Although orthopedic surgeons provide interventions to
improve quality of life and physical activity, the
emotional health of patients may be a key component in
determining the quality of function after surgery.
“Multiple authors in the orthopedic literature over
the past 5 years have shown that a patient’s emotional health influences
his or her functional recovery after surgery,” David C. Ayers, MD,
director of the Musculoskeletal Center of Excellence at the University of
Massachusetts Medical School and the Pappas Chair of the Department of
Orthopedics and Rehabilitation, told Orthopedics Today.
The link between patients’ emotional status and
outcomes has been highlighted in orthopedic areas such as spine, trauma, sports
medicine, joint reconstruction and upper extremity surgery. “Patients with
lower emotional health have a greater risk of less functional improvement after
surgery,” Ayers said.
David C. Ayers, MD, said orthopedic surgeons may
be able to improve postoperative function of patients with low emotional health
by enrolling them in different postoperative recovery pathways.
Image: Rob Carlin
Patients at risk for low emotional health span
traditional patient demographics, such as age, gender or socioeconomic
“However, patients at risk tend to be anxious, have
low grade depression, less coping skills and less social support …,”
Ayers, who is also chair of the department of orthopedics at the medical school
and UMass Memorial Medical Center, said. “In general, though, these are
not people who are undergoing clinical treatment for depression, but have a
The patients may also lack coping skills and have a
tendency toward poor social support, he said.
Patients at risk for suboptimal functional improvement
after surgery due to emotional issues can be identified preoperatively, Ayers
“The traditional approach is for surgeons to spend
time discussing areas with their patients that put them at high risk,” he
said. During such encounters, emotional health is explored, including anxiety,
depression and poor coping skills.
Validated patient questionnaires such as the SF-36 or
SF-12 can also help identify patients at higher risk. “Patients with low
[mental composite scores] MCS are at risk for less functional improvement after
surgery due to their emotional health,” Ayers said. “Such patients
can have a technically precise and successful operative procedure without
peri-operative complication, but patients with low emotional health may still
not achieve the functional improvement that the surgeon and patient
Ayers continued, “What has frustrated orthopedic
surgeons is their inability to intervene in such high-risk patients, even
though they can identify these patients pre-operatively. Once you identify this
at-risk population, does that mean that you need to cure the depression or
treat the anxiety or give them additional coping skills or improve their social
support? These are areas in which most orthopedic surgeons have limited ability
However, once a patient is identified as high risk,
Ayers said that an orthopedic surgeon may be able to improve a patient’s
postoperative function by enrolling the patient in a different postoperative
recovery pathway. Such a pathway may provide the patient with additional
resources to address their anxiety, and provide them with additional coping
skills and support above the routine postoperative pathway.
Pathway to recovery
This topic is the subject of an ongoing study funded by
the National Institutes of Health (NIH) to test an emotional health program for
patients undergoing total joint replacement. Nearly 200 patients are enrolled
in the randomized, single-center study spearheaded by Patricia D. Franklin, MD,
MPH, a professor of orthopedics at the University of Massachusetts Medical
“We want to offer patients the right emotional
support to get them through the process,” she told Orthopedics
Today. “Our model is to have more of a balanced rehabilitation
program that not only addresses the knee, but the patients’ spirits and
social support too.”
to be approached as people — not diseases — and their outcomes are
better when we do.”
— David C. Ring, MD,
As part of the emotional health program, a telephone
health counselor trained with the help of behavioral psychologist Milagros
Rosal, PhD, makes 12 weekly phone calls offering emotional support to patients
who show symptoms of depression and anxiety during the rehabilitation phase.
The first in-take call is 40 minutes, with follow-up calls ranging from 8 to 15
“The length of the calls is really driven by the
patient and his or her needs,” Franklin said.
Prospective randomized study
The calls cover an assessment of the patient’s
pain, function and goals for that week. The counselor also does problem-solving
with the patient about barriers to adhering to the exercise program for the
“The patient might say that because I was feeling
depressed, I didn’t feel like getting out of bed 3 days this week to do my
home exercises or attend physical therapy,” Franklin said. “We go
through strategies for motivation in the morning or strategies for doing
exercises during the day, even when the patient does not feel up to it.”
The prospective study will conclude this summer.
Franklin said because the trial is randomized, she could not comment on the
preliminary findings. However, she said no one dropped out of the intervention,
so the patients appeared to welcome the calls. In addition, patients reported
greater adherence to an exercise program when given individual contact, which
may have helped with their physical gains from surgery.
Although orthopedic practices can incorporate a similar
telephone program by training a staff member, Franklin and her colleagues
envision the use of a professional who is associated with a rehabilitation
center or insurance company.
High tech, low touch
David C. Ring, MD, PhD, director of research for the
hand and upper extremity service at Massachusetts General Hospital in Boston,
noted that a survey by the American Academy of Orthopaedic Surgeons (AAOS)
found patients perceived orthopedists as “high-tech and low-touch.” To counter this perception, the
AAOS “has promoted communication skills courses to try to improve how
patients perceive us. Patients want to be approached as people — not
diseases — and their outcomes are better when we do,” Ring, who is an
Orthopedics Today Editorial Board member, said.
He cited the “mind-body dichotomy” as a large
barrier to orthopedic surgeons placing more emphasis on the cognitive and
emotional aspects of healing. The stigma associated with psychology is another
roadblock to embracing cognitive and emotional health. “However, with
society’s increasing understanding that the physical and emotional aspects
of illness cannot be separated, and that stress is to be expected and should
not be considered shameful, we will be able to take advantage of a wider range
of options for optimizing health and wellness,” Ring said.
The power of thoughts
Ring noted a divide between subjective patient
disability and objective impairment that is better explained by mood, stress
and coping strategies than by pathophysiology.
“The cognitive and emotional aspects of illness are
quite responsive to techniques such as cognitive behavioral therapy, which can
be considered like a cognitive/emotional fitness program,” he said.
“Many of us readily go to the gym, run or do yoga for our physical
In essence, cognitive behavioral therapy allows a person
to more effectively separate subjective thoughts from facts.
“A lot of problems arise when you think of
something as a fact,” Ring said. “For instance, when you have a pain
that does not go away as quickly as you expected, then it might become pretty
convincing that the pain will never go away. The thought is, ‘This pain is
never going to go away.’ Although it seems factual, it is not true. Most
pains eventually go away.”
Caving into the idea that pain will never cease “is
very disturbing,” Ring said. “It makes the person more ill. You feel
less well. You feel less capable, and symptoms bother you more.”
In contrast, when people recognize and accept that most
pain is temporary “ it helps them feel more optimistic and that things are
going to work out,” Ring said. “It also helps people do more and be
less bothered by their symptoms.”
As the stigma of seeking psychological services
decreases, Ring expects patients will sign up for cognitive/emotional fitness
courses. However, he does not foresee these courses being offered by the
“I don’t think we can be the experts at that
and the experts at musculoskeletal care,” Ring said. “Ultimately, we
will need to do this as a team, which has already been accomplished in spine
and other fields.”
“We want to
offer patients the right emotional support to get them through the
— Patricia D. Franklin, MD,
Ring acknowledged that having a multidisciplinary
approach that includes social workers, counselors or psychologists in the
office can take time. Meanwhile, orthopedic surgeons should be aware of the
power of words and ideas. For example, surgeons should consider the emotional
content of the word “tear” when discussing rotator cuff tendinopathy
with patients, which can convey that patients are damaged and need repair. Ring
noted that best evidence suggests that most rotator cuff tendon defects are
“Calling it a tear actually feeds into
people’s worst fears,” he said.
Models of health
Arthur J. Barsky, MD, a psychiatrist and vice chair for
psychiatric research at Brigham and Women’s Hospital in Boston, also
highlighted the link between thoughts and outcomes.
“Clearly, people’s thoughts about their
symptoms, their attitude toward their illness and their expectations about the
future course of their disease have tremendous influence on people’s
functional status,” Barsky told Orthopedics Today.
Barsky, who has been principal investigator of several
NIH studies that evaluated the role of
psychological factors in medical symptoms, believes that
orthopedists tend to follow a mechanical model.
“There is a broken part that we are going to
replace or fix, but how the patient reacts is not so mechanical,” he said.
“It is not part of the biomechanical model. An important component of
recovery is emotional health.”
In certain instances, such as significant social
problems, it is appropriate for surgeons to refer to social workers or
“It’s just good medical care to pay attention
to the patient as a whole and not just to the disease,” Barsky said, who
cited anxiety and depression about an illness as major emotional health issues.
A physician should also be sensitive to such concerns prior to the procedure
and ask how patients are adjusting after surgery.
“Patients in whom physical function does not
improve to the extent that they expected may not be able to return to their
occupation, so there’s a great financial price to be paid right now.
Patient satisfaction after surgery is also greatly impacted” Ayers said.
“There will also be a challenge to define the practical, financial and
operational models needed to deliver the care. A lot of health care reform is
focused on improving the value that we are offering our patients.”
In the long term, he noted that services and
interventions for emotional health “may be less costly than having a
patient who continues to be dissatisfied and seeking additional medical care
because of lower functional improvement.” – by Bob
- David C. Ayers, MD, can be reached at University of Massachusetts
Medical School, 55 Lake Avenue North, Worcester, MA 01655; 508-334-9750; email:
- Arthur J. Barsky, MD, can be reached at Brigham and Women’s
Hospital, 75 Francis St., Boston, MA 02115; 617-732-5236; email:
- Patricia D. Franklin, MD, MPH, can be reached at University of
Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655;
508-856-5748; email: firstname.lastname@example.org.
- David C. Ring, MD, PhD, can be reached at Massachusetts General
Hospital, Yawkey 2100, 55 Fruit St., Boston, MA 02114; 617-643-7527; email:
- Disclosures: Ayers receives research funding for
investigator-initiated studies from the NIH. Barsky has no relevant financial
disclosures. Franklin receives research funding for investigator-initiated
studies from the NIH, Agency for Healthcare Research and Quality and Zimmer,
Inc. Ring has no relevant financial disclosures.
How much of an impact does a patient’s preoperative emotional
health play in your decision to perform a procedure or the type of
postoperative rehabilitation you prescribe?
Emotional health dictates surgery
If I feel that if the patient is emotionally unable to follow through
with rehabilitation, then I will not do the surgery. I think the rehabilitation
in orthopedic surgery and knee surgery, which is what I specialize in, is
extremely important. If the patient does not follow through properly, then he
is subject to stiffness after the surgery and can develop swelling that will
not subside. These things can become permanent disabilities for patients if
they don’t have good emotional responses to the surgery and, in turn, have
the desired emotional responses that will lead to a favorable rehabilitation
I think it is extremely important that the patient go into the surgery
with a positive attitude. If the patient becomes emotionally depressed during
the rehabilitation period, this may lead to a possible negative outcome.
Therefore, I try to screen out people who are emotionally depressed. I
encourage these patients to seek help for their depression before performing
The interview with the patient is important, not only to identify the
problem and the problem that might require surgery, but also to identify the
possibilities of the patient following through with rehabilitation and giving
adequate time to the rehabilitation after surgery. Because I perform on the
knee only, I am quite interested about the patient’s willingness and
ability to do rehabilitation after the surgery. A patient’s emotional
health does influence his ability to undertake proper rehabilitation.
In order for a patient to have a successful surgery, he needs a
successful rehabilitation. If the patient is not emotionally able to cope with
the postoperative period and the requirements for rehabilitation after the
operative period, then it is unlikely that the patient will have a successful
J. Richard Steadman, MD, is a partner at the Steadman Hawkins
Research Foundation in Vail, Colo.
The patient makes the final decision
James C. Esch
Preoperatively, I discuss with patients my awareness of their emotional
health. But in an emergency situation, you need to proceed forward, regardless.
However, certain procedures can be delayed, if it is agreeable to the patient.
My theory is that the patient makes the final decision, although I provide
input and advice.
The patients who have preoperative good emotional health have best
outcomes. The key for the surgeon is to be aware of how this affects the
patient. A simple question to ask the patient is, ‘How do you think
you’re going to do after surgery?’ And just listen to that
patient’s response. This can give an idea of the patient’s job
satisfaction. For example, the patient may respond that he plans on returning
to work in 2 weeks with his arm in a sling. Or that patient may say he does not
like his boss and that his job is terrible, so he doesn’t think he can
return to work for a full 6 months.
You also get an indication if the patient is worried about after-care at
home. Who is going to take care of me after surgery? Conversely, perhaps the
patient has plenty of help at home or exudes a sense that he is fairly
independent. Patients may also be worried about their finances. The key point
is for the surgeon to be aware of the patient’s particular circumstances.
You may be able to detect depression — whether the patient is just
bummed out or has a lot of anxiety. These patients may seek emotional health
through their family physician, a psychologist or a psychiatrist.
A patient may also stand out as having an emotional problem because that
patient does not treat my staff well. The patient may be rude, for instance.
This is a red flag for me.
Postoperatively, the patient may be able to do simple exercises on his
own for the first 6 weeks, during which time you can evaluate that
patient’s awareness and eagerness to do those exercises under your
control. Does the patient have good body awareness? Is the patient aware of
balance? Does the patient have the emotional makeup to do exercise on his own?
I assess the patient’s ability to follow instruction.
Most patients who seem to take care of themselves physically, in my
opinion, have better emotional health. By having a patient improve himself
physically before undergoing a procedure, his emotional health might improve as
well. For example, a patient with chronic depression coupled with smoking can
be asked to not smoke 1 month before surgery and increase his walking distance.
Finally, there is an emotional contact that the patient makes with the
surgeon. If the patient likes his surgeon and trusts his surgeon, then that
patient has a chance for a better result.
James C. Esch, MD, is a member of the Orthopedics
Today Editorial Board and practices at the Orthopaedic Surgeons of North
County in Oceanside, Calif.