [5Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
], this present report was delimited to an analysis of those data published in the past six years as reviewed over two distinctive time periods in order to examine the rate of current progress being made in this sphere of research. Stemming primarily from salient publications housed in PUBMED, this current review incorporates almost all salient publications in that database, if not all key topical reports published since 2014. However, to ensure a comprehensive report, the search strategy employed was supplemented using GOOGLE SCHOLAR, SCOPUS, ACADEMIC SEARCH COMPLETE, and WEB OF SCIENCE CONSOLIDATED databases over the same time period. Primary search terms used in all instances were Osteoarthritis and Anxiety, and others noted in Table 1. In this regard, all apparently pertinent reports were downloaded and carefully scrutinized. Those selected were summarized in a narrative manner given the diversity of the material, as well as a sizable number of research design issues.

Table 1
Items Listed on PUBMED from January 2014- August 2018 Using Different Key Words and Showing Minimal Overlap Between Mainstream Anxiety Literature and Osteoarthritis; Alongside Data Observed from August 2018-February 2020 Showing Similar Trends Despite Some Improved Level Of Interest.


To examine whether the present topic is being sufficiently explored, as recommended by earlier authors [5Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
], the degree to which anxiety is currently being increasingly explored as an independent correlate of osteoarthritis was compared over two distinctive time periods, as well as to the research volume of other topics published in the related research realm over the same periods. Which osteoarthritic joints have been studied recently, and to what degree, was also examined, as were suggestions for intervening upon anxiety among osteoarthritis cases.

The term anxiety as applied in this report refers either to anxiety in general or trait anxiety versus state anxiety given the fact that there is no clear differentiation among these sub-categories of anxiety in much of the related osteoarthritis literature.

Since it was observed that this topic has only been studied in a limited fragmented manner, data from all forms of research design and obtained using any type of anxiety survey, as well as data emanating from osteoarthritis of any type or joint were deemed acceptable. Excluded were reports published prior to 2014, those that predominantly examined pain catastrophizing, or mixed cohorts of arthritis or depression alongside anxiety with no differentiation. Readers seeking a prior overview of this topic can refer to [5Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
].

3. RESULTS

3.1. General Observations

As outlined in Table 1, showing some comparative research data over the past six years, it appears that despite its possible clinical relevance, only a very modest relative interest in the present topic of anxiety prevails, when weighed against other topics of osteoarthritis research. However, this interest is increasing more markedly, than other related health topics, as indicated. In addition, while Table 2 shows very few recent studies that have specifically discussed a role for anxiety as a potentially important osteoarthritis disease correlate in joints other than the knee and hip joints, the study of anxiety in multiple forms of osteoarthritis is increasing. Moreover, despite the significant increase in related research publications on anxiety as associated with osteoarthritis over the last 18 months, information relative to anxiety in the context of joint replacement surgery clearly shows this correlate to be of increasing relevance in mediating long term outcomes. The number of randomized trials that are potentially linked to the amelioration of anxiety symptoms in osteoarthritis, while increasing numerically, is still very low, if compared to reported interventions on this topic, in general, however.

Table 2
Table Showing PUBMED Search Results January 2014-August 2018 Depicting Joints Studied In Context Of Anxiety And Osteoarthritis, Followed By Data Revealed From Aug 2018-February 2020 And Revealing Most Attention Has Been And Continues To Be Given To Knee Joint Osteoarthritis.


These numbers as detailed on PUBMED are arguably not a precise reflection of the state of the art because search terms were limited and hence other data may have been overlooked. However, no further information was forthcoming when employing the same strategy for GOOGLE SCHOLAR, SCOPUS, ACADEMIC SEARCH COMPLETE and WEB OF SCIENCE CONSOLIDATED databases. Nonetheless, as in all the databases reviewed, the number of PUBMED data listings clearly overestimate numbers of salient research publications focusing on the specific topic of anxiety and osteoarthritis, since a sizeable number of housed articles only detailed depression or peripheral or central sensitization issues, or other forms of comorbid illnesses. Gaining a clear picture of what role anxiety plays or does not play in osteoarthritis, is further challenged by the presence of studies using mixed samples, samples with no clearly defined osteoarthritis, the application of unsubstantiated osteoarthritis treatment approaches, or proposed protocols, rather than completed intervention studies.

Confusion also arises when trying to organize the data for aggregation purposes because the definitions of anxiety are multiple, but not always stated, the instruments used to examine anxiety differ widely, and are commonly based on self-reports, with no clear clinical validation, or universally applied survey scoring procedures. The prevailing degrees of joint pathology, age ranges, and comorbid disease profiles studied are also highly diverse and not always clearly factored into the analyses. Surprisingly too, is the almost complete absence of any current documentation concerning the prevailing extent of any anxiety prevalence in a particular research sample, even when surveys are used, thus it is impossible to discern if anxiety rates are increasing, decreasing, or remaining static, or are clinically important or not; for example, whether they denote the possibility of a specific osteoarthritis sub-grouping, or are affected by gender, age, obesity, and extent of numbers of affected joints. Instead, most current researchers appear to have assumed anxiety as likely to exist in some form among osteoarthritis sufferers, and have thus applied this assumption as the rationale for examining the interrelationships of anxiety to the disease and its presentation and outcomes. However, in both related studies with significant results, as well as those with ‘null’ results, the percentage of cases with or without clinical anxiety is commonly impossible to estimate, and with very few carefully controlled prospective studies, the ability to estimate and record the independent or interactive effects or both of anxiety in adults with any form of osteoarthritis is virtually impossible at best.

Regardless of these shortcomings and others though, as outlined in several presently reviewed studies, screening osteoarthritis patients for anxiety appears warranted, especially for patients scheduled for surgery, and those with an anxiety history. But how and when this should be done and by whom is generally unclear as there seems to be little uniformity as regards the various instruments used in the related literature to screen for anxiety among people with osteoarthritis. Most anxiety assessment tools too, are somewhat complex research-oriented surveys that have not necessarily been validated for osteoarthritis cases, rather than practical clinical tools. Moreover, whether all or any have adequate as well as comparable measurement properties, adequate reliability and are sensitive to change in the context of progressively disabling osteoarthritis disease manifestations is not clear. The degree of accuracy when using these surveys listed in Table 3 is also in question because some may not capture all features of osteoarthritis that may provoke anxiety, while others may not clearly differentiate anxiety from depression or stress.

Table 3
Snapshot Of Key Findings Of Selected Representative Prospective Studies Published In PUBMED Between 2014 And 2020 And Examining The Impact Of Anxiety In The Context Of Osteoarthritis.


Finally, while many proposed intervention approaches to counter anxiety prevail, along with an untested assumption that treating osteoarthritis cases presenting with anxiety using these may prove more helpful than not, regardless of anxiety subtype, very few actual well-designed and carefully controlled supportive studies exist.

There are also very few new facts about anxiety in the realm of osteoarthritis when compared to the focus anxiety clearly assumes in the realm of other chronic conditions, and almost no studies attempt to examine the interactive correlates of anxiety on various aspects of osteoarthritis disease using validated biomechanical, biochemical, and advanced serological and neurological assays, among others.

3.2. Research-Based Observations

As outlined previously by Stubbs et al. [5Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
] as well as by Tan et al. [6Tan V, Jinks C, Chew-Graham C, Healey EL, Mallen C. The triple whammy anxiety depression and osteoarthritis in long-term conditions. BMC Fam Pract 2015; 16: 163.
[http://dx.doi.org/10.1186/s12875-015-0346-2] [PMID: 26530162]
], a sizeable number of patients with a diagnosis of osteoarthritis may be expected to exhibit various degrees of anxiety, ranging from moderate to severe. Of these cases however, Perez-Garcia et al. [7Pérez-García LF, Silveira LH, Moreno-Ramírez M, Loaiza-Félix J, Rivera V, Amezcua-Guerra LM. Frequency of depression and anxiety symptoms in Mexican patients with rheumatic diseases determined by self-administered questionnaires adapted to the Spanish language. Rev Invest Clin 2019; 71(2): 91-7.
[http://dx.doi.org/10.24875/RIC.18002698] [PMID: 31056610]
] found only 17 percent had been previously diagnosed, and only 5.8% were in therapy. Moreover, even though anxiety as a clinically relevant outcome indicator or mediator has been disputed in some cases [8Kang L, Nguyen J, Hashmi SZ, Lee SK, Weiland AJ, Mancuso CA. What demographic and clinical characteristics correlate with expectations with trapeziometacarpal arthritis? Clin Orthop Relat Res 2017; 475(11): 2704-11.
[http://dx.doi.org/10.1007/s11999-017-5359-9] [PMID: 28425053]
, 9Ostojic M, Ostojić M, Prlić J, Soljic V. Correlation of anxiety and chronic pain to grade of synovitis in patients with knee osteoarthritis. Psychiatr Danub 2019; 31(Suppl. 1): 126-30.
[PMID: 30946731]
], those osteoarthritis cases suffering from anxiety alone, or anxiety and depression appear more likely than not to suffer from chronic or excessive chronic pain, among other negative disease correlates [10Carmona-Terés V, Moix-Queraltó J, Pujol-Ribera E, et al. Understanding knee osteoarthritis from the patients’ perspective: a qualitative study. BMC Musculoskelet Disord 2017; 18(1): 225.
[http://dx.doi.org/10.1186/s12891-017-1584-3] [PMID: 28558738]
-12Clauw DJ, Hassett AL. The role of centralised pain in osteoarthritis 2017.]. These negative anxiety-associated consequences include, but are not limited to, an increased risk for post-operative joint replacement surgical complications [13Schwartz FH, Lange J. Factors that affect outcome following total joint arthroplasty: a review of the recent literature. Curr Rev Musculoskelet Med 2017; 10(3): 346-55.
[http://dx.doi.org/10.1007/s12178-017-9421-8] [PMID: 28664450]
] in addition to pain [14Burston JJ, Valdes AM, Woodhams SG, et al. The impact of anxiety on chronic musculoskeletal pain and the role of astrocyte activation. Pain 2019; 160(3): 658-69.
[http://dx.doi.org/10.1097/j.pain.0000000000001445] [PMID: 30779717]
, 15Akin-Akinyosoye K, Frowd N, Marshall L, et al. Traits associated with central pain augmentation in the Knee Pain In the Community (KPIC) cohort. Pain 2018; 159(6): 1035-44.
[http://dx.doi.org/10.1097/j.pain.0000000000001183] [PMID: 29438225]
], plus heightened difficulties with activities of daily living and physical functioning [16Stamm TA, Pieber K, Crevenna R, Dorner TE. Impairment in the activities of daily living in older adults with and without osteoporosis, osteoarthritis and chronic back pain: a secondary analysis of population-based health survey data. BMC Musculoskelet Disord 2016; 17: 139.
[http://dx.doi.org/10.1186/s12891-016-0994-y] [PMID: 27020532]
, 17Nur H, Sertkaya BS, Tuncer T. Determinants of physical functioning in women with knee osteoarthritis. Aging Clin Exp Res 2018; 30(4): 299-306.
[http://dx.doi.org/10.1007/s40520-017-0784-x] [PMID: 28608254]
].

Barnett et al. [18Barnett LA, Pritchard MG, Edwards JJ, et al. Relationship of anxiety with joint pain and its management: A population survey. Musculoskelet Care 2018; 16(3): 353-62.
[http://dx.doi.org/10.1002/msc.1243] [PMID: 29675943]
] likewise found adults with joint pain reporting clinical anxiety, were not only quite numerous, in general, but were more likely than not to exhibit severe, rather than mild pain. It was further observed that the number of pain sites was also positively associated with the presence of clinical anxiety, and that those adults with symptoms of clinical anxiety appeared less likely to undertake general fitness exercises. They were also more likely to use walking aids and assistive devices, plus opioids than non-anxious adults with joint pain.

While generally poorly studied at the early disease stages, it appears that as the disease progresses and requires surgical intervention, almost 50 percent of preoperative osteoarthritis surgical cases may be expected to exhibit anxiety symptoms as observed by Jones et al. [19Jones AR, Al-Naseer S, Bodger O, James ETR, Davies AP. 2018.]. While this high number of anxious cases may have been attributable in part to the self-report mode of estimating anxiety as normal or abnormal, Wong et al. [20Wong LY, Yiu RL, Chiu CK, et al. Prevalence of psychiatric morbidity in Chinese subjects with knee osteoarthritis in a Hong Kong orthopaedic clinic. East Asian Arch Psychiatry 2015; 25(4): 150-8.
[PMID: 26764289]
] as well as Castano et al. [21Castaño Carou A, Pita Fernández S, Pértega Díaz S. 2015.], Stubbs et al. [5Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
] and Guglielmo et al. [22Guglielmo D, Hootman JM, Boring MA, et al. Symptoms of anxiety and depression among adults with arthritis - United States, 2015-2017. MMWR Morb Mortal Wkly Rep 2018; 67(39): 1081-7.
[http://dx.doi.org/10.15585/mmwr.mm6739a2] [PMID: 30286053]
] all reported the presence of anxiety to be of the order of 20 percent or higher in various osteoarthritis or arthritis samples when this has been assessed. Moreover, anxiety rates observed among community-dwelling knee osteoarthritis clearly exceed those prevailing in the general population [23Sinikallio SH, Helminen EE, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Multiple psychological factors are associated with poorer functioning in a sample of community-dwelling knee osteoarthritis patients. J Clin Rheumatol 2014; 20(5): 261-7.
[http://dx.doi.org/10.1097/RHU.0000000000000123] [PMID: 25036567]
], and where present, these anxious osteoarthritis patients tend to have higher pain levels at rest as well as on initiating any activity when compared to non-anxious patients.

Bierke et al. [24Bierke S, Petersen W. Influence of anxiety and pain catastrophizing on the course of pain within the first year after uncomplicated total knee replacement: a prospective study. Arch Orthop Trauma Surg 2017; 137(12): 1735-42.
[http://dx.doi.org/10.1007/s00402-017-2797-5] [PMID: 28965133]
] found trait anxiety, which is commonly indicative of an inherent anxiety state, to be present in approximately 14 percent of cases with disabling osteoarthritis awaiting treatment. Importantly, those identified as having a habitual pattern of anxiety behavior had higher mean dissatisfaction scores at 6 and 12 months post-surgery than those with no anxiety. Khan et al. [11Khan S, Hanifa B, Begum R, Kalsoom U. Anxiety, depression and psychological distress in patients with osteo-arthritis. JPMI: J Postgrad Medical Ins 2017; 31(4): 410-3.] similarly found high levels of anxiety to prevail among osteoarthritis cases compared to non-osteoarthritis cases, especially among women.

More recently, Burston et al. [14Burston JJ, Valdes AM, Woodhams SG, et al. The impact of anxiety on chronic musculoskeletal pain and the role of astrocyte activation. Pain 2019; 160(3): 658-69.
[http://dx.doi.org/10.1097/j.pain.0000000000001445] [PMID: 30779717]
] reported that osteoarthritis cases with high anxiety levels, independently from depression, exhibited lower pressure pain detection thresholds at sites local to and distant from the painful joint site. Separately, high anxiety scores predicted an increased risk of knee pain onset in 3274 originally pain-free individuals over the 1-year period (odds ratio = 1.71; 95% confidence interval = 1.25-2.34, p < 0.001). Similarly, this group found that rats used to uncover the mechanisms of anxiety in humans in a parallel experiment, developed significantly lower ipsilateral and contralateral hind paw withdrawal thresholds, compared with control rats (p = 0.0005), thus their clinical finding was mirrored by that obtained from an accepted model of painful osteoarthritis. Of additional import was the finding that the augmented pain phenotype that was observed was significantly associated with increased glial fibrillary acidic protein immunofluorescence in those brain regions associated with pain, thus implying that supraspinal astrocyte activation may serve as a significant determinant of underlying anxiety-augmented pain behavior that might be extremely helpful to explore in the future.

According to Harmelink et al. [25Harmelink KEM, Zeegers AVCM, Hullegie W, Hoogeboom TJ, Nijhuis-van der Sanden MWG, Staal JB. Are there prognostic factors for one-year outcome after total knee arthroplasty? A systematic review. J Arthroplasty 2017; 32(12): 3840-3853.e1.
[http://dx.doi.org/10.1016/j.arth.2017.07.011] [PMID: 28927646]
] and others such as Liddle et al. [26Liddle AD, Judge A, Pandit H, Murray DW. Determinants of revision and functional outcome following unicompartmental knee replacement. Osteoarthritis Cartilage 2014; 22(9): 1241-50.
[http://dx.doi.org/10.1016/j.joca.2014.07.006] [PMID: 25042552]
], even if anxiety rates are deemed acceptable or clinically unimportant, based upon the findings of Burston et al. [14Burston JJ, Valdes AM, Woodhams SG, et al. The impact of anxiety on chronic musculoskeletal pain and the role of astrocyte activation. Pain 2019; 160(3): 658-69.
[http://dx.doi.org/10.1097/j.pain.0000000000001445] [PMID: 30779717]
] and others, it is hard to refute the fact that anxiety may accompany painful osteoarthritis, and that acknowledging the presence of any form of anxiety, if present, is very crucial not only in osteoarthritis remediation efforts, but also in primary, and secondary, as well as tertiary preventive efforts. In this regard, Hiyama et al. [27Hiyama Y, Kamitani T, Wada O. Association between disease-specific anxiety at discharge and functional outcome in patients after total knee arthroplasty. Knee 2019; 26(2): 477-83.
[http://dx.doi.org/10.1016/j.knee.2019.01.016] [PMID: 30772184]
] found the median score for anxiety post knee surgery for the factors of wounds, pain, and gait of 4.0 to be quite substantive at discharge five days after surgery. The median score for anxiety about falling, a very important risk factor for complications post-surgery, was also 4.0. The level of anxiety regarding wounds, pain, gait, and falling was also associated in a negative manner with the knee function scores six-months postoperatively even after adjusting for all confounding factors. As well, the severity of the anxiety symptoms at discharge was negatively associated with physical function recovery six-months postoperatively.

As well as its negative impact on post-surgical reconstructive outcomes [28Sorel JC, Veltman ES, Honig A, Poolman RW. The influence of preoperative psychological distress on pain and function after total knee arthroplasty: a systematic review and meta-analysis. Bone Joint J 2019; 101-B(1): 7-14.
[http://dx.doi.org/10.1302/0301-620X.101B1.BJJ-2018-0672.R1] [PMID: 30601044]
], unrelieved anxiety is expected to exacerbate harmful chronic oxidative stress levels and inflammatory responses that could impact healing [29Vida C, González EM, De la Fuente M. Increase of oxidation and inflammation in nervous and immune systems with aging and anxiety. Curr Pharm Des 2014; 20(29): 4656-78.
[http://dx.doi.org/10.2174/1381612820666140130201734] [PMID: 24588831]
]. Anxiety has been shown to raise the risk of premature mortality [30Wilkie R, Parmar SS, Blagojevic-Bucknall M, et al. Reasons why osteoarthritis predicts mortality: path analysis within a Cox proportional hazards model. RMD Open 2019; 5(2)e001048
[http://dx.doi.org/10.1136/rmdopen-2019-001048] [PMID: 31798954]
], in addition to explaining or mediating suboptimal post-operative physical improvements [31Galea VP, Rojanasopondist P, Ingelsrud LH, et al. Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study. Bone Joint J 2019; 101-B(7): 768-78.
[http://dx.doi.org/10.1302/0301-620X.101B7.BJJ-2018-1491.R1] [PMID: 31256661]
], especially in the short and medium post-operative periods [32Xu J, Twiggs J, Parker D, Negus J. 2019.]. The presence of anxiety is consistently found to heighten the risk of post-operative joint replacement surgical complications [33Zhang M, Selzer F, Losina E, Collins JE, Katz JN. Musculoskeletal symptomatic areas after total knee replacement for osteoarthritis. ACR Open Rheumatol 2019; 1(6): 373-81.
[http://dx.doi.org/10.1002/acr2.11055] [PMID: 31777817]
-36Rasouli MR, Menendez ME, Sayadipour A, Purtill JJ, Parvizi J. Direct cost and complications associated with total joint arthroplasty in patients with preoperative anxiety and depression. J Arthroplasty 2016; 31(2): 533-6.
[http://dx.doi.org/10.1016/j.arth.2015.09.015] [PMID: 26481408]
]. Anxious post-surgical osteoarthritis patients may also experience a lower subjective assessment of the possibility of returning to work during the lengthy post-operative rehabilitation period, plus a reduced degree of readiness to undergo treatment [37Janikowska-Hołoweńko D, Zaborowska-Sapeta K, Bidzan I. The level of anxiety and the subjective assessment of the quality of life in patients post hip replacement after primary and secondary rehabilitation. Acta Neuropsychol 2016; 12(2): 143-.
[http://dx.doi.org/10.5604/17307503.1111842]
] in addition to a heightened risk of post-surgical complications [38Hernández C, Díaz-Heredia J, Berraquero ML, Crespo P, Loza E, Ruiz Ibán MÁ. Pre-operative predictive factors of post-operative pain in patients with hip or knee arthroplasty: a systematic review. Reumatol Clin 2015; 11(6): 361-80.
[http://dx.doi.org/10.1016/j.reumae.2014.12.011] [PMID: 25840826]
, 39Pan X, Wang J, Lin Z, Dai W, Shi Z. Depression and anxiety are risk factors for postoperative pain-related symptoms and complications in patients undergoing primary total knee arthroplasty in the United States. J Arthroplasty 2019; 34(10): 2337-46.
[http://dx.doi.org/10.1016/j.arth.2019.05.035] [PMID: 31229373]
], poor life quality [40Ferreira AH, Godoy PB, Oliveira NR, et al. Investigation of depression, anxiety and quality of life in patients with knee osteoarthritis: a comparative study. Rev Bras Reumatol 2015; 55(5): 434-8.
[http://dx.doi.org/10.1016/j.rbr.2015.03.001] [PMID: 26198010]
], sleep disruptions [41Chen CJ, McHugh G, Campbell M, Luker K. Subjective and objective sleep quality in individuals with osteoarthritis in Taiwan. Musculoskelet Care 2014; •••
[http://dx.doi.org/10.1002/msc.1094] [PMID: 25491038]
], excess pain [42Hadlandsmyth K, Sabic E, Zimmerman MB, et al. Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis. Psychol Health Med 2017; 22(5): 552-63.
[http://dx.doi.org/10.1080/13548506.2016.1189581] [PMID: 27216314]
], plus non-surgical multidisciplinary treatment outcomes [43O’Leary S, Cottrell M, Raymer M, Smith D, Khan A. General health factors may be a barrier to effective non-surgical multidisciplinary rehabilitation of common orthopaedic conditions in tertiary care settings. BMC Musculoskelet Disord 2018; 19(1): 348.
[http://dx.doi.org/10.1186/s12891-018-2265-6] [PMID: 30261861]
].

Indeed, even where low anxiety rates prevail, anxiety appears to foster or mediate multiple negative osteoarthritis outcomes [44Hayashi K, Kako M, Suzuki K, et al. Gait speeds associated with anxiety responses to pain in osteoarthritis patients. Pain Med 2015; •••
[http://dx.doi.org/10.1111/pme.12897] [PMID: 26352158]
, 45Legha A, Burke DL, Foster NE, et al. Do comorbidities predict pain and function in knee osteoarthritis following an exercise intervention, and do they moderate the effect of exercise? Analyses of data from three randomized controlled trials. Musculoskelet Care 2019; •••
[http://dx.doi.org/10.1002/msc.1425] [PMID: 31837126]
]. Conversely, efforts to reduce prevailing anxiety severity, for example, among those requiring surgery for ameliorating their osteoarthritis disability, tend to yield better pain and functional outcomes than those not requiring any surgery [46Helminen EE, Sinikallio SH, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study. Clin Rehabil 2016; 30(9): 890-900.
[http://dx.doi.org/10.1177/0269215515619660] [PMID: 27496698]
, 47Hassett AL, Marshall E, Bailey AM, et al. Changes in anxiety and depression are mediated by changes in pain severity in patients undergoing lower-extremity total joint arthroplasty. Reg Anesth Pain Med 2018; 43(1): 14-8.
[http://dx.doi.org/10.1097/AAP.0000000000000682] [PMID: 29077589]
].

Unfortunately, despite these potentially relevant findings, as well as those published previously, results of recent community-based efforts to address and treat anxiety among osteoarthritis cases have not shown any degree of anticipated promise [48Mallen CD, Nicholl BI, Lewis M, et al. The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care. PLoS Med 2017; 14(4)e1002273
[http://dx.doi.org/10.1371/journal.pmed.1002273] [PMID: 28399129]
-50Karp JF, Zhang J, Wahed AS, et al. Improving patient reported outcomes and preventing depression and anxiety in older adults with knee osteoarthritis: results of a Sequenced Multiple Assignment Randomized Trial (SMART) study. Am J Geriatr Psychiatry 2019; 27(10): 1035-45.
[http://dx.doi.org/10.1016/j.jagp.2019.03.011] [PMID: 31047790]
]. However, as pointed out by Hirakawa et al. [51Hirakawa Y, Hara M, Fujiwara A, Hanada H, Morioka S. The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty. Pain Res Manag 2014; 19(5): 251-6.
[http://dx.doi.org/10.1155/2014/471529] [PMID: 25101335]
], and others highlighted in Table 3, at a minimum, efforts to uncover and reduce persistent and oftentimes pervasive negative thoughts regarding future pain among osteoarthritis cases may yet help to minimize feelings of low self-efficacy and excess pain [48Mallen CD, Nicholl BI, Lewis M, et al. The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care. PLoS Med 2017; 14(4)e1002273
[http://dx.doi.org/10.1371/journal.pmed.1002273] [PMID: 28399129]
], plus lower than desirable satisfaction, and life quality [52Dieppe P, Goldingay S, Greville-Harris M. The power and value of placebo and nocebo in painful osteoarthritis. Osteoarthritis Cartilage 2016; 24(11): 1850-7.
[http://dx.doi.org/10.1016/j.joca.2016.06.007] [PMID: 27338671]
], along with protracted recovery post-surgery, as well as excess post-operative pain [53Ali A, Lindstrand A, Sundberg M, Flivik G. Preoperative anxiety and depression correlate with dissatisfaction after total knee arthroplasty: a prospective longitudinal cohort study of 186 patients, with 4-year follow-up. J Arthroplasty 2017; 32(3): 767-70.
[http://dx.doi.org/10.1016/j.arth.2016.08.033] [PMID: 27692782]
-70Cho CH, Song KS, Hwang I, Coats-Thomas MS, Warner JJP. Changes in psychological status and health-related quality of life following total shoulder arthroplasty. J Bone Joint Surg Am 2017; 99(12): 1030-5.
[http://dx.doi.org/10.2106/JBJS.16.00954] [PMID: 28632592]
]. To this end, and as implied by several authors cited in Table 3, the use of careful routine mental health assessments, as well as the application of appropriate follow-up interventions to minimize anxiety may yet prove helpful not only for attenuating or averting its oftentimes long-term negative effects in a fair proportion of disabled osteoarthritis patients, but for heightening overall health status, even if evidence is presently weak in this regard [33Zhang M, Selzer F, Losina E, Collins JE, Katz JN. Musculoskeletal symptomatic areas after total knee replacement for osteoarthritis. ACR Open Rheumatol 2019; 1(6): 373-81.
[http://dx.doi.org/10.1002/acr2.11055] [PMID: 31777817]
]. Moreover, even if anxiety is actually reduced by surgery, or does not have any long-term impact on recovery from joint replacement surgery [66Jiménez Ortiz M, Espinosa Ruiz A, Martínez Delgado C, et al. Do preoperative anxiety and depression influence the outcome of knee arthroplasty? 2018., 67Wylde V, Trela-Larsen L, Whitehouse MR, Blom AW. Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement. Acta Orthop 2017; 88(5): 530-6.
[http://dx.doi.org/10.1080/17453674.2017.1334180] [PMID: 28562150]
], identifying anxiety or its risk earlier, rather than later, as well as its correlates [68Celik F, Edipoglu IS. Evaluation of preoperative anxiety and fear of anesthesia using APAIS score. Eur J Med Res 2018; 23(1): 41.
[http://dx.doi.org/10.1186/s40001-018-0339-4] [PMID: 30205837]
], is cited to be more likely than not to benefit a sizeable number of subjects with osteoarthritis, and inherent trait or chronic generalized anxiety disorders, as well as state anxiety, regardless of disease status. However, examining recommended interventions such as those advocated in Table 4 more closely must also be forthcoming to determine whether one or more of these approaches would be efficacious, and in what respect. Alternately, a fair percentage of patients may continue to experience excess pain and delayed surgical recovery [71Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2018; 28(1): 119-26.
[http://dx.doi.org/10.3171/2017.5.SPINE1734] [PMID: 29125426]
], and contrary to findings of Cho et al. [70Cho CH, Song KS, Hwang I, Coats-Thomas MS, Warner JJP. Changes in psychological status and health-related quality of life following total shoulder arthroplasty. J Bone Joint Surg Am 2017; 99(12): 1030-5.
[http://dx.doi.org/10.2106/JBJS.16.00954] [PMID: 28632592]
] may not improve as anticipated simply by undergoing joint replacement surgery alone if pre-surgical anxiety is not specifically treated or even identified as observed by Balik et al. [72Balik MS, Hocaoğlu Ç, Erkut A, Güvercin Y, Keskin D. Evaluation of the quality of life and psychiatric symptoms of patients with primary coxarthrosis after total hip arthroplasty. Acta Chir Orthop Traumatol Cech 2017; 84(6): 436-40.
[PMID: 29351526]
].

Table 4
Potential Strategies That May Be Applied Independently or Interactively For Countering Anxiety in the Context Of Osteoarthritis Care and that Should Be Carefully Examined In The Future to Avoid Highlighted Negative Impacts And Lack of Apparent Potency [Adapted from references [71Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2018; 28(1): 119-26.
[http://dx.doi.org/10.3171/2017.5.SPINE1734] [PMID: 29125426]
-94McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement 2014.
[http://dx.doi.org/10.1002/14651858.CD003526.pub3]
].



4. DISCUSSION

Osteoarthritis, a highly prevalent health condition remains a serious impediment to the well-being of many older adults who seek to remain independent and mobile. However, even though life quality is often impacted negatively and significantly by osteoarthritis [40Ferreira AH, Godoy PB, Oliveira NR, et al. Investigation of depression, anxiety and quality of life in patients with knee osteoarthritis: a comparative study. Rev Bras Reumatol 2015; 55(5): 434-8.
[http://dx.doi.org/10.1016/j.rbr.2015.03.001] [PMID: 26198010]
], and may stem from physical as well as psychosocial issues among others, care often appears to remain suboptimal despite evidence that well-conceived primary care and community-based interventions can effectively reduce osteoarthritic pain and disability [49Hay E, Dziedzic K, Foster N, et al. Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomized controlled trials 2018.
[http://dx.doi.org/10.3310/pgfar06040]
]. In this respect, the present review examined the current evidence base concerning the possible role of either preexisting or emergent anxiety or both in mediating, moderating, or exacerbating osteoarthritis disability, given its potential for prevention or remediation. It also sought to examine if more research, as well as routine screening and attention in this realm is warranted, and if so, in what way.

Fig. 1
Schematic Depiction Of Challenges Commonly Faced By People With Osteoarthritis Who Are Anxious And Remain Untreated Or Undiagnosed Or Are Diagnosed Suboptimally.


In this regard, results of the present data search that focused largely on published reports from 2014 to February 2020 showed that anxiety, deemed to be a state of emotional distress of varying degrees is generally a mental health correlate that has a negative impact on adults suffering from osteoarthritis, as outlined by Nur et al. [17Nur H, Sertkaya BS, Tuncer T. Determinants of physical functioning in women with knee osteoarthritis. Aging Clin Exp Res 2018; 30(4): 299-306.
[http://dx.doi.org/10.1007/s40520-017-0784-x] [PMID: 28608254]
], Wilke et al. [30Wilkie R, Parmar SS, Blagojevic-Bucknall M, et al. Reasons why osteoarthritis predicts mortality: path analysis within a Cox proportional hazards model. RMD Open 2019; 5(2)e001048
[http://dx.doi.org/10.1136/rmdopen-2019-001048] [PMID: 31798954]
], Zhang et al. [95Zhang L, Fu T, Zhang Q, et al. Effects of psychological interventions for patients with osteoarthritis: a systematic review and meta-analysis. Psychol Health Med 2018; 23(1): 1-17.
[http://dx.doi.org/10.1080/13548506.2017.1282160] [PMID: 28140653]
], Zambon et al. [96Zambon S, Siviero P, Denkinger M, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European project on osteoarthritis. Arthritis Care Res (Hoboken) 2016; 68(6): 801-10.
[http://dx.doi.org/10.1002/acr.22755] [PMID: 26474272]
], Mat et al. [97Mat S, Razack AH, Lim J, et al. Factors determining the increased risk of falls in individuals with knee pain in the Malaysian Elders Longitudinal Research (MELoR) Study. Front Med (Lausanne) 2019; 6: 277.
[http://dx.doi.org/10.3389/fmed.2019.00277] [PMID: 31850355]
]. However, even when compelling new evidence shows how the extent of drug dependence is related to anxiety [99Michopoulos V, Powers A, Gillespie CF, Ressler KJ, Jovanovic T. Inflammation in fear- and anxiety-based disorders: PTSD, GAD, and beyond. Neuropsychopharmacology 2017; 42(1): 254-70.
[http://dx.doi.org/10.1038/npp.2016.146] [PMID: 27510423]
], and that mortality is heightened by anxiety [30Wilkie R, Parmar SS, Blagojevic-Bucknall M, et al. Reasons why osteoarthritis predicts mortality: path analysis within a Cox proportional hazards model. RMD Open 2019; 5(2)e001048
[http://dx.doi.org/10.1136/rmdopen-2019-001048] [PMID: 31798954]
], it is striking that when examined in the larger context of osteoarthritis as well as anxiety research that only a meager degree of research of acceptable quality on this issue prevails or is emerging. Indeed, in light of the fact that osteoarthritis is the most prevalent musculoskeletal disabler of older adults and that the disease has no known cure, or all encompassing remedial treatment approach is safe and effective, its widespread negative disease influence is bound to increase rather than decrease as society ages and years of life are extended if this correlate continues and its independent and interactive effects are largely ignored in the mainstream literature and primary care and surgical settings.

On the contrary, while assessing anxiety clinically is arguably very time consuming, and negated in importance by some [e.g8Kang L, Nguyen J, Hashmi SZ, Lee SK, Weiland AJ, Mancuso CA. What demographic and clinical characteristics correlate with expectations with trapeziometacarpal arthritis? Clin Orthop Relat Res 2017; 475(11): 2704-11.
[http://dx.doi.org/10.1007/s11999-017-5359-9] [PMID: 28425053]
, 9Ostojic M, Ostojić M, Prlić J, Soljic V. Correlation of anxiety and chronic pain to grade of synovitis in patients with knee osteoarthritis. Psychiatr Danub 2019; 31(Suppl. 1): 126-30.
[PMID: 30946731]
, 19Jones AR, Al-Naseer S, Bodger O, James ETR, Davies AP. 2018.], it is very hard to refute any argument in favor of ignoring a possible highly salient role for anxiety in exacerbating osteoarthritis disability wherein routine clinical screening [42Hadlandsmyth K, Sabic E, Zimmerman MB, et al. Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis. Psychol Health Med 2017; 22(5): 552-63.
[http://dx.doi.org/10.1080/13548506.2016.1189581] [PMID: 27216314]
] followed by personalized carefully construed intervention if indicated, will prove more effective, as well as more cost-effective than not based on the overall weight of the evidence [see Table 3]. Kohan et al. [55Kohan EM, Hill JR, Schwabe M, Aleem AW, Keener JD, Chamberlain AM. The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis. J Shoulder Elbow Surg 2019; 28(2): e40-8.
[http://dx.doi.org/10.1016/j.jse.2018.07.033] [PMID: 30552069]
], for example, found patients with glenohumeral osteoarthritis who had scores corresponding to a diagnosis of anxiety to experience lower functional and higher pain scores compared to those with scores in the normal range (p < .001). Analysis of variance showed progressively lower functional and higher pain scores as anxiety severity increased (p < .001).

It is also possible that a higher number of studies that are designed to include more diverse osteoarthritis cases, such as those with neck and back pain [98Heikkinen J, Honkanen R, Williams L, et al. Depressive disorders, anxiety disorders and subjective mental health in common musculoskeletal diseases: A review. Maturitas 2019; 127: 18-25.
[http://dx.doi.org/10.1016/j.maturitas.2019.05.011] [PMID: 31351516]
], will help to strengthen the case in favor of anxiety screening, as well as to provide new insights, and possibly to expand osteoarthritis treatment options and more desirable long-lasting treatment outcomes. Carefully controlling for age, gender, co-interventions disease manifestations, and disease prognosis in comparison studies, along with the use of advanced measurement technologies, and universally agreed upon anxiety measures, will also help to more clearly demonstrate support for or against anxiety screening among at-risk osteoarthritis patients. Alternately, examining whether those osteoarthritis cases functioning suboptimally despite treatment are suffering from some form of anxiety may prove highly revealing.

Indeed, as discussed by several authors, and as per Fig. (1), more work to tease out both the unique as well as the interactive effects of anxiety among cases with osteoarthritis with advanced technologies and in a prospective manner may greatly highlight the important interactive role played by cognitive factors in the disease cycle, even if these are currently ignored or overlooked more often than not. Such research is expected to reveal that the presence of anxiety is closely correlated with ensuing clinical outcomes, life quality, adherence to intervention recommendations and patient satisfaction.

In short, efforts to strengthen the current evidence base regarding the salience of anxiety in the context of the pathogenesis and treatment of osteoarthritis appears warranted. However, as outlined by Pan et al. [39Pan X, Wang J, Lin Z, Dai W, Shi Z. Depression and anxiety are risk factors for postoperative pain-related symptoms and complications in patients undergoing primary total knee arthroplasty in the United States. J Arthroplasty 2019; 34(10): 2337-46.
[http://dx.doi.org/10.1016/j.arth.2019.05.035] [PMID: 31229373]
] despite sufficient clinical as well as scientific rationale to more pro-actively, and comprehensively identify and treat prevailing modifiable mental health issue among cases suffering from osteoarthritis, not enough research or practice-based translation of the research prevails. As such, the immense personal and fiscal costs, plus the prevalence of anxiety and its adverse impacts are not only incalculable, but are more likely than not to continue to increase steadily each year, rather than decrease. Since this situation has enormous ramifications and implications not only for patients, but for families, employers, governments, and society as a whole-for example if we consider the opioid epidemic and its anxiety linkage, we strongly encourage osteoarthritis researchers and clinicians to keep anxiety in the forefront of their respective efforts.

CONCLUSION

Although the literature concerning the extent to which anxiety is a clinically relevant osteoarthritis determinant is very sparse with few robust studies when compared to the immense volume of literature on osteoarthritis and other independent topics shown in Table 1, it is concluded that there is a fairly strong case for considering anxiety as a contributor to disease burden, and that more extensive insightful careful scrutiny to address this possibility is not only warranted, but will be fruitful. In particular, further research to examine if the presence of anxiety is closely correlated with ensuing clinical outcomes, comorbid conditions, obesity, depression, central and peripheral pain sensitization, excess future disability, plus premature mortality is strongly indicated.

To further support this set of recommendations, efforts towards developing a clinically valid anxiety screening tool will be helpful in identifying those who may need psychological support. Researchers may also want to examine what would constitute best practices for the individual patient if anxiety is present, as there may be many diverse sources of anxiety among osteoarthritis cases, rather than any simple uniform manifestation. How to conduct a differential diagnosis in this respect and what degrees of anxiety are highly linked to suboptimal osteoarthritis outcomes also deserves attention. The possible use of a single modality that can be used at home to treat the physical as well as any anxiety correlate of osteoarthritis, such as QiGong versus the more passive approach of a provider-based intervention approach, or group therapy, should be explored as well.

In summary, psychological factors such as anxiety appear to be of significant importance in the context of efforts to comprehend and treat a substantive number of cases suffering from osteoarthritis disability, whether inherent, present as a generalized disorder, or a reactive state.

Indeed, while osteoarthritis is commonly considered a medical condition with distinct biological and biophysical attributes attributable to aging, rather than the presence of cognitive-associated attributes, anxiety in any form can clearly hamper the attainment of favorable osteoarthritis outcomes, including inflammation [99Michopoulos V, Powers A, Gillespie CF, Ressler KJ, Jovanovic T. Inflammation in fear- and anxiety-based disorders: PTSD, GAD, and beyond. Neuropsychopharmacology 2017; 42(1): 254-70.
[http://dx.doi.org/10.1038/npp.2016.146] [PMID: 27510423]
] and desired surgical outcomes [100Tetsunaga T, Tetsunaga T, Nishida K, et al. Drug dependence in patients with chronic pain: A retrospective study. Medicine (Baltimore) 2018; 97(40)e12748
[http://dx.doi.org/10.1097/MD.0000000000012748] [PMID: 30290690]
]. As such, the societal burden attributable to the presence of untreated or unrecognized anxiety in fair numbers of osteoarthritis is inestimable, especially if this situation can be readily remediated early on in the disease process.

To this end, while it is encouraging to see a marked trend in the extent of research data in this field of thought as shown in Table 1, more research to examine the extent of, as well as the implications of anxiety in its various forms in the context of diverse stages of osteoarthritis and among a broad array of joints, not just the knee, or hip, is strongly urged. In addition, the application of a universally agreed upon valid and practical anxiety assessment method that can be used clinically for screening purposes is strongly indicated [101See MTA, Kowitlawakul Y, Tan AJQ, Liaw SY. Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review. Int J Nurs Pract 2018; 24(2)e12621
[http://dx.doi.org/10.1111/ijn.12621] [PMID: 29336515]
, 102Tyser AR, Gaffney CJ, Zhang C, Presson AP. The association of patient satisfaction with pain, anxiety, and self-reported physical function. J Bone Joint Surg Am 2018; 100(21): 1811-8.
[http://dx.doi.org/10.2106/JBJS.17.00372] [PMID: 30399075]
], with a strong focus on a collaborative approach between patient and provider[s] in understanding the patient’s as well as the provider’s disease and outcome perspectives, along with appropriately tailored psychological interventions to minimize anxiety [103Codding JL, Getz CL. Pain management strategies in shoulder arthroplasty. Orthop Clin North Am 2018; 49(1): 81-91.
[http://dx.doi.org/10.1016/j.ocl.2017.08.010] [PMID: 29145989]
-105Lindner M, Nosseir O, Keller-Pliessnig A, Teigelack P, Teufel M, Tagay S. Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 2018; 19(1): 159.
[http://dx.doi.org/10.1186/s12891-018-2058-y] [PMID: 29788969]
] and possible prolonged opioid usage [106Prentice HA, Inacio MCS, Singh A, Namba RS, Paxton EW. Preoperative risk factors for opioid utilization after total hip arthroplasty. J Bone Joint Surg Am 2019; 101(18): 1670-8.
[http://dx.doi.org/10.2106/JBJS.18.01005] [PMID: 31567804]
] and other ill effect consequents [107Kim SH, Yun JM, Chang CB, Piao H, Yu SJ, Shin DW. Prevalence of upper gastrointestinal bleeding risk factors among the general population and osteoarthritis patients. World J Gastroenterol 2016; 22(48): 10643-52.
[http://dx.doi.org/10.3748/wjg.v22.i48.10643] [PMID: 28082817]
].

As depicted in Fig. (1), and subject to further study, a thorough assessment of the whole patient (not just the anxiety), including comorbidities, the extent of anxiety plus other cognitive/emotional/behavioral characteristics, the social environment, and functional limitations of the patient is likely to help to foster more successful treatment outcomes [108Clauw DJ, Essex MN, Pitman V, Jones KD. Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management. Postgrad Med 2019; 131(3): 185-98.
[http://dx.doi.org/10.1080/00325481.2019.1574403] [PMID: 30700198]
]. In addition, sufficient research indicates that anxiety should be viewed as a probable potent osteoarthritis disease mediator or moderator, and one topic that warrants deserved attention clinically and empirically [17Nur H, Sertkaya BS, Tuncer T. Determinants of physical functioning in women with knee osteoarthritis. Aging Clin Exp Res 2018; 30(4): 299-306.
[http://dx.doi.org/10.1007/s40520-017-0784-x] [PMID: 28608254]
] to tease out possible clinically relevant behavioral versus neurobiological associations, and early indicators of a future pathogenic correlation [14Burston JJ, Valdes AM, Woodhams SG, et al. The impact of anxiety on chronic musculoskeletal pain and the role of astrocyte activation. Pain 2019; 160(3): 658-69.
[http://dx.doi.org/10.1097/j.pain.0000000000001445] [PMID: 30779717]
, 31Galea VP, Rojanasopondist P, Ingelsrud LH, et al. Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study. Bone Joint J 2019; 101-B(7): 768-78.
[http://dx.doi.org/10.1302/0301-620X.101B7.BJJ-2018-1491.R1] [PMID: 31256661]
, 46Helminen EE, Sinikallio SH, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study. Clin Rehabil 2016; 30(9): 890-900.
[http://dx.doi.org/10.1177/0269215515619660] [PMID: 27496698]
, 59Alattas SA, Smith T, Bhatti M, Wilson-Nunn D, Donell S. Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25(11): 3403-10.
[http://dx.doi.org/10.1007/s00167-016-4314-8] [PMID: 27734110]
, 109Harth M, Nielson WR. Pain and affective distress in arthritis: relationship to immunity and inflammation. Expert Rev Clin Immunol 2019; 15(5): 541-52.
[http://dx.doi.org/10.1080/1744666X.2019.1573675] [PMID: 30669892]
-112Sofat N, Ejindu V, Heron C, et al. Biomarkers in painful symptomatic knee oa demonstrate that MRI assessed joint damage and type II Collagen degradation products are linked to disease progression. Front Neurosci 2019; 13: 1016.
[http://dx.doi.org/10.3389/fnins.2019.01016] [PMID: 31680799]
], even if disputed or weakly supported by some [e.g9Ostojic M, Ostojić M, Prlić J, Soljic V. Correlation of anxiety and chronic pain to grade of synovitis in patients with knee osteoarthritis. Psychiatr Danub 2019; 31(Suppl. 1): 126-30.
[PMID: 30946731]
, 25Harmelink KEM, Zeegers AVCM, Hullegie W, Hoogeboom TJ, Nijhuis-van der Sanden MWG, Staal JB. Are there prognostic factors for one-year outcome after total knee arthroplasty? A systematic review. J Arthroplasty 2017; 32(12): 3840-3853.e1.
[http://dx.doi.org/10.1016/j.arth.2017.07.011] [PMID: 28927646]
, 66Jiménez Ortiz M, Espinosa Ruiz A, Martínez Delgado C, et al. Do preoperative anxiety and depression influence the outcome of knee arthroplasty? 2018., 67Wylde V, Trela-Larsen L, Whitehouse MR, Blom AW. Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement. Acta Orthop 2017; 88(5): 530-6.
[http://dx.doi.org/10.1080/17453674.2017.1334180] [PMID: 28562150]
, 70Cho CH, Song KS, Hwang I, Coats-Thomas MS, Warner JJP. Changes in psychological status and health-related quality of life following total shoulder arthroplasty. J Bone Joint Surg Am 2017; 99(12): 1030-5.
[http://dx.doi.org/10.2106/JBJS.16.00954] [PMID: 28632592]
].

CONSENT FOR PUBLICATION

Not applicable.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None

CONFLICT OF INTEREST

The author declares that there is no conflict of interest regarding the publication of this article.

ACKNOWLEDGEMENTS

Not applicable.

REFERENCES

[1] Williams A, Kamper SJ, Wiggers JH, et al. Musculoskeletal conditions may increase the risk of chronic disease: a systematic review and meta-analysis of cohort studies. BMC Med 2018; 16(1): 167.
[http://dx.doi.org/10.1186/s12916-018-1151-2] [PMID: 30249247]
[2] Risal A, Manandhar K, Linde M, Steiner TJ, Holen A. Anxiety and depression in Nepal: prevalence, comorbidity and associations. BMC Psychiatry 2016; 16: 102.
[http://dx.doi.org/10.1186/s12888-016-0810-0] [PMID: 27075664]
[3] Vancampfort D, Koyanagi A, Hallgren M, Probst M, Stubbs B. The relationship between chronic physical conditions, multimorbidity and anxiety in the general population: A global perspective across 42 countries. Gen Hosp Psychiatry 2017; 45: 1-6.
[http://dx.doi.org/10.1016/j.genhosppsych.2016.11.002] [PMID: 28274332]
[4] Dell’Isola A, Allan R, Smith SL, Marreiros SS, Steultjens M. Identification of clinical phenotypes in knee osteoarthritis: a systematic review of the literature. BMC Musculoskelet Disord 2016; 17(1): 425.
[http://dx.doi.org/10.1186/s12891-016-1286-2] [PMID: 27733199]
[5] Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing 2016; 45(2): 228-35.
[http://dx.doi.org/10.1093/ageing/afw001] [PMID: 26795974]
[6] Tan V, Jinks C, Chew-Graham C, Healey EL, Mallen C. The triple whammy anxiety depression and osteoarthritis in long-term conditions. BMC Fam Pract 2015; 16: 163.
[http://dx.doi.org/10.1186/s12875-015-0346-2] [PMID: 26530162]
[7] Pérez-García LF, Silveira LH, Moreno-Ramírez M, Loaiza-Félix J, Rivera V, Amezcua-Guerra LM. Frequency of depression and anxiety symptoms in Mexican patients with rheumatic diseases determined by self-administered questionnaires adapted to the Spanish language. Rev Invest Clin 2019; 71(2): 91-7.
[http://dx.doi.org/10.24875/RIC.18002698] [PMID: 31056610]
[8] Kang L, Nguyen J, Hashmi SZ, Lee SK, Weiland AJ, Mancuso CA. What demographic and clinical characteristics correlate with expectations with trapeziometacarpal arthritis? Clin Orthop Relat Res 2017; 475(11): 2704-11.
[http://dx.doi.org/10.1007/s11999-017-5359-9] [PMID: 28425053]
[9] Ostojic M, Ostojić M, Prlić J, Soljic V. Correlation of anxiety and chronic pain to grade of synovitis in patients with knee osteoarthritis. Psychiatr Danub 2019; 31(Suppl. 1): 126-30.
[PMID: 30946731]
[10] Carmona-Terés V, Moix-Queraltó J, Pujol-Ribera E, et al. Understanding knee osteoarthritis from the patients’ perspective: a qualitative study. BMC Musculoskelet Disord 2017; 18(1): 225.
[http://dx.doi.org/10.1186/s12891-017-1584-3] [PMID: 28558738]
[11] Khan S, Hanifa B, Begum R, Kalsoom U. Anxiety, depression and psychological distress in patients with osteo-arthritis. JPMI: J Postgrad Medical Ins 2017; 31(4): 410-3.
[12] Clauw DJ, Hassett AL. The role of centralised pain in osteoarthritis 2017.
[13] Schwartz FH, Lange J. Factors that affect outcome following total joint arthroplasty: a review of the recent literature. Curr Rev Musculoskelet Med 2017; 10(3): 346-55.
[http://dx.doi.org/10.1007/s12178-017-9421-8] [PMID: 28664450]
[14] Burston JJ, Valdes AM, Woodhams SG, et al. The impact of anxiety on chronic musculoskeletal pain and the role of astrocyte activation. Pain 2019; 160(3): 658-69.
[http://dx.doi.org/10.1097/j.pain.0000000000001445] [PMID: 30779717]
[15] Akin-Akinyosoye K, Frowd N, Marshall L, et al. Traits associated with central pain augmentation in the Knee Pain In the Community (KPIC) cohort. Pain 2018; 159(6): 1035-44.
[http://dx.doi.org/10.1097/j.pain.0000000000001183] [PMID: 29438225]
[16] Stamm TA, Pieber K, Crevenna R, Dorner TE. Impairment in the activities of daily living in older adults with and without osteoporosis, osteoarthritis and chronic back pain: a secondary analysis of population-based health survey data. BMC Musculoskelet Disord 2016; 17: 139.
[http://dx.doi.org/10.1186/s12891-016-0994-y] [PMID: 27020532]
[17] Nur H, Sertkaya BS, Tuncer T. Determinants of physical functioning in women with knee osteoarthritis. Aging Clin Exp Res 2018; 30(4): 299-306.
[http://dx.doi.org/10.1007/s40520-017-0784-x] [PMID: 28608254]
[18] Barnett LA, Pritchard MG, Edwards JJ, et al. Relationship of anxiety with joint pain and its management: A population survey. Musculoskelet Care 2018; 16(3): 353-62.
[http://dx.doi.org/10.1002/msc.1243] [PMID: 29675943]
[19] Jones AR, Al-Naseer S, Bodger O, James ETR, Davies AP. 2018.
[20] Wong LY, Yiu RL, Chiu CK, et al. Prevalence of psychiatric morbidity in Chinese subjects with knee osteoarthritis in a Hong Kong orthopaedic clinic. East Asian Arch Psychiatry 2015; 25(4): 150-8.
[PMID: 26764289]
[21] Castaño Carou A, Pita Fernández S, Pértega Díaz S. 2015.
[22] Guglielmo D, Hootman JM, Boring MA, et al. Symptoms of anxiety and depression among adults with arthritis - United States, 2015-2017. MMWR Morb Mortal Wkly Rep 2018; 67(39): 1081-7.
[http://dx.doi.org/10.15585/mmwr.mm6739a2] [PMID: 30286053]
[23] Sinikallio SH, Helminen EE, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Multiple psychological factors are associated with poorer functioning in a sample of community-dwelling knee osteoarthritis patients. J Clin Rheumatol 2014; 20(5): 261-7.
[http://dx.doi.org/10.1097/RHU.0000000000000123] [PMID: 25036567]
[24] Bierke S, Petersen W. Influence of anxiety and pain catastrophizing on the course of pain within the first year after uncomplicated total knee replacement: a prospective study. Arch Orthop Trauma Surg 2017; 137(12): 1735-42.
[http://dx.doi.org/10.1007/s00402-017-2797-5] [PMID: 28965133]
[25] Harmelink KEM, Zeegers AVCM, Hullegie W, Hoogeboom TJ, Nijhuis-van der Sanden MWG, Staal JB. Are there prognostic factors for one-year outcome after total knee arthroplasty? A systematic review. J Arthroplasty 2017; 32(12): 3840-3853.e1.
[http://dx.doi.org/10.1016/j.arth.2017.07.011] [PMID: 28927646]
[26] Liddle AD, Judge A, Pandit H, Murray DW. Determinants of revision and functional outcome following unicompartmental knee replacement. Osteoarthritis Cartilage 2014; 22(9): 1241-50.
[http://dx.doi.org/10.1016/j.joca.2014.07.006] [PMID: 25042552]
[27] Hiyama Y, Kamitani T, Wada O. Association between disease-specific anxiety at discharge and functional outcome in patients after total knee arthroplasty. Knee 2019; 26(2): 477-83.
[http://dx.doi.org/10.1016/j.knee.2019.01.016] [PMID: 30772184]
[28] Sorel JC, Veltman ES, Honig A, Poolman RW. The influence of preoperative psychological distress on pain and function after total knee arthroplasty: a systematic review and meta-analysis. Bone Joint J 2019; 101-B(1): 7-14.
[http://dx.doi.org/10.1302/0301-620X.101B1.BJJ-2018-0672.R1] [PMID: 30601044]
[29] Vida C, González EM, De la Fuente M. Increase of oxidation and inflammation in nervous and immune systems with aging and anxiety. Curr Pharm Des 2014; 20(29): 4656-78.
[http://dx.doi.org/10.2174/1381612820666140130201734] [PMID: 24588831]
[30] Wilkie R, Parmar SS, Blagojevic-Bucknall M, et al. Reasons why osteoarthritis predicts mortality: path analysis within a Cox proportional hazards model. RMD Open 2019; 5(2)e001048
[http://dx.doi.org/10.1136/rmdopen-2019-001048] [PMID: 31798954]
[31] Galea VP, Rojanasopondist P, Ingelsrud LH, et al. Longitudinal changes in patient-reported outcome measures following total hip arthroplasty and predictors of deterioration during follow-up: a seven-year prospective international multicentre study. Bone Joint J 2019; 101-B(7): 768-78.
[http://dx.doi.org/10.1302/0301-620X.101B7.BJJ-2018-1491.R1] [PMID: 31256661]
[32] Xu J, Twiggs J, Parker D, Negus J. 2019.
[33] Zhang M, Selzer F, Losina E, Collins JE, Katz JN. Musculoskeletal symptomatic areas after total knee replacement for osteoarthritis. ACR Open Rheumatol 2019; 1(6): 373-81.
[http://dx.doi.org/10.1002/acr2.11055] [PMID: 31777817]
[34] de Koning EJ, Timmermans EJ, van Schoor NM, et al. EPOSA Group. Within-person pain variability and mental health in older adults with osteoarthritis: an analysis across 6 European cohorts. J Pain 2018; 19(6): 690-8.
[http://dx.doi.org/10.1016/j.jpain.2018.02.006] [PMID: 29496636]
[35] Gil JA, Goodman AD, Mulcahey MK. Psychological factors affecting outcomes after elective shoulder surgery. J Am Acad Orthop Surg 2018; 26(5): e98-e104.
[http://dx.doi.org/10.5435/JAAOS-D-16-00827] [PMID: 29389727]
[36] Rasouli MR, Menendez ME, Sayadipour A, Purtill JJ, Parvizi J. Direct cost and complications associated with total joint arthroplasty in patients with preoperative anxiety and depression. J Arthroplasty 2016; 31(2): 533-6.
[http://dx.doi.org/10.1016/j.arth.2015.09.015] [PMID: 26481408]
[37] Janikowska-Hołoweńko D, Zaborowska-Sapeta K, Bidzan I. The level of anxiety and the subjective assessment of the quality of life in patients post hip replacement after primary and secondary rehabilitation. Acta Neuropsychol 2016; 12(2): 143-.
[http://dx.doi.org/10.5604/17307503.1111842]
[38] Hernández C, Díaz-Heredia J, Berraquero ML, Crespo P, Loza E, Ruiz Ibán MÁ. Pre-operative predictive factors of post-operative pain in patients with hip or knee arthroplasty: a systematic review. Reumatol Clin 2015; 11(6): 361-80.
[http://dx.doi.org/10.1016/j.reumae.2014.12.011] [PMID: 25840826]
[39] Pan X, Wang J, Lin Z, Dai W, Shi Z. Depression and anxiety are risk factors for postoperative pain-related symptoms and complications in patients undergoing primary total knee arthroplasty in the United States. J Arthroplasty 2019; 34(10): 2337-46.
[http://dx.doi.org/10.1016/j.arth.2019.05.035] [PMID: 31229373]
[40] Ferreira AH, Godoy PB, Oliveira NR, et al. Investigation of depression, anxiety and quality of life in patients with knee osteoarthritis: a comparative study. Rev Bras Reumatol 2015; 55(5): 434-8.
[http://dx.doi.org/10.1016/j.rbr.2015.03.001] [PMID: 26198010]
[41] Chen CJ, McHugh G, Campbell M, Luker K. Subjective and objective sleep quality in individuals with osteoarthritis in Taiwan. Musculoskelet Care 2014; •••
[http://dx.doi.org/10.1002/msc.1094] [PMID: 25491038]
[42] Hadlandsmyth K, Sabic E, Zimmerman MB, et al. Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis. Psychol Health Med 2017; 22(5): 552-63.
[http://dx.doi.org/10.1080/13548506.2016.1189581] [PMID: 27216314]
[43] O’Leary S, Cottrell M, Raymer M, Smith D, Khan A. General health factors may be a barrier to effective non-surgical multidisciplinary rehabilitation of common orthopaedic conditions in tertiary care settings. BMC Musculoskelet Disord 2018; 19(1): 348.
[http://dx.doi.org/10.1186/s12891-018-2265-6] [PMID: 30261861]
[44] Hayashi K, Kako M, Suzuki K, et al. Gait speeds associated with anxiety responses to pain in osteoarthritis patients. Pain Med 2015; •••
[http://dx.doi.org/10.1111/pme.12897] [PMID: 26352158]
[45] Legha A, Burke DL, Foster NE, et al. Do comorbidities predict pain and function in knee osteoarthritis following an exercise intervention, and do they moderate the effect of exercise? Analyses of data from three randomized controlled trials. Musculoskelet Care 2019; •••
[http://dx.doi.org/10.1002/msc.1425] [PMID: 31837126]
[46] Helminen EE, Sinikallio SH, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study. Clin Rehabil 2016; 30(9): 890-900.
[http://dx.doi.org/10.1177/0269215515619660] [PMID: 27496698]
[47] Hassett AL, Marshall E, Bailey AM, et al. Changes in anxiety and depression are mediated by changes in pain severity in patients undergoing lower-extremity total joint arthroplasty. Reg Anesth Pain Med 2018; 43(1): 14-8.
[http://dx.doi.org/10.1097/AAP.0000000000000682] [PMID: 29077589]
[48] Mallen CD, Nicholl BI, Lewis M, et al. The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care. PLoS Med 2017; 14(4)e1002273
[http://dx.doi.org/10.1371/journal.pmed.1002273] [PMID: 28399129]
[49] Hay E, Dziedzic K, Foster N, et al. Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomized controlled trials 2018.
[http://dx.doi.org/10.3310/pgfar06040]
[50] Karp JF, Zhang J, Wahed AS, et al. Improving patient reported outcomes and preventing depression and anxiety in older adults with knee osteoarthritis: results of a Sequenced Multiple Assignment Randomized Trial (SMART) study. Am J Geriatr Psychiatry 2019; 27(10): 1035-45.
[http://dx.doi.org/10.1016/j.jagp.2019.03.011] [PMID: 31047790]
[51] Hirakawa Y, Hara M, Fujiwara A, Hanada H, Morioka S. The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty. Pain Res Manag 2014; 19(5): 251-6.
[http://dx.doi.org/10.1155/2014/471529] [PMID: 25101335]
[52] Dieppe P, Goldingay S, Greville-Harris M. The power and value of placebo and nocebo in painful osteoarthritis. Osteoarthritis Cartilage 2016; 24(11): 1850-7.
[http://dx.doi.org/10.1016/j.joca.2016.06.007] [PMID: 27338671]
[53] Ali A, Lindstrand A, Sundberg M, Flivik G. Preoperative anxiety and depression correlate with dissatisfaction after total knee arthroplasty: a prospective longitudinal cohort study of 186 patients, with 4-year follow-up. J Arthroplasty 2017; 32(3): 767-70.
[http://dx.doi.org/10.1016/j.arth.2016.08.033] [PMID: 27692782]
[54] Dhurve K, Scholes C, El-Tawil S, et al. Multifactorial analysis of dissatisfaction after primary total knee replacement. Knee 2017; 24(4): 856-62.
[http://dx.doi.org/10.1016/j.knee.2017.04.005] [PMID: 28551201]
[55] Kohan EM, Hill JR, Schwabe M, Aleem AW, Keener JD, Chamberlain AM. The influence of mental health on Patient-Reported Outcomes Measurement Information System (PROMIS) and traditional outcome instruments in patients with symptomatic glenohumeral arthritis. J Shoulder Elbow Surg 2019; 28(2): e40-8.
[http://dx.doi.org/10.1016/j.jse.2018.07.033] [PMID: 30552069]
[56] French HP, Galvin R, Cusack T, McCarthy GM. Predictors of short-term outcome to exercise and manual therapy for people with hip osteoarthritis. Phys Ther 2014; 94(1): 31-9.
[http://dx.doi.org/10.2522/ptj.20130173] [PMID: 23929827]
[57] Hanusch BC, O’Connor DB, Ions P, Scott A, Gregg PJ. Effects of psychological distress and perceptions of illness on recovery from total knee replacement. Bone Joint J 2014; 96-B(2): 210-6.
[http://dx.doi.org/10.1302/0301-620X.96B2.31136] [PMID: 24493186]
[58] Shang X, Peng W, Hill E, Szoeke C, He M, Zhang L. Incidence of medication-treated depression and anxiety associated with long-term cancer, cardiovascular disease, diabetes and osteoarthritis in community-dwelling women and men. EClinicalMedicine 2019; 15: 23-32.
[http://dx.doi.org/10.1016/j.eclinm.2019.08.010] [PMID: 31709411]
[59] Alattas SA, Smith T, Bhatti M, Wilson-Nunn D, Donell S. Greater pre-operative anxiety, pain and poorer function predict a worse outcome of a total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25(11): 3403-10.
[http://dx.doi.org/10.1007/s00167-016-4314-8] [PMID: 27734110]
[60] De Caro MF, Vicenti G, Abate A, et al. Optimal improvement in function after total hip and knee replacement: how deep do you know your patient’s mind? J Biol Regul Homeost Agents 2015; 29(4)(Suppl.): 95-102.
[PMID: 26652495]
[61] Khatib Y, Jenkin D, Naylor JM, Harris IA. Psychological traits in patients waiting for total knee arthroplasty. a cross-sectional study. J Arthroplasty 2016; 31(8): 1661-6.
[http://dx.doi.org/10.1016/j.arth.2016.01.053] [PMID: 26944015]
[62] Rice DA, Kluger MT, McNair PJ, et al. Persistent postoperative pain after total knee arthroplasty: a prospective cohort study of potential risk factors. Br J Anaesth 2018; 121(4): 804-12.
[http://dx.doi.org/10.1016/j.bja.2018.05.070] [PMID: 30236242]
[63] Utrillas-Compaired A, De la Torre-Escuredo BJ, Tebar-Martínez AJ, Asúnsolo-Del Barco Á. Does preoperative psychologic distress influence pain, function, and quality of life after TKA? Clin Orthop Relat Res 2014; 472(8): 2457-65.
[http://dx.doi.org/10.1007/s11999-014-3570-5] [PMID: 24671514]
[64] Waimann CA, Fernandez-Mazarambroz RJ, Cantor SB, et al. Effect of body mass index and psychosocial traits on total knee replacement costs in patients with osteoarthritis. J Rheumatol 2016; 43(8): 1600-6.
[http://dx.doi.org/10.3899/jrheum.151301] [PMID: 27307528]
[65] Roger C, Debuyzer E, Dehl M, et al. Factors associated with hospital stay length, discharge destination, and 30-day readmission rate after primary hip or knee arthroplasty: Retrospective Cohort Study. Orthop Traumatol Surg Res 2019; 105(5): 949-55.
[http://dx.doi.org/10.1016/j.otsr.2019.04.012] [PMID: 31208932]
[66] Jiménez Ortiz M, Espinosa Ruiz A, Martínez Delgado C, et al. Do preoperative anxiety and depression influence the outcome of knee arthroplasty? 2018.
[67] Wylde V, Trela-Larsen L, Whitehouse MR, Blom AW. Preoperative psychosocial risk factors for poor outcomes at 1 and 5 years after total knee replacement. Acta Orthop 2017; 88(5): 530-6.
[http://dx.doi.org/10.1080/17453674.2017.1334180] [PMID: 28562150]
[68] Celik F, Edipoglu IS. Evaluation of preoperative anxiety and fear of anesthesia using APAIS score. Eur J Med Res 2018; 23(1): 41.
[http://dx.doi.org/10.1186/s40001-018-0339-4] [PMID: 30205837]
[69] Nandi M, Schreiber KL, Martel MO, et al. Sex differences in negative affect and postoperative pain in patients undergoing total knee arthroplasty. Biol Sex Differ 2019; 10(1): 23.
[http://dx.doi.org/10.1186/s13293-019-0237-7] [PMID: 31060622]
[70] Cho CH, Song KS, Hwang I, Coats-Thomas MS, Warner JJP. Changes in psychological status and health-related quality of life following total shoulder arthroplasty. J Bone Joint Surg Am 2017; 99(12): 1030-5.
[http://dx.doi.org/10.2106/JBJS.16.00954] [PMID: 28632592]
[71] Dunn LK, Durieux ME, Fernández LG, et al. Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery. J Neurosurg Spine 2018; 28(1): 119-26.
[http://dx.doi.org/10.3171/2017.5.SPINE1734] [PMID: 29125426]
[72] Balik MS, Hocaoğlu Ç, Erkut A, Güvercin Y, Keskin D. Evaluation of the quality of life and psychiatric symptoms of patients with primary coxarthrosis after total hip arthroplasty. Acta Chir Orthop Traumatol Cech 2017; 84(6): 436-40.
[PMID: 29351526]
[73] Eilenberg T. Acceptance and Commitment Group Therapy (ACT-G) for health anxiety. Dan Med J 2016; 63(10): B5294.
[PMID: 27697138]
[74] Kelley GA, Kelley KS, Callahan LF. Community-deliverable exercise and anxiety in adults with arthritis and other rheumatic diseases: a systematic review with meta-analysis of randomised controlled trials. BMJ Open 2018; 8(2)e019138
[http://dx.doi.org/10.1136/bmjopen-2017-019138] [PMID: 29455165]
[75] Pereira L, Figueiredo-Braga M, Carvalho IP. Preoperative anxiety in ambulatory surgery: The impact of an empathic patient-centered approach on psychological and clinical outcomes. Patient Educ Couns 2016; 99(5): 733-8.
[http://dx.doi.org/10.1016/j.pec.2015.11.016] [PMID: 26654958]
[76] Sahin HG, Kunduracilar Z, Sonmezer E, Ayas S. Effects of two different aquatic exercise trainings on cardiopulmonary endurance and emotional status in patients with knee osteoarthritis. J Back Musculoskeletal Rehabil 2019; 32(4): 539-48.
[http://dx.doi.org/10.3233/BMR-171116] [PMID: 30584113]
[77] Smyth JM, Johnson JA, Auer BJ, Lehman E, Talamo G, Sciamanna CN. Online positive affect journaling in the improvement of mental distress and well-being in general medical patients with elevated anxiety symptoms: a preliminary randomized controlled trial. JMIR Ment Health 2018; 5(4)e11290
[http://dx.doi.org/10.2196/11290] [PMID: 30530460]
[78] Wang CW, Chan CH, Ho RT, Chan JS, Ng SM, Chan CL. Managing stress and anxiety through qigong exercise in healthy adults: a systematic review and meta-analysis of randomized controlled trials. BMC Complement Altern Med 2014; 14: 8.
[http://dx.doi.org/10.1186/1472-6882-14-8] [PMID: 24400778]
[79] Đurović A, Sovilj S, Đokić I, et al. Pastoral care and religious support as a part of treatment of religious patient with the severe form of osteoarthritis. Vojnosanit Pregl 2017; 74(1): 69-77.
[http://dx.doi.org/10.2298/VSP1508025059D] [PMID: 29350895]
[80] Özkuk K, Uysal B, Ateş Z, Ökmen BM, Sezer R, Dilek G. The effects of inpatient versus outpatient spa therapy on pain, anxiety, and quality of life in elderly patients with generalized osteoarthritis: a pilot study. Int J Biometeorol 2018; 62(10): 1823-32.
[http://dx.doi.org/10.1007/s00484-018-1584-5] [PMID: 30022244]
[81] Steels E, Venkatesh R, Steels E, Vitetta G, Vitetta L. A double-blind randomized placebo controlled study assessing safety, tolerability and efficacy of palmitoylethanolamide for symptoms of knee osteoarthritis. Inflammopharmacology 2019; 27(3): 475-85.
[http://dx.doi.org/10.1007/s10787-019-00582-9] [PMID: 30927159]
[82] McPherson F, McGraw L. Treating generalized anxiety disorder using complementary and alternative medicine. Altern Ther Health Med 2013; 19(5): 45-50.
[PMID: 23981404]
[83] Giacobbi PR Jr, Stabler ME, Stewart J, Jaeschke AM, Siebert JL, Kelley GA. Guided imagery for arthritis and other rheumatic diseases: a systematic review of randomized controlled trials. Pain Manag Nurs 2015; 16(5): 792-803.
[http://dx.doi.org/10.1016/j.pmn.2015.01.003] [PMID: 26174438]
[84] das Nair R, Mhizha-Murira JR, Anderson P, et al. Home-based pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES): a feasibility randomized controlled trial. Clin Rehabil 2018; 32(6): 777-89.
[http://dx.doi.org/10.1177/0269215518755426] [PMID: 29424236]
[85] Büyükyılmaz F, Aştı T. The effect of relaxation techniques and back massage on pain and anxiety in Turkish total hip or knee arthroplasty patients. Pain Manag Nurs 2013; 14(3): 143-54.
[http://dx.doi.org/10.1016/j.pmn.2010.11.001] [PMID: 23972865]
[86] Ottaviani S, Bernard JL, Bardin T, Richette P. Effect of music on anxiety and pain during joint lavage for knee osteoarthritis. Clin Rheumatol 2012; 31(3): 531-4.
[http://dx.doi.org/10.1007/s10067-011-1925-9] [PMID: 22207250]
[87] Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: a randomized controlled study. J Altern Complement Med 2012; 18(5): 463-72.
[http://dx.doi.org/10.1089/acm.2010.0320] [PMID: 22537508]
[88] Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int 2017; 37(3): 389-98.
[http://dx.doi.org/10.1007/s00296-016-3620-2] [PMID: 27913870]
[89] Van Denburg AN, Shelby RA, Caldwell DS, O’Sullivan ML, Keefe FJ. Self-efficacy for pain communication moderates the relation between ambivalence over emotional expression and pain catastrophizing among patients with osteoarthritis. J Pain 2018; 19(9): 1006-14.
[http://dx.doi.org/10.1016/j.jpain.2018.04.001] [PMID: 29631037]
[90] Karasawa Y, Yamada K, Iseki M, et al. Association between change in self-efficacy and reduction in disability among patients with chronic pain. PLoS One 2019; 14(4)e0215404
[http://dx.doi.org/10.1371/journal.pone.0215404] [PMID: 30990842]
[91] Kuvačić G, Fratini P, Padulo J, Antonio DI, De Giorgio A. Effectiveness of yoga and educational intervention on disability, anxiety, depression, and pain in people with CLBP: A randomized controlled trial. Complement Ther Clin Pract 2018; 31: 262-7.
[http://dx.doi.org/10.1016/j.ctcp.2018.03.008] [PMID: 29705466]
[92] Nazari G, Bobos P, Billis E, MacDermid JC. Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck pain by a clinically important amount: A prospective cohort study. Physiother Res Int 2018; 23(3)e1712
[http://dx.doi.org/10.1002/pri.1712] [PMID: 29536618]
[93] Klainin-Yobas P, Oo WN, Suzanne Yew PY, Lau Y. Effects of relaxation interventions on depression and anxiety among older adults: a systematic review. Aging Ment Health 2015; 19(12): 1043-55.
[http://dx.doi.org/10.1080/13607863.2014.997191] [PMID: 25574576]
[94] McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement 2014.
[http://dx.doi.org/10.1002/14651858.CD003526.pub3]
[95] Zhang L, Fu T, Zhang Q, et al. Effects of psychological interventions for patients with osteoarthritis: a systematic review and meta-analysis. Psychol Health Med 2018; 23(1): 1-17.
[http://dx.doi.org/10.1080/13548506.2017.1282160] [PMID: 28140653]
[96] Zambon S, Siviero P, Denkinger M, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European project on osteoarthritis. Arthritis Care Res (Hoboken) 2016; 68(6): 801-10.
[http://dx.doi.org/10.1002/acr.22755] [PMID: 26474272]
[97] Mat S, Razack AH, Lim J, et al. Factors determining the increased risk of falls in individuals with knee pain in the Malaysian Elders Longitudinal Research (MELoR) Study. Front Med (Lausanne) 2019; 6: 277.
[http://dx.doi.org/10.3389/fmed.2019.00277] [PMID: 31850355]
[98] Heikkinen J, Honkanen R, Williams L, et al. Depressive disorders, anxiety disorders and subjective mental health in common musculoskeletal diseases: A review. Maturitas 2019; 127: 18-25.
[http://dx.doi.org/10.1016/j.maturitas.2019.05.011] [PMID: 31351516]
[99] Michopoulos V, Powers A, Gillespie CF, Ressler KJ, Jovanovic T. Inflammation in fear- and anxiety-based disorders: PTSD, GAD, and beyond. Neuropsychopharmacology 2017; 42(1): 254-70.
[http://dx.doi.org/10.1038/npp.2016.146] [PMID: 27510423]
[100] Tetsunaga T, Tetsunaga T, Nishida K, et al. Drug dependence in patients with chronic pain: A retrospective study. Medicine (Baltimore) 2018; 97(40)e12748
[http://dx.doi.org/10.1097/MD.0000000000012748] [PMID: 30290690]
[101] See MTA, Kowitlawakul Y, Tan AJQ, Liaw SY. Expectations and experiences of patients with osteoarthritis undergoing total joint arthroplasty: An integrative review. Int J Nurs Pract 2018; 24(2)e12621
[http://dx.doi.org/10.1111/ijn.12621] [PMID: 29336515]
[102] Tyser AR, Gaffney CJ, Zhang C, Presson AP. The association of patient satisfaction with pain, anxiety, and self-reported physical function. J Bone Joint Surg Am 2018; 100(21): 1811-8.
[http://dx.doi.org/10.2106/JBJS.17.00372] [PMID: 30399075]
[103] Codding JL, Getz CL. Pain management strategies in shoulder arthroplasty. Orthop Clin North Am 2018; 49(1): 81-91.
[http://dx.doi.org/10.1016/j.ocl.2017.08.010] [PMID: 29145989]
[104] Raghavan G, Shyam V, Murdoch JAC. A survey of anesthetic preference and preoperative anxiety in hip and knee arthroplasty patients: the utility of the outpatient preoperative anesthesia appointment. J Anesth 2019; 33(2): 250-6.
[http://dx.doi.org/10.1007/s00540-018-02608-y] [PMID: 30607650]
[105] Lindner M, Nosseir O, Keller-Pliessnig A, Teigelack P, Teufel M, Tagay S. Psychosocial predictors for outcome after total joint arthroplasty: a prospective comparison of hip and knee arthroplasty. BMC Musculoskelet Disord 2018; 19(1): 159.
[http://dx.doi.org/10.1186/s12891-018-2058-y] [PMID: 29788969]
[106] Prentice HA, Inacio MCS, Singh A, Namba RS, Paxton EW. Preoperative risk factors for opioid utilization after total hip arthroplasty. J Bone Joint Surg Am 2019; 101(18): 1670-8.
[http://dx.doi.org/10.2106/JBJS.18.01005] [PMID: 31567804]
[107] Kim SH, Yun JM, Chang CB, Piao H, Yu SJ, Shin DW. Prevalence of upper gastrointestinal bleeding risk factors among the general population and osteoarthritis patients. World J Gastroenterol 2016; 22(48): 10643-52.
[http://dx.doi.org/10.3748/wjg.v22.i48.10643] [PMID: 28082817]
[108] Clauw DJ, Essex MN, Pitman V, Jones KD. Reframing chronic pain as a disease, not a symptom: rationale and implications for pain management. Postgrad Med 2019; 131(3): 185-98.
[http://dx.doi.org/10.1080/00325481.2019.1574403] [PMID: 30700198]
[109] Harth M, Nielson WR. Pain and affective distress in arthritis: relationship to immunity and inflammation. Expert Rev Clin Immunol 2019; 15(5): 541-52.
[http://dx.doi.org/10.1080/1744666X.2019.1573675] [PMID: 30669892]
[110] Hott A, Brox JI, Pripp AH, Juel NG, Liavaag S. Predictors of pain, function, and change in patellofemoral pain. Am J Sports Med 2020; 48(2): 351-8.
[http://dx.doi.org/10.1177/0363546519889623] [PMID: 31821014]
[111] Carlesso LC, Hawker GA, Waugh EJ, Davis AM. Disease-specific pain and function predict future pain impact in hip and knee osteoarthritis. Clin Rheumatol 2016; 35(12): 2999-3005.
[http://dx.doi.org/10.1007/s10067-016-3401-z] [PMID: 27601231]
[112] Sofat N, Ejindu V, Heron C, et al. Biomarkers in painful symptomatic knee oa demonstrate that MRI assessed joint damage and type II Collagen degradation products are linked to disease progression. Front Neurosci 2019; 13: 1016.
[http://dx.doi.org/10.3389/fnins.2019.01016] [PMID: 31680799]
Track Your Manuscript:


Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents




Webmaster Contact: info@benthamopen.net
Copyright © 2020 Bentham Open