Original Article|Articles in Press

Cognitive behavioral therapy achieves better benefits in relieving postoperative pain and improving joint function: A systematic review and meta-analysis of randomized controlled trials

Published:February 10, 2023DOI:



      Cognitive behavioral therapy (CBT) is a structured, short-term psychotherapy approach that may have positive effects in terms of relieving postoperative pain. The main objective of this study was to determine the effect of CBT on pain and joint function in patients after total joint arthroplasty.


      We searched 3 electronic databases including randomized controlled studies (RCTs) using CBT as an intervention. The main results of this study were to determine pain intensity by NRS, VAS, WOMAC pain Scale, PCS, and joint function by HHS, OKS, EQ-5D, ROM. Data extraction and quality assessment of included RCTs were independently performed by the authors and date analysis was performed by RevMan V.5.4.


      Among the 605 studies, 9 RCTS were included in this systematic review and meta-analysis. The study showed that the difference between CBT and usual care groups in PCS (≤3months), NRS, VAS (≤3months) were statistically significant (P < 0.05); the difference between CBT and usual care groups in PCS (≥12months), WOMAC Pain Scale, and VAS (≥12months) were not statistically significant (P > 0.05), indicating that CBT can improve pain in patients after arthroplasty in the early term. In addition, the difference between CBT and usual care groups in OKS (≤3months), HSS, ROM (≤3months), EQ-5D (≤3months) were not statistically significant (P > 0.05); the difference between CBT and usual care groups in EQ-5D (≥12months) were statistically significant (P < 0.05), indicating that the quality of life in patients after total joint arthroplasty were improved with the extension of follow-up time.


      This study shows that CBT can relieve pain in patients with total joint arthroplasty in the early postoperative period and improve quality of life to some extent over time.


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        • Fang M.
        • Noiseux N.
        • Linson E.
        • Cram P.
        The effect of advancing age on total joint replacement outcomes.
        Geriatr Orthop Surg Rehabil. 2015 Sep; 6: 173-179
        • Bang H.
        • Chiu Y.L.
        • Memtsoudis S.G.
        • Mandl L.A.
        • Della Valle A.G.
        • Mushlin A.I.
        • et al.
        Total hip and total knee arthroplasties: trends and disparities revisited.
        Am J Orthop (Belle Mead NJ). 2010 Sep; 39: E95-E102
        • Cram P.
        • Lu X.
        • Kaboli P.J.
        • Vaughan-Sarrazin M.S.
        • Cai X.
        • Wolf B.R.
        • et al.
        Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991-2008.
        JAMA. 2011 Apr 20; 305: 1560-1567
        • Kurtz S.
        • Ong K.
        • Lau E.
        • Mowat F.
        • Halpern M.
        Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
        J Bone Joint Surg Am. 2007 Apr; 89: 780-785
        • Khatib Y.
        • Madan A.
        • Naylor J.M.
        • Harris I.A.
        Do psychological factors predict poor outcome in patients undergoing TKA? A systematic review.
        Clin Orthop Relat Res. 2015 Aug; 473: 2630-2638
        • Lee D.M.
        • Pendleton N.
        • Tajar A.
        • O'Neill T.W.
        • O'Connor D.B.
        • Bartfai G.
        • et al.
        Chronic widespread pain is associated with slower cognitive processing speed in middle-aged and older European men.
        Pain. 2010 Oct; 151: 30-36
        • Gerhart J.I.
        • Burns J.W.
        • Bruehl S.
        • Smith D.A.
        • Post K.M.
        • Porter L.S.
        • et al.
        Variability in negative emotions among individuals with chronic low back pain: relationships with pain and function.
        Pain. 2018 Feb; 159: 342-350
        • Birch S.
        • Stilling M.
        • Mechlenburg I.
        • Hansen T.B.
        Effectiveness of a physiotherapist delivered cognitive-behavioral patient education for patients who undergoes operation for total knee arthroplasty: a protocol of a randomized controlled trial.
        BMC Muscoskel Disord. 2017 Mar 21; 18: 116
        • Broderick J.E.
        • Keefe F.J.
        • Bruckenthal P.
        • Junghaenel D.U.
        • Schneider S.
        • Schwartz J.E.
        • et al.
        Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: a randomized, controlled trial.
        Pain. 2014 Sep; 155: 1743-1754
        • Somers T.J.
        • Blumenthal J.A.
        • Guilak F.
        • Kraus V.B.
        • Schmitt D.O.
        • Babyak M.A.
        • et al.
        Pain coping skills training and lifestyle behavioral weight management in patients with knee osteoarthritis: a randomized controlled study.
        Pain. 2012 Jun; 153: 1199-1209
        • Cai L.
        • Gao H.
        • Xu H.
        • Wang Y.
        • Lyu P.
        • Liu Y.
        Does a program based on cognitive behavioral therapy affect kinesiophobia in patients following total knee arthroplasty? A randomized, controlled trial with a 6-month follow-up.
        J Arthroplasty. 2018 Mar; 33: 704-710
        • Bennell K.L.
        • Ahamed Y.
        • Jull G.
        • Bryant C.
        • Hunt M.A.
        • Forbes A.B.
        • et al.
        Physical therapist-delivered pain coping skills training and exercise for knee osteoarthritis: randomized controlled trial.
        Arthritis Care Res. 2016 May; 68: 590-602
        • Sun J.N.
        • Chen W.
        • Zhang Y.
        • Zhang Y.
        • Feng S.
        • Chen X.Y.
        Does cognitive behavioral education reduce pain and improve joint function in patients after total knee arthroplasty? A randomized controlled trial.
        Int Orthop. 2020 Oct; 44: 2027-2035
        • Birch S.
        • Stilling M.
        • Mechlenburg I.
        • Hansen T.B.
        No effect of cognitive behavioral patient education for patients with pain catastrophizing before total knee arthroplasty: a randomized controlled trial.
        Acta Orthop. 2020 Feb; 91: 98-103
        • Chen W.
        • Sun J.N.
        • Hu Z.H.
        • Zhang Y.
        • Chen X.Y.
        • Feng S.
        Cognitive behavioral therapy cannot relieve postoperative pain and improve joint function after total knee arthroplasty in patients aged 70 years and older.
        Aging Clin Exp Res. 2021 Dec; 33: 3293-3302
        • Buvanendran A.
        • Sremac A.C.
        • Merriman P.A.
        • Della Valle C.J.
        • Burns J.W.
        • McCarthy R.J.
        Preoperative cognitive-behavioral therapy for reducing pain catastrophizing and improving pain outcomes after total knee replacement: a randomized clinical trial.
        Reg Anesth Pain Med. 2021 Apr; 46: 313-321
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • Boutron I.
        • Hoffmann T.C.
        • Mulrow C.D.
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        Int J Surg. 2021 Apr; 88105906
        • O'Connor D.
        • Green S.
        • Higgins J.P.T.
        Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration, London, UK2011 (updated March 2011)
        Version: Version 5.1.0
        ([Defining the review question and developing criteria for including studies])
        • Systematic Reviews
        CRD's guidance for undertaking reviews in health care.
        Centre for Reviews and Dissemination, University of York, York, UK2009 Jan
        • Higgins J.P.
        • Altman D.G.
        • Gøtzsche P.C.
        • Jüni P.
        • Moher D.
        • Oxman A.D.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011 Oct 18; 343: d5928
        • Hanley A.W.
        • Gililland J.
        • Erickson J.
        • Pelt C.
        • Peters C.
        • Rojas J.
        • et al.
        Brief preoperative mind-body therapies for total joint arthroplasty patients: a randomized controlled trial.
        Pain. 2021 Jun 1; 162: 1749-1757
        • Lerman S.F.
        • Finan P.H.
        • Smith M.T.
        • Haythornthwaite J.A.
        Psychological interventions that target sleep reduce pain catastrophizing in knee osteoarthritis.
        Pain. 2017 Nov; 158: 2189-2195
        • Riddle D.L.
        • Keefe F.J.
        • Ang D.C.
        • Slover J.
        • Jensen M.P.
        • Bair M.J.
        • et al.
        Pain coping skills training for patients who catastrophize about pain prior to knee arthroplasty: a multisite randomized clinical trial.
        J Bone Joint Surg Am. 2019 Feb 6; 101: 218-227
        • Huysmans E.
        • Baeyens J.P.
        • Dueñas L.
        • Falla D.
        • Meeus M.
        • Roose E.
        • et al.
        Do sex and pain characteristics influence the effectiveness of pain neuroscience education in people scheduled for total knee arthroplasty? Secondary analysis of a randomized controlled trial.
        Phys Ther. 2021 Dec 1; 101: pzab197
        • Hadlandsmyth K.
        • Sabic E.
        • Zimmerman M.B.
        • Sluka K.A.
        • Herr K.A.
        • Clark C.R.
        • 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 Jun; 22: 552-563
        • Lowry V.
        • Ouellet P.
        • Vendittoli P.A.
        • Carlesso L.C.
        • Wideman T.H.
        • Desmeules F.
        Determinants of pain, disability, health-related quality of life and physical performance in patients with knee osteoarthritis awaiting total joint arthroplasty.
        Disabil Rehabil. 2018 Nov; 40: 2734-2744
        • Bastick A.N.
        • Runhaar J.
        • Belo J.N.
        • Bierma-Zeinstra S.M.
        Prognostic factors for progression of clinical osteoarthritis of the knee: a systematic review of observational studies.
        Arthritis Res Ther. 2015 Jun 8; 17: 152
        • Tuominen U.
        • Blom M.
        • Hirvonen J.
        • Seitsalo S.
        • Lehto M.
        • Paavolainen P.
        • et al.
        The effect of co-morbidities on health-related quality of life in patients placed on the waiting list for total joint replacement.
        Health Qual Life Outcome. 2007 Mar 15; 5: 16
        • Lindberg M.F.
        • Aamodt A.
        • Badawy M.
        • Bergvad I.B.
        • Borchgrevink P.
        • Furnes O.
        • et al.
        The effectiveness of exercise therapy and education plus cognitive behavioral therapy, alone or in combination with total knee arthroplasty in patients with knee osteoarthritis - study protocol for the MultiKnee trial.
        BMC Muscoskel Disord. 2021 Dec 20; 22: 1054
        • Seng E.K.
        • Singer A.B.
        • Metts C.
        • Grinberg A.S.
        • Patel Z.S.
        • Marzouk M.
        • et al.
        Does mindfulness-based cognitive therapy for migraine reduce migraine-related disability in people with episodic and chronic migraine? A phase 2b pilot randomized clinical trial.
        Headache. 2019 Oct; 59: 1448-1467
        • Bae J.Y.
        • Sung H.K.
        • Kwon N.Y.
        • Go H.Y.
        • Kim T.J.
        • Shin S.M.
        • et al.
        Cognitive behavioral therapy for migraine headache: a systematic review and meta-analysis.
        Medicina (Kaunas). 2021 Dec 28; 58: 44
        • Dixon K.E.
        • Keefe F.J.
        • Scipio C.D.
        • Perri L.M.
        • Abernethy A.P.
        Psychological interventions for arthritis pain management in adults: a meta-analysis.
        Health Psychol. 2007 May; 26: 241-250
        • Williams A.C.C.
        • Fisher E.
        • Hearn L.
        • Eccleston C.
        Psychological therapies for the management of chronic pain (excluding headache) in adults.
        Cochrane Database Syst Rev. 2020 Aug 12; 8: CD007407
        • Beck A.T.
        The past and future of cognitive therapy.
        J Psychother Pract Res. 1997 Fall; 6: 276-284