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American Journal of  Physical Education 
and Health Science (AJPEHS)

Postoperative Psychological Distress in Patients with Total Knee Replacement at Tertiary 
Care Hospital: A Cross Sectional Survey

Shehzad Sethi1*, Um e Habiba1, Kainat Suleman1, Hisham1, Inderyas1, Irfan Ullah1

Volume 2 Issue 2, Year 2024
ISSN: 2992-9679 (Online) 

DOI: https://doi.org/10.54536/ajpehs.v2i2.2857
https://journals.e-palli.com/home/index.php/ajpehs

Article Information ABSTRACT

Received: May 12, 2024

Accepted: June 10, 2024

Published: June 14, 2024

TKR One of  the most popular and effective surgical procedures is total knee replacement 
(TKR), which significantly reduces pain and improves functional impairment in individuals 
with knee arthritis A number of  psychological issues, such as depression, low self-efficacy, 
ineffective pain coping mechanisms, somatization, a lack of  social support, and patient 
expectations occurs after a major surgery like TKR. This study aims to determine the level 
of  psychological distress and pain threshold level among post-operative TKR patients.  It 
was a cross sectional study with the sample size of  77. The subjects aged>40 years were 
enrolled, who had undergone the TKR procedure. After obtaining the informed consent 
form, the data was collected by filing the NPRS and HADS Performa from the enrolled 
subjects. Data was analysed via SPSS version 26. The subjects have the mean age of  55.55 
with the standard deviation of  11.621. Pearson correlation test was applied to observe the 
correlation of  time duration with NPRS and HADS which showed a negative correlation, 
interpreting that with the increase in time duration there is decrease in the scores of  NPRS 
and HADS with the P-value of  <0.05. There is a decrease in psychological distress with the 
increase in time duration in patients undergoing total knee replacement surgery. The current 
study reveals that with time, the level of  pain and psychological distress, including anxiety 
and depression, as well as the pain threshold, decreases in the subjects who undergone 
through the TKR procedure.

Keywords
Anxiety, Depression, Knee 
Arthroplasty, Pain, Psychological 
Distress, Total Knee 
Replacement

INTRODUCTION
In 1968, the first knee replacement procedure was 
carried out. Since then, surgical equipment and methods 
advancements have significantly boosted its efficacy. One 
of  the most effective medical procedures is TKR(Choi & 
Ra, 2016; Wylde, Dieppe, Hewlett, & Learmonth, 2007). 
The treatment of  chronic knee pain and disability is thought 
to be beneficial with (TKR). Based on studies employing 
patient-based outcome measures, there is growing evidence 
that a sizable percentage of  TKR patients endure chronic 
knee pain, functional impairment, a low quality of  life, and 
dissatisfaction (Klement et al., 2016).
According to a study done in 2019, 23% of  people 
reported experiencing psychological anguish who were 
done with TKR. Psychologically distressed patients were 
younger (P .0001) and more likely to experience depression 
(Halawi et al., 2019). A cohort study looked into how 
psychological factors, such as how people perceive their 
health, anxiety, and depression, affected their recovery 
and functional outcomes following to TKR surgery. 
Additionally linked to a higher (worse) knee score at one 
year were depression and anxiety (Hanusch, O’connor, 
Ions, Scott, & Gregg, 2014). A meta-analysis examining 
the relationship between psychological distress before 
surgery and postoperative pain and function following 
(TKR). Pain and function following TKR appear to be 
negatively impacted by re-operative pain catastrophizing, 
mental anguish, anxiety and/or depressive symptoms, 
and somatoform disorders. Because of  this, some TKR 

patients might require psychological assistance to enhance 
their recovery and quality of  life (Sorel, Veltman, Honig, 
& Poolman, 2019). 
Chronic pain following TKR can have an impact on all 
aspects of  quality of  life relating to health, and has been 
linked to functional restrictions, depression, anxiety, 
worsening general health, sleep issues, and long-term 
opiate use (Howells, Murray, Wylde, Dieppe, & Blom, 
2016). Chronic pain following TKR is best described 
as pain that is present and bothersome at least three to 
six months after surgery because the level of  pain peaks 
between three and six months after surgery (Lenguerrand 
et al., 2016).
The thesis major objective was to better understand 
patient who had both psychological discomfort and 
co existing knee arthritis before and after (TKR). 
Understanding the viewpoint and experience of  patients 
who are unhappy after surgery was another goal, with the 
hope of  enhancing patient’s satisfaction following TKR.

Objectives
• To determine the level of  psychological distress 

among post-operative TKR patients.  
• To measure the pain threshold level in post TKR 

patients.

METHODOLOGY
It was a cross-sectional study conducted at Hayatabad 
Medical Complex (HMC), Khyber Teaching Hospital 

1 Rehman Medical Institute, Pakistan
* Corresponding author’s e-mail: shahzadwaqar5@gmail.com



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Am. J. Phys. Educ. Health Sci. 2(2) 1-3, 2024

(KTH), and Rehman Medical Institute (RMI) Peshawar. 
Subjects were enrolled using non-probability convenience 
sampling. The sample size was 77 participants calculated 
from Raosoft, including both male and Female patients.

Participants
Post-operative TKR patients with age of  aged 40 
and above years. The exclusion criteria include the 
patients who repeatedly suffered from TKR or having 
uni-compartmental Arthroplasty or Patella-femoral 
Arthroplasty.

Data Collection Procedure and Analysis
After the approval from the Research committee of  AMI, 
permission had taken from the concerned Hospitals 
HODS through official permission letter. All the willing 
patients were briefed about the purpose and procedure 
of  the study and then an informed consent was taken 
from them. Data was collected using the data collection 
tools i.e. NPRS and HADS Performa. 
The data was analysed using SPSS version 26. For 
continuous data, mean and standard deviation was 
calculated, while categorical variable was presented in the 
form of  frequency and percentages in the form of  tables 
and graph. Chi-square test and Pearson correlation were 
used for the association of  different variables.

RESULT
About 40 male and 37 female students were included in 
the research, with a mean age of  55.55 ± 11.621. The 
frequency for the duration after knee arthroplasty has 
also been calculated with the categories as recent, a few 
weeks ago, a few months ago, and past 1 year or more 
with the subjects as 34. 23. 10 and 10 respectively. 

and HADS (anxiety and depression). The result showed 
a moderately negative correlative of  time duration with 
NPRS which interpret that with increase in time there 
was low level of  pain observed in the subjects undergone 
through TKR. A negative correlation was observed 
between time duration and HADS with the p-value of  < 
0.05 which means that with the passage of  time, the level 
of  anxiety and depression decreases to some extent.

Figure 1:

Chi Square of  Categories of  Time Duration with 
NPRS and HADS 
The correlation of  categories of  time duration with 
Numerical Pain Rating Scale and Hospital Anxiety and 
Depression Scale was significant with the p-value of  <0.05.

Pearson Correlation of  Time Duration with NPRS 
and HADS
The correlation test of  duration of  TKR with NPRS 

Table 1:
NPRS HADS 

(anxiety)
HADS 
(depression)

Time duration -0.509 -0.361 -0.327
P-value 0.000 0.001 0.004

DISCUSSION
The current study illustrates the patients’ physical and 
psychological anguish following TKR surgery. A total 
of  77 people were recruited for the study, both male 
and female. The Hospital Anxiety and Depression Scale 
and the Numerical Pain Rating Scale were employed as 
outcome variables. According to the statistical research, 
patients who have had recent surgery report higher pain 
levels along with higher levels of  anxiety and sadness, 
which diminish over time. Following knee surgery, 
there was a notable decline in the frequency of  anxiety 
and depressed symptoms, which improved patient 
satisfaction. The current study has demonstrated a 
negative correlation between the length of  time and the 
level of  pain and psychological distress experienced by 
patients undergoing total knee replacement procedures. 
This suggests that an increase in time leads to a decrease 
in these symptoms, which in turn has a significant impact 
on the functional outcome of  the patients. 
Depression is a common co-morbidity among individuals 
who have had arthroplasty, according to Bistolfi et al. 
Given the established relationship between pain and 
depression, it’s possible that patients have higher rates of  
depression than the general population. Pain alleviation 
and enhanced function following arthroplasty may lead 
to an improvement in the patient’s depressive symptoms. 
(Tarakji, Wynkoop, Srivastava, O’Connor, & Atkinson, 
2018). Approximately thirty percent of  TKR patients 
endure psychological distress before to surgery. Studies 
have shown that patients with anxiety or depression 
perform worse on the outcome scale compared to those 
with higher psycho-social component scores. (Ayers, 
Franklin, Trief, Ploutz-Snyder, & Freund, 2004; Judge 
et al., 2012; Lungu, Vendittoli, & Desmeules, 2016). A 
considerable portion of  TKR patients have subclinical 
depression. (Bistolfi et al., 2017).
Acute postoperative pain (APP) is the main cause of  
postoperative misery, yet conventional methods of  pain 
assessment provide little information about the dynamics 
and course of  APP. After a minimum of  thirty of  the 
short reports from thirty-two patients were provided, 
the investigation revealed a quadratic temporal effect 



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Am. J. Phys. Educ. Health Sci. 2(2) 1-3, 2024

and significant (P=0.001) linear and quadratic declines, 
resulting in 1217 records in APP. Some notable random 
intercepts and slopes indicated variations in mean pain 
levels amongst patients as well as a decrease in pain 
(Balthasar, Willemen, Vossen, Boymans, & Lousberg, 
2023). Similar effects related to pain were observed 
in the current study, revealing that with the increase in 
time, the intensity of  pain decreases significantly with 
the P-value of  <0.05. One study reported that the level 
of  pain subsides with the duration of  time, so the level 
of  distress decreases, which has also been proven in the 
current study.
Two studies reported that those patients who show 
evidence of  clinical depression with time, they are more 
likely to experience more severe pain even with successful 
surgery, up to 30% of  patients report feeling dissatisfied 
(Patil, Kane, Dhamangaonkar, & Avhad, 2020) (Schindler 
et al., 2022).

CONCLUSION
The study concluded that outcome patients, pain, and 
emotional distress are the major factors for functional 
outcomes. The current study reveals that with the 
passage of  time, the level of  pain and psychological 
distress, including anxiety and depression, as well as the 
pain threshold, decreases in the subjects who undergone 
the TKR procedure. There were some limitations of  
the study, which included patients with repeated TKR 
procedures were not included, and factors contributing 
to the decrease in pain and psychological distress had not 
been determined.

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