Accepted Manuscript

The use of adjunct psychosocial interventions can decrease

postoperative pain and improve the quality of clinical care in
orthopedic surgery. A systematic review and meta-analysis of
randomized controlled trials

Csenge Szeverenyi MD , Zoltan Kekecs PhD , Alisa Johnson MA ,

Gary Elkins PhD , Zoltan Csernatony MD, Professor, PhD, DSc ,
Katalin Varga Professor, PhD, DSc

PII: S1526-5900(18)30194-9
DOI: 10.1016/j.jpain.2018.05.006
Reference: YJPAI 3590

To appear in: Journal of Pain

Received date: 4 August 2017

Revised date: 15 April 2018
Accepted date: 14 May 2018

Please cite this article as: Csenge Szeverenyi MD , Zoltan Kekecs PhD ,
Alisa Johnson MA , Gary Elkins PhD , Zoltan Csernatony MD, Professor, PhD, DSc ,
Katalin Varga Professor, PhD, DSc , The use of adjunct psychosocial interventions can decrease post-
operative pain and improve the quality of clinical care in orthopedic surgery. A systematic review and
meta-analysis of randomized controlled trials, Journal of Pain (2018), doi: 10.1016/j.jpain.2018.05.006

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Highlights:
 Psychosocial interventions may improve clinical care in orthopedic procedures.
 Patient education and relaxation produced the most consistent positive effects.
 Cognitive or behavioral techniques improved recovery.
 Interventions were more effective at acute surgeries compared to elective ones.
 More well powered high-quality studies are needed to further support our findings.

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The use of adjunct psychosocial interventions can decrease postoperative pain and

improve the quality of clinical care in orthopedic surgery. A systematic review and

meta-analysis of randomized controlled trials.

Csenge Szeverenyia, MD; szcsenge@med.unideb.hu

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Zoltan Kekecsb, PhD; kekecs.zoltan@gmail.com

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Alisa Johnsonc, MA; Alisa_Johnson@baylor.edu

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Gary Elkinsc, PhD; Gary_Elkins@baylor.edu

Zoltan Csernatonya, MD, Professor, PhD, DSc; csz@med.unideb.hu

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Katalin Vargad, Professor, PhD, DSc; varga.katalin@ppk.elte.hu
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a
Department of Orthopedic Surgery, Faculty of Medicine, University of Debrecen, 4032
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Debrecen, Nagyerdei krt. 98., Hungary

b
Department of Psychology, Lund University, Box 213, Lund, Sweden
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c
Department of Psychology and Neuroscience, Baylor University,
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One Bear Place 97334, Waco, TX, USA

d
Institute of Psychology, Eotvos Lorand University, 1064 Budapest, Izabella u. 46. Hungary
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Disclosures: The reviewers‘ nominated record is from the unpublished work of the first (CS),
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fifth (ZC) and sixth (KV) author. Each author certifies that he or she has no commercial

associations (eg. consultancies, stock ownership, equity interest, patent/licensing

arrangements, etc.) that might pose a conflict of interest in connection with the submitted

article.

No funding was received for the research.

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The study was performed at the University of Debrecen, Clinical Center, Department of

Orthopedic Surgery, at Baylor University, Department of Psychology and Neuroscience and

at Department of Surgery and Cancer, Division of Surgery, Imperial College London.

Corresponding Author:

Csenge, Szeverenyi, MD

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Department of Orthopedic Surgery, University of Debrecen, Clinical Center, Nagyerdei krt.

98. Debrecen, Hungary 4032

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Email: szcsenge@med.unideb.hu

ORCID identifier: 0000-0002-7332-1687

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Abstract: The present study aims to assess the effectiveness of psychosocial techniques to

decrease postoperative pain and improve perioperative clinical care in orthopedic surgery. A

systematic review and meta-analysis was performed to evaluate the effects of psychosocial

methods among adults undergoing orthopedic surgeries. The systematic review included both

randomized and non-randomized trials, but only randomized controlled clinical trials (RCTs)

were included in the meta-analysis. Key outcomes were postoperative pain, analgesic

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requirement, perioperative anxiety, quality of life, and recovery. After searching the

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databases from January 1980 to September 2016, sixty-two RCTs were included with a

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pooled sample size of 4908. Psychosocial interventions significantly reduced postoperative

pain (Hedges‘ g = 0.31 [95%CI = 0.14, 0.48]), and pre- and postoperative anxiety (g = 0.26

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[0.11, 0.42] and g = 0.4 [0.21, 0.59], respectively). Furthermore, psychosocial interventions
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improved recovery (g = 0.38 [0.22, 0.54]). However, no significant effects were found for

postoperative analgesic use (g = 0.16 [-0.01, 0.32]) and quality of life (g = 0.14 [-0.05, 0.33]).
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Patient education and relaxation techniques produced the most consistent positive effects,

showing benefits on pain, anxiety, and recovery. Cognitive or behavioral techniques

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improved recovery. Furthermore, larger effects were found for studies that included acute
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surgeries compared to elective surgeries. The results indicate that psychosocial interventions,

especially patient education and relaxation training, may reduce perioperative side effects and
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improve recovery in patients undergoing orthopedic procedures, but the quality of evidence is

generally low. More well powered high-quality studies are needed to increase confidence.
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Perspective:
In this meta-analysis of RCTs in orthopedic surgeries, significant benefits in postoperative

pain, perioperative anxiety and recovery were found, suggesting that psychosocial

interventions, especially patient education and relaxation techniques, are useful in improving

the clinical care.

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Key words:

orthopedic surgery; psychological interventions; patient education; prospective

controlled trials; meta-analysis; review

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Introduction

The number of orthopedic surgeries performed each year is growing rapidly

worldwide.38,46,88,119,153 For example, by 2030, total knee and hip arthroplasties are expected

to reach 3.48 million (673% increase) and 572,000 (174% increase), respectively, in the

United States alone.88 In Australia, the demand for knee replacement surgeries has increased

by 150% over the past 10 years.10 Growth is expected to continue as the world‘s population

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continues to age and rates of obesity and osteoarthritis rise.48,86,110

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Orthopedic surgeries are among the most painful types of surgeries and are associated

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with a high incidence of severe postoperative pain and anxiety.8,28,31,56,62,103,106,121,133

Undertreated postoperative pain increases patient risk for pulmonary and cardiovascular

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morbidity, post-surgical complications, and persistent post-surgical chronic pain.5 In addition,
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functional recovery following orthopedic surgery is dependent upon early mobilization and

physical therapy. Regaining functional recovery following orthopedic surgery is a top priority
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due to the short hospital stays following these, often times, major surgeries.38 Inadequate pain

control may hinder this process and lead to longer hospitalization and higher medical
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costs.5,26,31,80,81 Perioperative anxiety and pain are associated with suboptimal short- and long-

term recovery.45,74,79,84,103,142,144 It is also well known that anxiety and pain are closely linked,
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with patients experiencing higher levels of perioperative anxiety also reporting more
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pain.69,109

The safe and effective management of pain following orthopedic surgery is

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challenging.28,99 Pharmacological methods are the first line treatments for pain and anxiety

following orthopedic surgery, but they provide limited relief and carry high risks for side-

effects.8,23,30,154 There is a growing need for improved perioperative pain management in

orthopedic surgeries.18,26,45,63,74,79,84,91,73,138,142,144

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There is evidence for the positive effects of different psychosocial interventions on

pain and anxiety, indicating that they could be good adjuncts for pain management following

orthopedic surgery.7,24,29,33,35,49,94,98 Psychosocial techniques influence the thoughts, feelings,

and actions of persons experiencing post-surgical pain.120 In a recent meta-analysis120,

researchers examined the effectiveness of preparatory psychological interventions and found

support for their utility for postoperative pain, anxiety, and recovery in elective surgeries.

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However, other reviews investigating the effects of patient education for orthopedic surgical

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patients indicated little to no beneficial effect on perioperative outcomes.11,96,104 This review

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will add to previously conducted meta-analysis and reviews by examining the effects of

psychological interventions delivered before, during and after, acute and elective surgeries on

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multiple outcomes. In addition, this study will provide a narrative review of non-RCTs to
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better elucidate the possible benefits of psychological interventions delivered at multiple time

points on various surgical outcomes.

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The purpose of this study was to conduct a systematic literature review and meta-

analysis to determine the effectiveness of psychosocial interventions (e.g. patient education,

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relaxation techniques, therapeutic suggestions, cognitive or behavioral interventions, and

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combinations of these) for pain and anxiety in short and long-term recovery following

orthopedic surgery. The study was designed to specifically answer the following questions:
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Can the applied psychosocial techniques reduce 1) postoperative pain, 2) analgesic use, 3)

preoperative anxiety 4) postoperative anxiety, and enhance 5) quality of life and 6) recovery
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in adults undergoing orthopedic surgery; and, 7) what are the moderating factors of

effectiveness? This information is needed to aid healthcare providers and insurance

companies in identifying best practices in orthopedic procedures.

Materials and Methods

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Study protocol was determined and published a-priori.82 Reporting is based on

PRISMA guidelines (Supplement 1).

Search Strategy

PubMed, PsycINFO, CINAHL, and ProQuest Dissertations & Theses were searched

for studies published between January 1980 and September 2016. The World Health

Organization‘s International Clinical Trials Registry Platform (ICTRP) was accessed to

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search for unpublished trials. ICTRP searches in the database of 17 major trial registries

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worldwide, including ClinicalTrials.gov. For more information on the data provider trial

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registries see: http://www.who.int/ictrp/search/data_providers/en/. References of relevant

papers were hand searched. (See search entries in Supplement 2.)

Selection Criteria and Data Extraction US

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Both randomized and non-randomized prospective controlled clinical trials that

included adults (age ≥ 18), undergoing orthopedic surgery, comparing the effects of
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psychosocial interventions to control groups on at least one of the following outcomes:

postoperative pain, analgesic use, pre- and postoperative anxiety, quality of life and recovery,
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were selected and included in the systematic review. Control groups received either standard
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care, or placebo (e.g. receiving a booklet with easily available information, or listening to a

non-specific music), or increased attention (e.g. conversation with a care provider but no
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specific treatment).

Based on a preliminary literature search and previous meta-analysis76, the following

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psychological interventions were included in this review: patient education, cognitive or

behavioral interventions, relaxation techniques, hypnosis, therapeutic suggestion

interventions, and emotion-focused interventions (more details are available in the published

protocol82). Patient education interventions provide information regarding the surgical

procedure or the recovery and may reduce pain and anxiety by preparing the patient

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cognitively for the surgical experience. Cognitive behavioral interventions are also designed

to improve pain and anxiety by modifying the patient‘s cognitive appraisals and subsequent

behaviors related to the surgical experience.13 Cognitive behavioral therapies are thought to

reduce pain and anxiety by helping patients to reframe negative thoughts, develop positive

coping strategies, and foster positive emotions.120,141Relaxation techniques are used to relax

the patient mentally and/or physically.51 Relaxation techniques may reduce pain by relaxing

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the skeletal muscles near the surgical site, or by reducing anxiety.147,148 Hypnosis consists of

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a hypnotic induction followed by suggestions for symptom control.44 Hypnosis may also

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reduce pain through relaxation, changes in cognitive appraisals, and fostering positive

emotions.73 Therapeutic suggestion interventions differs from hypnosis in that suggestions

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and positive communication are given without a formal hypnotic induction.83 Therapeutic
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suggestions are also thought to reduce anxiety and pain by reducing negative cognitions,

providing a positive coping strategy and setting positive expectations.113 Emotion-focused

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interventions concentrate on the expression or on the discussion of emotions.120 Emotion-

focused interventions may also reduce pain and anxiety by reducing negative emotions and
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cognitions and promoting positive coping strategies.85,120

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Quantitative analysis was run on RCTs only. Postoperative pain, pre- and

postoperative anxiety and quality of life were assessed using standardized self-report
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measures (e.g VAS, NRS, Brief Pain Inventory, McGill Pain Questionnaire, WOMAC, State

Trait Anxiety Inventory, Short Form Health Survey). Analgesic use was reported by patients
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or study staff. Standardized effect size (Hedge‘s g) was used to combine data from different

outcome measures. Patient recovery was defined as time taken to return to normal

functioning, and by subjective or objective ratings of recovered normal physical functioning.

Physical recovery was either measured by different questionnaires, like Barthel Index Scoring

Form, Functional Independence Measure Test or by physical tests, like measuring muscle

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strength or range of motions. A random–effects approach was used to combine results from

individual studies. Language of eligible publications was not restricted. Interventions

including non-psychological techniques were not eligible. Full text screening and data

extraction was performed independently by two review authors (CS screened all papers; ZK

and AJ each screened half of the papers). A third author (ZK or AJ) was consulted to resolve

any disagreements between the other authors. Measurements were recorded for every

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reported time point up to one month post-surgery for pain and anxiety, and six months post-

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surgery for quality of life and recovery (Table 1). Time ranges of interest for recovery

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outcome were modified from the protocol82 (i.e. the first three months post-surgery were

divided into two time periods: 1 to 14 days and 15 days to 3 months post-surgery), to better

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distinguish between recovery during and after hospitalization.
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Risk of Bias and Quality of Evidence Assessment

The Cochrane Risk of Bias Assessment Tool65 was used to assess methodological bias
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by two authors (CS, ZK, AJ). Publication bias was assessed by inspecting the funnel plot,

Begg and Muzumdar rank correlation14 and Egger test136. Quality of evidence was assessed in
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duplicate using the Grading of Recommendations Assessment, Development and Evaluation

(GRADE) system (CS, ZK).61 GRADE classification starts at high (―Further research is very
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unlikely to change our confidence in the estimate of effect‖) when evidence is derived from
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RCTs. However, confidence in evidence can be downgraded to moderate (―Further research

is likely to have an important impact on our confidence in the estimate of effect and may
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change the estimate‖), low (―Further research is very likely to have an important impact on

our confidence in the estimate of effect and is likely to change the estimate‖), or very low

(―Any estimate of effect is very uncertain‖) for several reasons. In our study, the following

criteria were considered when assessing confidence in evidence: (1) study limitations

(significant risk of bias identified in the studies providing the evidence); (2) inconsistency of

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results (large heterogeneity within effect estimates, I2 > 50%); (3) indirectness of evidence

(indirect population, intervention, control, outcomes); (4) imprecision (wide confidence

intervals or effect estimate is based on less than pooled N = 1000); (5) reporting bias

(significant risk of publication bias is identified).

Statistical Analysis

Analyses were conducted in R v3.3.1. using the ‗metafor‘ package.

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Power analysis. Based on a-priori power analysis82, meta-analyses and sensitivity analyses

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were performed if at least four studies contributed to the pooled effect size and total pooled

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samples ≥ 300.

Calculating treatment effect. Corrected Hedges’ g (g)64, a standardized mean difference

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measure, was used as a measure of effect size. Effect sizes were calculated using means and
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standard deviations where possible; otherwise, effect sizes were derived from test statistics

(for details see protocol82). The main hypothesis tests were performed using the effect size of
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psychosocial interventions in general. In addition, effect sizes for each intervention type were

calculated to provide critical information regarding the efficacy of specific psychosocial

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interventions for orthopedic postoperative pain.

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Main analyses. Due to expected heterogeneity across studies and multiple study arms, a

multilevel random-effect meta-analysis was used to estimate pooled effect sizes and 95%
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confidence intervals. Heterogeneity was assessed using the Q, and I2 statistics. A sensitivity

analysis was conducted on the following data subsets: (1) different follow-up time points
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(Table 1), (2) studies involving only joint replacement surgeries, (3) low risk of bias studies,

and (4) dataset with influential cases omitted.

Moderator analysis. Meta-regressions were conducted for each outcome using the following

predictors and groupings: (1) type of the psychological intervention (patient education,

cognitive behavioral interventions, relaxation techniques, hypnosis, therapeutic suggestion

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interventions, emotion-focused interventions, or combined interventions),(2) timing of

psychological intervention (intervention performed before or during surgery only vs.

interventions having post-surgery components as well), (3) purely elective surgery studies vs.

studies involving acute surgeries, and (4) studies only including patients undergoing major

surgery vs. studies involving minor surgery patients as well. Lack of reporting prevented the

use of anesthesia type as a predictor. Categorical moderator levels were included only if they

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were represented in at least two studies. Influence of Cochrane risk of bias (the effect of low

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bias vs. unclear or high bias in each of the Cochrane risk of bias categories) and zero

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imputation (whether it was used or not) were also tested with meta-regressions. All sensitivity

analyses and meta-regressions were specified a priori.82

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Results

As shown in Figure 1, 89 research reports fit the inclusion criteria.1-4,6,7,9,12,15-17,19-

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21,24,25,27,29,32,34-37,3-43,47,49-55,57,58,60,67,71,73,75,77,78,90,92-94,97,98,100-112,105,107,108,111-112,114-118,124-

126,128,129,132,134,135,137-140,143,145,146,149-152,155-159
Studies excluded after the full-text review are
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listed in Supplement 3. Study characteristics of RCT‘s are displayed in Table 2, while those

of non-RCTs‘ are shown in Supplement 4. Details about the participant characteristics, the
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content and delivery of the interventions and control conditions are listed in Supplement 5.
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Supplement 6 lists the conflict of interests and funders of each study.

Of the eligible studies, 1 assessed hypnosis, 40 patient education, 15 relaxation

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techniques, 3 therapeutic suggestions, and 19 cognitive or behavioral interventions. Thirteen

studies assessed a combination of the above methods.

Main effects and moderating factors

Sixty-six of the eligible research reports were RCTs, 62 of which had outcome data in

the time period of interest, while 23 studies were non-RCTs. The meta-analysis was restricted

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to RCTs only to improve reliability of the findings. There were 48 original journal articles, 13

dissertations, and one unpublished research report used for the meta-analysis. Among these

studies, 26 used patient education, 15 cognitive or behavioral techniques, 11 relaxation

techniques, 3 therapeutic suggestions, and 8 some combination of these as psychological

interventions. Seven studies examined the effects in multiple intervention groups (6 had 3

groups, 1 had 4 groups). All the others had one intervention group and one control group.

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Most of the control groups received treatment as usual (52 studies), six of the control groups

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got placebo, while 4 got increased attention. The results of the main meta-analysis are

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summarized in Figures 2-7. Supplement 7 provides the detailed test and heterogeneity

statistics for the meta-analysis on the complete dataset and subgroup analyses. The results of

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the moderator analyses are shown in Supplement 8. A narrative description of the results of
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the eligible non-randomized controlled studies are included in Supplement 9.

Postoperative pain. Psychosocial interventions significantly reduced postoperative

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pain (g = 0.31 [95% confidence interval: 0.14, 0.48], pooled N = 2750, GRADE rating: ―low

quality evidence‖) (Figure 2). Results were robust across all sensitivity analyses including all
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follow-up time ranges. Pain reduction was also significant in the subset of studies involving
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joint replacement surgery patients (g = 0.23 [0.07, 0.38], pooled N = 1639, GRADE rating:

―low quality‖). Heterogeneity was substantial (I2 = 60.31%) and was not considerably
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reduced by including the planned moderators in the model (I2 change = -13.27%) indicating

that surgical and intervention characteristics were not influential for postoperative pain
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reduction. This conclusion is further supported by the lack of significance of the likelihood

test, and model fit indices. Nevertheless, pain reductions were significantly moderated by

surgery electiveness; larger pain reductions were reported in studies involving acute surgeries

(β = 0.58, p < 0.026). Subset analyses for intervention type provided further support for the

effectiveness of patient education (g = 0.21 [0.02, 0.39], pooled N = 1242, GRADE rating:

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―low quality‖) and relaxation techniques (g = 0.45 [0.11, 0.79], pooled N = 473, GRADE

rating: ―low quality‖) in reducing postoperative pain.

Analgesic use. Psychosocial interventions did not show statistically significant effects

for analgesic use in the main meta-analysis (g = 0.16 [-0.01, 0.32], pooled N = 1521, GRADE

rating: ―not enough evidence‖) (Figure 3) or in the planned sensitivity analyses. Electiveness

of surgery was a significant moderating factor: psychosocial interventions significantly

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decreased analgesic use in acute surgeries compared to elective. However, this finding is

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based on limited evidence (i.e. two studies).

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Preoperative anxiety. Overall, psychosocial interventions reduced preoperative

anxiety (g = 0.26 [0.11, 0.42], pooled N = 1699, GRADE rating: ―moderate quality‖) (Figure

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4). In addition, subset analyses showed preoperative anxiety was significantly reduced in
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joint replacement surgeries (g = 0.27 [0.04, 0.5], pooled N = 1091, GRADE rating: ―low

quality‖) and on the day of the operation time-point (g = 0.40 [0.21, 0.58], pooled N = 1112,
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GRADE rating: ―moderate quality‖), but not on earlier measurement points. Heterogeneity

was negligible in the dataset (I2 = 0%), and the model including moderators was not
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significantly better than the reduced model. The most promising intervention for preoperative
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anxiety is patient education (g = 0.27 [0.10, 0.44], pooled N = 1260, GRADE rating:

―moderate quality‖).
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Postoperative anxiety. Psychosocial interventions significantly reduced

postoperative anxiety (g = 0.40 [0.21, 0.59], pooled N = 2110, GRADE rating: ―very low
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quality‖) (Figure 5). The size of the effect was very similar for all follow-up time ranges.

However, these reductions were not significant when assessed in joint replacement surgeries

only (g = 0.17 [-0.02, 0.35], pooled N = 1102, GRADE rating: ―not enough evidence‖).

Residual heterogeneity was significantly reduced from 62.79% to I2 = 8.51% when all

moderators were included in the model. Anxiety reduction was higher in acute surgery

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patients compared to elective surgeries (β = 0.89, p < 0.001). When analyzed separately,

patient education and relaxation techniques significantly reduced postoperative anxiety, with

the former showing a consistent small effect (I2 = 0%, g = 0.26 [0.08, 0.43], pooled N = 921,

GRADE rating: ―very low quality‖), while the latter had a larger, but more heterogeneous

effect (I2 = 74.01%, g = 0.69 [0.23, 1.15], pooled N = 403, GRADE rating: ―very low

quality‖).

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Quality of life. No evidence was found for significant improvements in quality of life

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either in the full dataset (g = 0.14 [-0.05, 0.33], pooled N = 1026, GRADE rating: ―not

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enough evidence‖) (Figure 6) or in any of the subgroup analyses. There was no substantial

heterogeneity (I2 = 18.7%), and the inclusion of moderators did not significantly improve the

model. US
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Recovery. Patients receiving psychosocial interventions showed significantly better

recovery compared to controls overall (g = 0.38 [0.22, 0.54], pooled N = 3315, GRADE
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rating: ―low quality‖) (Figure 7), and in joint replacement surgeries only (g = 0.18 [0.06,

0.31], pooled N = 1839, GRADE rating: ―low quality‖). Recovery was significantly
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improved at each follow-up time point, with increasing effects after the first two

postoperative weeks. One study15 was identified as an influential outlier with a Cook‘s
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distance of 0.77 and effect size of 3.74 [2.85, 4.63]. If excluded, heterogeneity decreased
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from I2 = 62.62% to I2 = 28.82%, and the pooled estimate of the effect size changed from

0.38 [0.22, 0.54] to 0.31 [0.19, 0.42]. There were no significant moderators for this outcome.
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The effectiveness of cognitive or behavioral interventions (g = 0.47 [0.25, 0.69], pooled N =

816, GRADE rating: ―low quality‖) and relaxation techniques (g = 0.59 [0.11, 1.08], pooled

N = 1655, GRADE rating: ―low quality‖) were supported.

Non-RCTs. The narrative review of non-RCTs assessing psychosocial interventions

also demonstrated a consistent beneficial effect on pain and recovery. Evidence from non-

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RCTs indicated a variable but positive effect of psychosocial interventions on postoperative

anxiety. There was no consistent support for the effects of psychosocial interventions on

analgesic consumption or quality of life. One eligible non-RCT assessed preoperative anxiety

but did not report an effect. (For details see Supplement 9.)

Risk of bias

Significantly less risk for bias was identified in RCTs compared to eligible non-RCTs

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in all Cochrane risk of bias categories except selective reporting (χs2 > 4.76, ps < 0.029).

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Figure 8 summarizes the results of the Cochrane risk of bias assessment among RCTs (study-

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by-study ratings are displayed in Supplement 10). The highest risk occurred in blinding of

personnel and outcome assessors. In addition, only 50% of the RCTs adequately reported

randomization procedures. US
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High or unclear risk of blinding of outcome assessors had a significant influence on

postoperative analgesic requirement (β = 0.53, p = 0.024), and recovery (β = -0.4, p = 0.005).

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Inadequate randomization and selective reporting negatively influenced the effects of

postoperative anxiety, β = -0.53, p = 0.010, and β = -0.50, p = 0.002, respectively. The main
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effect for recovery was not significant when high risk studies were excluded from the
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analysis (g = 0.23 [-0.07, 0.53]). This type of sensitivity analysis was not possible for all

outcomes due to a limited number of studies achieving a low risk of bias rating.
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Indications for publication bias were found using Begg and Muzumdar rank

correlation and Egger tests and funnel plots, for analgesic use, postoperative anxiety, quality
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of life and recovery (Supplement 11-16). However, trim and fill estimates matched

uncorrected estimates for all outcomes, indicating that the effect of publication bias was

minimal.

Zero imputation had no significant effect on the pooled effect size in any of the

outcomes.

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Quality of evidence

We found that psychological interventions probably decrease preoperative anxiety.

The quality of evidence for this outcome is rated as moderate because a significant number of

studies assessing preoperative anxiety, had a high or unclear risk of bias. Our results also

suggest that psychological techniques might decrease postoperative pain, and improve

recovery, but the quality of evidence was rated as low due to risk of bias in study designs and

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substantial heterogeneity of effects (pain), and risk of reporting bias (recovery). The largest

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positive effect of psychological interventions was found on postoperative anxiety, but our

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effect estimates are very uncertain because of significant risk of bias in study designs,

possible publication bias and heterogeneity of effects across studies, thus, quality of evidence

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in the case of this outcome was rated as very low. There is not enough evidence to support
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the use of psychological interventions to improve quality of life or decrease analgesic use.
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Discussion
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Summary of evidence
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Pain management is a primary concern for physicians and patients. Adequate pain

management is crucial to achieve good clinical outcomes, appropriate recovery and to

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improve patient satisfaction. Clinical care may be improved through introducing innovative

non-pharmacological techniques in order to supplement pharmacological approaches and

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meet the need for more efficient patient care in orthopedic surgeries. Because of the high

incidence of pain and anxiety and importance of early mobilization in orthopedic surgeries, it

is imperative to find effective treatments that will improve patient outcomes. Psychosocial

interventions show promise, but knowledge on their effectiveness for orthopedic

postoperative pain and perioperative anxiety is lacking. This review expands the knowledge

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base and highlights the need for more methodologically rigorous studies in this high priority

area. Through the inclusion of multiple types of orthopedic surgeries, various psychological

interventions and delivery time points, this review expands on findings from previous meta-

analyses and reviews.11,76,96,104,120 Findings from this meta-analysis may be used to inform

future studies of psychological interventions in orthopedic surgery and improve patient care.

The meta-analysis of 62 RCTs demonstrated that psychosocial interventions

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decreased postoperative pain and both pre- and postoperative anxiety, and enhanced

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recovery, but had no significant effect on analgesic use and quality of life. Electiveness of

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surgery was a statistically significant moderator of effectiveness (e.g. pain, analgesic use,

anxiety). Type of surgery (major vs minor) and timing of interventions did not moderate

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effects. Compared with a previous orthopedic surgery meta-analysis104, this meta-analysis
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expands the current knowledge base by including preoperative measures, long-term recovery

outcomes, and several types of psychological interventions.

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Similar to previous systematic reviews76,120, findings from this study demonstrate the

effectiveness of psychosocial interventions in reducing postoperative pain, anxiety, and

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enhancing recovery, yet the quality of evidence was low, mainly because of poor study
PT

design and high heterogeneity of effects. In contrast to a recent meta-analysis of

psychological interventions for post surgical outcomes120, this review included studies that
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delivered interventions at multiple time points on acute and elective orthopedic surgeries.

Postoperative pain was significantly reduced, yet decrease in analgesic use was not
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statistically significant. The confidence interval for the effect size of decreased analgesic use

narrowly included zero, which might hint at the presence of an effect. Nevertheless, if there is

an effect, it is probably very small when looking at all psychological interventions and

surgery types combined. There are several possible explanations for these seemingly

contradictory results. Subjective pain reports and analgesic consumption are not perfectly

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related and are influenced by different predictors to a different extent.68,70 For example,

psychosocial interventions may decrease pain intensity and pain reporting by alleviating

anxiety, but not pain anticipation. High pain anticipation may lead to more analgesic use.95 In

addition, subjective reports of pain may be influenced by demand characteristics that lead to

under-reporting, while external factors, such as nurse availability or protocol-based

medication therapy, may influence analgesic consumption.122

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In contrast, Johnston and Vögele76 found that psychosocial interventions reduced

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analgesic use. However, the methods used in this study are now considered outdated. Our

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study pool for analgesic use was also considerably smaller resulting in lower statistical

power, which might also lead to the borderline significance. Future studies with higher power

US
might resolve this inconsistency. In addition, our study pool assessing analgesic use also
AN
mainly contained elective surgeries. The moderator analysis suggests that psychosocial

interventions may be more effective in acute surgeries. Therefore, the statistically non-
M

significant result for analgesic use may not be reflective of all surgeries (e.g. acute vs.

elective).
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Electiveness of surgery was a statistically significant predictor in three outcomes:

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postoperative pain, analgesic use, and postoperative anxiety. In all cases, effectiveness was

higher in acute surgeries, implying, that electiveness of surgery was an important predictor
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for more immediate surgical side effects, but not for long term outcomes. One possible

explanation for this effect is that patients with unexpected surgeries have higher baseline
AC

anxiety and pain scores, therefore the interventions have a greater impact. There was

evidence for significant benefit in preoperative anxiety on the day of surgery, but floor effects

may have masked these effects at earlier measurement points when anxiety is not as high.

Results of the joint replacement subset mirrored those of the total dataset, with

statistically significant reductions in pain and preoperative anxiety, and improvement in

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recovery. However, postoperative anxiety reduction was only nearly significant in this data

subset. Severe postoperative pain, possible late surgical complications, like infections,

implantation luxation, or loosening and unrealistic expectations about the speed of recovery

may result in patients‘ anxiety levels remaining high for months post-surgery.

Our study provided evidence for the use of relaxation, patient education and cognitive

or behavioral intervention as adjuncts to orthopedic surgery. Though previous reviews on

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joint replacement surgeries implied that patient education only decreases preoperative

IP
anxiety11,104, this meta-analysis found a statistically significant effect for postoperative pain

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and anxiety. Prior studies might have been unsuccessful in detecting these effects because

they were restricted to hip and knee replacement surgeries only. For total hip and knee

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replacement there is a lot of easily accessible information for the patients, (e.g. Internet),
AN
therefore high baseline knowledge might have masked the effects of the intervention.

In line with previous non-orthopedic studies22,59,66,89,123, relaxation techniques reduced

M

postsurgical pain and anxiety, and improved recovery. Cognitive or behavioral interventions

were effective in improving recovery and showed strong yet non-significant effects on quality
ED

of life. This may indicate that cognitive or behavioral interventions are more effective in
PT

improving long term outcomes. Further evidence is needed to support this observation.

For most outcomes, moderators (i.e. intervention type and timing, electiveness and
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severity of surgery) substantially decreased heterogeneity. However, for postoperative pain

reduction, further sources of heterogeneity need to be explored, such as method of analgesic

AC

delivery, availability of physiotherapists, and psychological and demographic factors.

In this paper we aimed to answer the question whether adding psychological

interventions to standard orthopedic procedures can have beneficial effects, and if so, what

are these beneficial effects. It needs to be acknowledged that psychological interventions are

very heterogeneous, and sometimes can have very different proposed mechanisms of action.

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Thus, we also provided effect size estimates for each intervention type separately, and drew

conclusions related to the specific interventions that are most supported for use in orthopedic

surgery by data accumulated thus far. Nevertheless, it is also important to realize that it has

long been suspected that a large component of the treatment effect of psychological

interventions such as psychotherapies are derived from nonspecific factors that are common

among many different treatment modalities87,131. Thus, it is meaningful to think about the

T
level of increase in quality of care by adding psychological interventions in general. This

IP
information can be useful to physicians, healthcare stakeholders, and policy makers alike, and

CR
may guide decisions such as whether to employ psychologists to support orthopedic

surgeries, or whether to encourage trainings that empower hospital staff to use psychological

tools around orthopedic procedures. US

AN
Limitations

This study was powered to detect medium sized main effects. The low number of
M

studies available for each intervention subtype resulted in an underpowered moderator

analysis, preventing the ranking of interventions for comparison. The overall conclusions are
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limited by the low quality of evidence of the published studies. The main issue that
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negatively impacted quality of evidence was risk of methodological bias, one especially

influential factor being lack of blinding, which can lead to researcher and subject expectancy
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(placebo) effects. Even though low methodological quality is concerning, for several

outcomes we found, that low quality studies actually had lower effect sizes. One possible
AC

explanation for this unexpected phenomenon is that the most effective interventions were

designed by experienced investigators who conducted the highest quality studies.

Nevertheless, higher design quality studies are required to increase certainty about the size of

the intervention effects. A further limitation was that anesthesia type could not be evaluated

due to the lack of reported information.

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Conclusions

The current analysis revealed encouraging findings regarding the effects of

psychosocial interventions on postoperative pain and related outcomes such as anxiety and

recovery, warranting future clinical investigations to improve researcher‘s confidence in the

size of the effects. More well powered high-quality studies are needed. The effects of

psychosocial interventions are most consistent on decreasing preoperative anxiety. Evidence

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supports the use of patient education to decrease postoperative pain, pre- and postoperative

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anxiety, relaxation techniques to ameliorate postsurgical pain and anxiety, and improve

CR
recovery, and cognitive or behavioral interventions to improve recovery.

US
AN
M
ED
PT
CE
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References

1. Abramson H: The effectiveness of communication skills training for older orthopedic

patients [PhD dissertation]. Memphis: University of Memphis, 1998

2. Achterberg J, Kenner C, Casey D: Behavioral strategies for the reduction of pain and

anxiety associated with orthopedic trauma. Biofeedback and self-regulation 14:101-114,

T
1989

IP
3. Akhavan J: The effect of a dyadic intervention on self-efficacy, physical functioning and

CR
anxiety in older adults post joint replacement surgery [PhD dissertation]. Los Angeles:

UCLA, 2008

US
4. Alexander GP: The effects of personalized information upon the recovery of surgical

patients [PhD dissertation]. East Lansing: Michigan State University, 1982

AN
5. American Society of Anesthesiologists Task Force on Acute Pain Management: Practice

guidelines for acute pain management in the perioperative setting: an updated report by
M

the American Society of Anesthesiologists Task Force on Acute Pain Management.

ED

Anesthesiology 116:248-273, 2012

6. Andiric LR: Patient education and involvement in care [PhD dissertation]. Jacksonville:
PT

University of North Flordia, 2011

7. Antall GF, Kresevic D: The use of guided imagery to manage pain in an elderly
CE

orthopaedic population. Orthopaedic Nursing 23:335-340, 2004

AC

8. Apfelbaum JL, Chen C, Mehta SS, Gan TJ: Postoperative pain experience: Results from a

national survey suggest postoperative pain continues to be undermanaged. Anesth Analg

97:534-540, 2003

9. Appler FL: The effects of training surgery patients to self-regulate stress [PhD

dissertation]. San Diego: California School of Professional Psychology, 1982

23
 ACCEPTED MANUSCRIPT

10. Australia Orthopaedic Association National Joint Replacement Registry: annual report,

Adelaide, Australian Orthopaedic Association, 2012 Available at:

https://aoanjrr.dmac.adelaide.edu.au. Accessed June 15, 2017

11. Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H: No major effects of preoperative

education in patients undergoing hip or knee replacement-A systematic review. Dan Med

J 62:A5106, 2015

T
12. Ayral X, Gicquere C, Duhalde A, Boucheny D, Dougados M: Effects of video

IP
information on preoperative anxiety level and tolerability of joint lavage in knee

CR
osteoarthritis. Arthritis Care Res 47:380-382, 2002

13. Beck AT, Haigh EA: Advances in cognitive theory and therapy: The generic cognitive

model. Annu Rev Clin Psychol 10:1–24, 2014 US

AN
14. Begg CB, Mazumdar M: Operating characteristics of a rank correlation test for

publication bias. Biometrics 50:1088-1101, 1994

M

15. Bellelli G, Buccino G, Bernardini B, Padovani A, Trabucchi M: Action observation

treatment improves recovery of postsurgical orthopedic patients: Evidence for a top-down

ED

effect?. Arch Phys Med Rehabil 91:1489-1494, 2010

PT

16. Berge DJ, Dolin SJ, Williams AC, Harman R: Pre-operative and post-operative effect of a

pain management programme prior to total hip replacement: A randomized controlled

CE

trial. Pain 110:33-39, 2004

17. Berger RS: The effect of stress inoculation training on athletes' anxiety, pain and return to
AC

functioning during rehabilitation from orthopedic injury [PhD dissertation]. Saint Louis:

Saint Louis University, 1992

18. Bertholf L: Clinical pathways from conception to outcome. Topics in health information

management 19:30-34, 1998

24
 ACCEPTED MANUSCRIPT

19. Best JK: Reducing the length of hospital stay and facilitating the recovery process of

orthopedic surgical patients through crisis intervention and pastoral care [PhD

dissertation]. Evanston: Northwestern University, 1981

20. Biau DJ, Porcher R, Roren A, Babinet A, Rosencher N, Chevret S, Poiraudeau S, Anract

P: Neither pre-operative education or a minimally invasive procedure have any influence

on the recovery time after total hip replacement. Int Orthop 39:1475-1481, 2015

T
21. Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ: The effect of anesthetic patient

IP
education on preoperative patient anxiety. Reg Anesth Pain Med 24:158-164, 1999

CR
22. Broadbent E, Kahokehr A, Booth RJ, Thomas J, Windsor JA, Buchanan CM, Wheeler

BR, Sammour T, Hill AG: A brief relaxation intervention reduces stress and improves

US
surgical wound healing response: A randomised trial. Brain Behav Immun 26:212-217,
AN
2012

23. Bucx MJ, Krijtenburg P, Kox M: Preoperative use of anxiolytic-sedative agents; Are we
M

on the right track? J Clin Anesth 33:135-140, 2016

24. Burns A, Banerjee S, Morris J, Woodward Y, Baldwin R, Proctor R, Tarrier N, Pendleton

ED

N, Sutherland D, Andrew G, Horan M: Treatment and prevention of depression after

PT

surgery for hip fracture in older people: Randomized, controlled trials. J Am Geriatr Soc

55:75-80, 2007
CE

25. Butler GS, Hurley CA, Buchanan KL, Smith-VanHorne J: Prehospital education:

effectiveness with total hip replacement surgery patients. Patient Educ Couns 29:189-197,
AC

196

26. Castillo RC, Raja SN, Frey KP, Vallier HA, Tornetta III P, Jaeblon T, Goff BJ,

Gottschalk A, Scharfstein DO, O'Toole RV: Improving Pain Management and Long-

Term Outcomes Following High-Energy Orthopaedic Trauma (Pain Study). J Orthop

Trauma 31:S71-S77, 2017

25
 ACCEPTED MANUSCRIPT

27. Ceccio CM: Postoperative pain relief through relaxation in elderly patients with fractured

hips. Orthop Nurs 3:11-19, 1984

28. Chan EY, Blyth FM, Nairn L, Fransen M: Acute postoperative pain following hospital

discharge after total knee arthroplasty. Osteoarthritis and Cartilage 21:1257-1263, 2013

29. Chen SR, Chen CS, Lin PC: The effect of educational intervention on the pain and

rehabilitation performance of patients who undergo a total knee replacement. J Clin Nurs

T
23:279-287, 2014

IP
30. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, Carter

CR
T, Cassidy CL, Chittenden EH, Degenhardt E, Griffith S, Manworren R, McCarberg B,

Montgomery R, Murphy J, Perkal MF, Suresh S, Sluka K, Strassels S, Thirlby R, Viscusi

US
E, Walco GA, Warner L, Weisman SJ, Wu CL: Management of Postoperative Pain: a
AN
clinical practice guideline from the American pain society, the American Society of

Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists'
M

committee on regional anesthesia, executive committee, and administrative council. J

Pain 17:131-157, 2016

ED

31. Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg

PT

85:808-816, 1997

32. Clari M, Frigerio S, Ricceri F, Pici A, Alvaro R, Dimonte V: Follow-up telephone calls to
CE

patients discharged after undergoing orthopaedic surgery: double-blind, randomised

controlled trial of efficacy. J Clin Nurs 24:2736-2744, 2015

AC

33. Clarke TC, Nahin RL, Barnes PM, Stussman, BJ: Use of complementary health

approaches for musculoskeletal pain disorders among adults: United States, 2012.

National health statistics reports 98:1-12, 2016

26
 ACCEPTED MANUSCRIPT

34. Clode-Baker E, Draper E, Raymond N, Haslam C, Gregg P: Preparing patients for total

hip replacement: A randomized controlled trial of a preoperative educational

intervention. J Health Psychol 2:107-114, 1997

35. Cooke M, Walker R, Aitken LM, Freeman A, Pavey S, Cantrill R: Pre-operative self-

efficacy education vs. usual care for patients undergoing joint replacement surgery: A

pilot randomised controlled trial. Scand J Caring Sci 30:74-82, 2016

T
36. Cupal DD, Brewer BW: Effects of relaxation and guided imagery on knee strength,

IP
reinjury anxiety, and pain following anterior cruciate ligament reconstruction. Rehabil

CR
Psychol 46:28-43, 2001

37. Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH: Preoperative education for total

US
hip and knee replacement patients. Arthritis Rheum 11:469-478, 1998
AN
38. Datamonitor: Epidemiology: Major orthopedic surgery. 2011. Available at:

http://store.datamonitorhealthcare.com/Product/toc.aspx?productId=HC00119-001.
M

Accessed February 15, 2016

39. Diaz M, Larsen B: Preparing for successful surgery: An implementation study. Perm J
ED

9:23-27, 2005
PT

40. Doering S, Behensky H, Rumpold G, Schatz DS, Rössler S, Hofstötter B, Schüssler, G:

Videotape preparation of patients before hip replacement surgery improves mobility after
CE

three months. Zeitschrift fur Psychosomatische Medizin und Psychotherapie 47:140-152,

2000
AC

41. Doering S, Katzlberger F, Rumpold G, Roessler S, Hofstoetter B, Schatz DS, Behensky

H, Krismer M, Luz G, Innerhofer P, Benzer H: Videotape preparation of patients before

hip replacement surgery reduces stress. Psychosom Med 62:365-373, 2000

42. Douglas TS, Mann NH, Hodge AL: Evaluation of preoperative patient education and

computer-assisted patient instruction. J Spinal Disord Tech 11:29-35, 1998

27
 ACCEPTED MANUSCRIPT

43. Durso-Cupal D: The efficacy of guided imagery for recovery from anterior cruciate

ligament (ACL) replacement [PhD dissertation]. Utah: Utah State University, 1997

44. Elkins GR, Barabasz AF, Council JR, Spiegel D: Advancing research and practice: the

revised APA Division 30 definition of hypnosis. Int J Clin Exp Hypn 63:1-9, 2015

45. Ellis HB, Howard KJ, Khaleel MA, Bucholz R: Effect of psychopathology on patient-

perceived outcomes of total knee arthroplasty within an indigent population. J Bone Joint

T
Surg Am 94:e84, 2012

IP
46. Etzioni DA, Liu JH, Maggard MA, Ko CY: The aging population and its impact on the

CR
surgery workforce. Ann Surg 238:170–177, 2003

47. Farlinger SP: An educational intervention to decrease pain following ambulatory

US
orthopedic surgery [PhD dissertation]. Kingston: Queen‘s University, 2001
AN
48. Fingar KR, Stocks C, Weiss AJ, Steiner CA: Most frequent operating room procedures

performed in US hospitals, 2003–2012: Statistical Brief# 186. 2006

M

49. Forward JB, Greuter NE, Crisall SJ, NP-C P, Lester HF: Effect of structured touch and

guided imagery for pain and anxiety in elective joint replacement patients—A
ED

randomized controlled trial: M-TIJRP. Perm J 19:18-28, 2015

PT

50. Fraval A, Chandrananth J, Chong YM, Tran P, Coventry LS: Internet based patient

education improves informed consent for elective orthopaedic surgery: A randomized

CE

controlled trial. BMC Musculoskelet Disord 16:14, 2015

51. Friesner SA, Curry DM, Moddeman GR: Comparison of two pain-management strategies
AC

during chest tube removal: Relaxation exercise with opioids and opioids alone. Heart

Lung 35:269–276, 2006

52. Frost KL: Influence of a motivational exercise counseling intervention on rehabilitation

outcomes in individuals with arthritis who received total hip replacement [PhD

dissertation]. Pittsburgh: University of Pittsburgh, 2004

28
 ACCEPTED MANUSCRIPT

53. Gambatesa M, D‘Ambrosio A, D‘Antini D, Mirabella L, De Capraris A, Iuso S, Bellomo

A, Macchiarola A, Dambrosio M, Cinnella, G: Counseling, quality of life, and acute

postoperative pain in elderly patients with hip fracture. J Multidiscip Healthc 6:335-346,

2013

54. Gammon J, Mulholland CW: Effect of preparatory information prior to elective total hip

replacement on post-operative physical coping outcomes. Int J Nurs Stud 33:589-604,

T
1996

IP
55. Gammon J, Mulholland CW: Effect of preparatory information prior to elective total hip

CR
replacement on post-operative physchological coping outcomes. J Adv Nurs 24:303-308,

1996

US
56. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL: Incidence, patient satisfaction,
AN
and perceptions of post-surgical pain: results from a US national survey. Curr Med Res

Opin 30:149-60, 2014

M

57. Gavin M, Litt M, Khan A, Onyiuke H, Kozol R: A prospective, randomized trial of

cognitive intervention for postoperative pain. Am Surg 72:414-418, 2006

ED

58. Giraudet-Le Quintrec J, Coste J, Vastel L, Pacault V, Jeanne L, Lamas J, Courpied, J:

PT

Positive effect of patient education for hip surgery: a randomized trial. Clin Orthop Relat

Res 1:112-120, 2003

CE

59. Gonzales EA, Ledesma RJA, McAllister DJ, Perry SM, Dyer CA, Maye JP: Effects of

guided imagery on postoperative outcomes in patients undergoing same-day surgical

AC

procedures: A randomized, single-blind study. AANA Journal 78:181–188, 2010

60. Grondin F, Bourgault P, Bolduc N: Intervention focused on the patient and family for

better postoperative pain relief. Pain Manag Nurs 15:76-86, 2014

29
 ACCEPTED MANUSCRIPT

61. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P,

Sch ̈ nemman HJ: GRADE: an emerging consensus on rating quality of evidence and

strength of recommendations. BMJ 336:924-926, 2008

62. Hamilton TW, Strickland LH, Pandit HG: A meta-analysis on the use of gabapentinoids

for the treatment of acute postoperative pain following total knee arthroplasty. J Bone

Joint Surg Am 98:1340-1350, 2016

T
63. Hanusch BC, O'Connor DB, Ions P, Scott A, Gregg PJ: Effects of psychological distress

IP
and perceptions of illness on recovery from total knee replacement. Bone Joint J 96:210-

CR
216, 2014

64. Hedges LV: Distribution theory for Glass's estimator of effect size and related estimators.

J Educ Behav Stat 6:107-128, 1981 US

AN
65. Higgins JPT, Altman DG, Sterne JAC: Assessing risk of bias in included studies. In:

Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions.
M

Version 5.1.0. The Cochrane Collaboration: www.cochrane-handbook.org 2008:187-241,

2011
ED

66. Holden-Lund C: Effects of relaxation with guided imagery on surgical stress and wound
PT

healing. Res Nurs Health 11:235-244, 1988

67. Hørdam B, Sabroe S, Pedersen PU, Mejdahl S, Søballe K: Nursing intervention by

CE

telephone interviews of patients aged over 65 years after total hip replacement improves

health status: A randomised clinical trial. Scand J Caring Sci 24:94-100, 2010
AC

68. Ip HYV, Abrishami A, Peng PW, Wong J, Chung F: Predictors of postoperative pain and

analgesic consumption. A qualitative systematic review. Anesthesiology 111:657-677,

2009

30
 ACCEPTED MANUSCRIPT

69. Jackson T, Tian P, Wang Y, Iezzi T, Xie W: Toward identifying moderators of

associations between presurgery emotional distress and postoperative pain outcomes: a

meta-analysis of longitudinal studies. J Pain 17:874-888, 2016

70. Jacobsen PB, Butler RW: Relation of cognitive coping and catastrophizing to acute pain

and analgesic use following breast cancer surgery. J Behav Med 19:17-29, 1996

71. Jacobson AF, Umberger WA, Palmieri PA, Alexander TS, Myerscough RP, Draucker

T
CB, Steudte-Schmiedgen S, Kirschbaum C: Guided imagery for total knee replacement:

IP
A randomized, placebo-controlled pilot study. J Altern Complement Med 22:563-575,

CR
2016

72. Janzen JA: Coping with anxiety while waiting for surgery [PhD dissertation]. Regina:

University of Regina, 2007 US

AN
73. Jensen MP, Adachi T, Tome-Pires C, Lee J, Osman ZJ, Miro J: Mechanisms of hypnosis:

toward the development of a biopsychosocial model. Int J Clin Exp Hypn 63:34-75, 2015
M

74. Jeschke E, Gehrke T, Günster C, Hassenpflug J, Malzahn J, Niethard FU, Schr ̈ der P,

Zacher J, Halder A: Five-year survival of 20,946 unicondylar knee replacements and

ED

patient risk factors for failure. J Bone Joint Surg Am 98:1691-1698, 2016
PT

75. Johansson K, Salanterä S, Katajisto J: Empowering orthopaedic patients through

preadmission education: results from a clinical study. Patient Educ Couns 66:84-91, 2007
CE

76. Johnston M, Vögele C: Benefits of psychological preparation for surgery: A meta-

analysis. Ann Behav Med 15:245, 1993

AC

77. Jones D, Duffy ME, Flanagan J: Randomized clinical trial testing efficacy of a nurse-

coached intervention in arthroscopy patients. Nurs Res 60:92-99, 2011

78. Jones S, Alnaib M, Kokkinakis M, Wilkinson M, Gibson ASC, Kader D: Pre-operative

patient education reduces length of stay after knee joint arthroplasty. Ann R Coll Surg

Engl 93:71-75, 2010

31
 ACCEPTED MANUSCRIPT

79. Kagan I, Bar-Tal Y: The effect of preoperative uncertainty and anxiety on short-term

recovery after elective arthroplasty. J Clin Nurs 17:576-583, 2008

80. Kehlet H, Dahl JB: Anaesthesia, surgery, and challenges in postoperative recovery.

Lancet 362:1921-1928, 2003

81. Kehlet H, Jensen TS, Woolf CJ: Persistent postsurgical pain: risk factors and prevention.

Lancet 367:1618-1625, 2006

T
82. Kekecs Z, Szeverenyi C, Johnson AJ, Elkins G, Csernatony Z, Varga K: The

IP
effectiveness of psychosocial interventions as adjuncts to orthopaedic surgery: A

CR
systematic review protocol. Musculoskeletal Care 15:69-78, 2017

83. Kekecs Z, Varga K: Positive suggestion techniques in somatic medicine: A review of the

US
empirical literature. Interv Med Appl Sci 5:101-111, 2013
AN
84. Khatib Y, Madan A, Naylor JM, Harris IA: Do psychological factors predict poor

outcome in patients undergoing TKA? A systematic review. Clin Orthop Relat Res
M

473:2630-2638, 2015

85. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R: Psychological
ED

influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol

PT

53:1209–1218, 1998

86. Kim S: Changes in surgical loads and economic burden of hip and knee replacements in
CE

the US: 1997–2004. Arthritis Care & Research 59:481-488, 2008

87. Kirsch I: Placebo psychotherapy: synonym or oxymoron?. Journal of clinical psychology

AC

61:791-803, 2005

88. 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 89:780-

785, 2007

32
 ACCEPTED MANUSCRIPT

89. Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, Logan H,

Spiegel D: Adjunctive non-pharmacological analgesia for invasive medical procedures: a

randomised trial. Lancet 355:1486-1490, 2000

90. Langford DP, Fleig L, Brown KC, Cho NJ, Frost M, Ledoyen M, Lehn J,

Panagiotopoulos K, Sharpe N, Ashe MC: Back to the future–feasibility of recruitment and

retention to patient education and telephone follow-up after hip fracture: A pilot

T
randomized controlled trial. Patient Prefer Adher 9:1343-1351, 2015

IP
91. Lavand'homme P, Thienpont E: Pain after total knee arthroplasty: a narrative review

CR
focusing on the stratification of patients at risk for persistent pain. Bone Joint J 97-

B(Suppl A 10):45-48, 2015

US
92. Lehrl S, Gusinde J, Schulz-Drost S, Rein A, Schlechtweg PM, Jacob H, Krinner S, Gelse
AN
K, Pauser J, Brem MH: Advancement of physical process by mental activation: A

prospective controlled study. J Rehabil Res Dev 49:1221-1228, 2012

M

93. Lilja Y, Rydén S, Fridlund B: Effects of extended preoperative information on

perioperative stress: An anaesthetic nurse intervention for patients with breast cancer and
ED

total hip replacement. Intensive Crit Care Nurs 14:276-282, 1998

PT

94. Lin PC: An evaluation of the effectiveness of relaxation therapy for patients receiving

joint replacement surgery. J Clin Nurs 21:601-608, 2012

CE

95. Logan DE, Rose JB: Is postoperative pain a self-fulfilling prophecy? Expectancy effects

on postoperative pain and patient-controlled analgesia use among adolescent surgical

AC

patients. J Pediatr Psychol 30:187-196, 2005

96. Louw A, Diener I, Butler DS, Puentedura EJ: Preoperative education addressing

postoperative pain in total joint arthroplasty: Review of content and educational delivery

methods. Physiother Theory Pract 29:175-194, 2013

33
 ACCEPTED MANUSCRIPT

97. Macchiaroli JM: Relationships between pre-operative education, patient self-efficacy,

patient anxiety, body mass index, and patient satisfaction of geriatric patients receiving

primary total hip or total knee arthroplasty [PhD dissertation]. Oakdale: Dowling College,

2012

98. Maddison R, Prapavessis H, Clatworthy M, Hall C, Foley L, Harper T, Cupal D, Brewer

B: Guided imagery to improve functional outcomes post-anterior cruciate ligament repair:

T
Randomized-controlled pilot trial. Scand J Med Sci Spor 22:816-821, 2012

IP
99. Majuta LA, Longo G, Fealk MN, McCaffrey G, Mantyh PW: Orthopedic surgery and

CR
bone fracture pain are both significantly attenuated by sustained blockade of nerve growth

factor. Pain 156:157-165, 2015

100. US
Mauer M: Medical hypnosis and orthopedic hand surgery: pain perception, post-
AN
operative recovery, and adherence [PhD Dissertation]. Coral Gables: University of

Miami, 1994
M

101. Mayer J, Bohn J, Görlich P, Eberspächer H: [Mental gait training--effectiveness of a

therapy method in the rehabilitation after hip-replacement]. Zeitschrift fur Orthopadie und
ED

ihre Grenzgebiete 143:419-423, 2004

PT

102. Mayich DJ, Tieszer C, Lawendy A, McCormick W, Sanders D: Role of patient

information handouts following operative treatment of ankle fractures: A prospective

CE

randomized study. Foot Ankle Int 34:2-7, 2013

103. McCartney CJ, Nelligan K: Postoperative pain management after total knee
AC

arthroplasty in elderly patients: Treatment options. Drugs & Aging 31:83-91, 2014

104. McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A: Preoperative education

for hip or knee replacement. The Cochrane Library, 2004

34
 ACCEPTED MANUSCRIPT

105. McGregor AH, Rylands H, Owen A, Doré CJ, Hughes SP: Does preoperative hip

rehabilitation advice improve recovery and patient satisfaction?. J Arthroplasty 19:464-

468, 2004

106. Mitchell M: General anesthesia and day-case patient anxiety. J Adv Nurs 66:1059-

1071, 2010

107. Monticone M, Ferrante S, Teli M, Rocca B, Foti C, Lovi A, Bruno MB: Management

T
of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar

IP
spondylolisthesis and stenosis. A randomised controlled trial. Eur Spine J 23:87-95, 2014

CR
108. Murphy S, Conway C, McGrath NB, O‘Leary B, O‘Sullivan MP, O‘Sullivan D: An

intervention study exploring the effects of providing older adult hip fracture patients with

US
an information booklet in the early postoperative period. J Clini Nurs 20:3404-3413, 2011
AN
109. Nelson FV, Zimmerman L, Barnason S, Nieveen J, Schmaderer M: The relationship

and influence of anxiety on postoperative pain in the coronary artery bypass graft patient.
M

J Pain Symptom Manage 15:102-109, 1998

110. Obalum DC, Fiberesima F, Eyesan SU, Ogo CN, Nzew C, Mijinyawa M: A review of
ED

obesity and orthopaedic surgery: the critical issues. Niger Postgrad Med J 19:175-180,
PT

2012

111. O'Connor MI, Brennan K, Kazmerchak S, Pratt J: YouTube videos to create a ―virtual
CE

hospital experience‖ for hip and knee replacement patients to decrease preoperative

anxiety: A randomized trial. Interact J Med Res 5:e10, 2016

AC

112. O'Halloran P, Sheilds N, Blackstock F, Wintle E, Taylor NF: Motivational

interviewing increases physical activity and self-efficacy in people living in the

community after hip fracture: A randomized controlled trial. Clin Rehabil 30:1108-1119,

2016

35
 ACCEPTED MANUSCRIPT

113. Oktay C, Eken C, Goksu E, Dora B: Contribution of verbal suggestion to the

therapeutic efficacy of an analgesic agent for acute primary headache. Cephalagia 35:

579–584, 2015

114. Osterbrink J, Evers G: The influence of nursing-measurements regarding incision pain

and the use of opioid in the post surgery phase [German]. Pflege 13:306-314, 2000

115. Parsons G: Exploring the experience of osteoarthritic patients awaiting hip and knee

T
arthroplasty: Informing and evaluating the effectiveness of a health maintenance

IP
intervention [PhD dissertation]. Bristol: University of West England, 2011

CR
116. Peebhoy D: The influence of psychological preparation on short- and long-term

recovery from surgery [PhD dissertation]. Liverpool: University of Liverpool, 2000

117. US
Pellino T, Tluczek A, Collins M, Trimborn S, Norwick H, Engelke ZK, Broad J:
AN
Increasing self-efficacy through empowerment: Preoperative education for orthopaedic

patients. Orthop Nurs 17:48-59, 1998

M

118. Pellino TA, Gordon DB, Engelke ZK, Busse KL, Collins MA, Silver CE, Norcross

NJ: Use of nonpharmacologic interventions for pain and anxiety after total hip and total
ED

knee arthroplasty. Orthop Nurs 24:182-190, 2005

PT

119. Pivec R, Johnson AJ, Mears SC, Mont MA: Hip arthroplasty. Lancet 380:1768–1777,

2012
CE

120. Powell R, Scott NW, Manyande A, Bruce J, Vögele C, Byrne-Davis LM, Unsworth

M, Osmer C, Johnston M: Psychological preparation and postoperative outcomes for

AC

adults undergoing surgery under general anaesthesia. The Cochrane Library, 2016

121. Puolakka PA, Rorarius MG, Roviola M, Puolakka TJ, Nordhausen K, Lindgren L:

Persistent pain following knee arthroplasty. Eur J Anaesthesiol 27:455-460, 2010

36
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122. Rejeh N, Ahmadi F, Mohammadi E, Kazemnejad A, Anoosheh M: Nurses'

experiences and perceptions of influencing barriers to postoperative pain management.

Scand J Caring Sci 23:274-281, 2009

123. Rejeh N, Heravi-Karimooi M, Vaismoradi M, Jasper M: Effect of systematic

relaxation techniques on anxiety and pain in older patients undergoing abdominal surgery.

Int J Nurs Pract 19:462-470, 2013

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124. Rolving N, Nielsen CV, Christensen FB, Holm R, Bünger CE, Oestergaard LG:

IP
Preoperative cognitive-behavioural intervention improves in-hospital mobilisation and

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analgesic use for lumbar spinal fusion patients. BMC Musculoskelet Disord 17:217, 2016

125. Rolving N, Nielsen CV, Christensen FB, Holm R, Bünger CE, Oestergaard LG: Does

US
a preoperative cognitive-behavioral intervention affect disability, pain behavior, pain, and
AN
return to work the first year after lumbar spinal fusion surgery?. Spine 40:593-600, 2015

126. Santavirta N, Lillqvist G, Sarvimäki A, Honkanen V, Konttinen Y, Santavirta S:

M

Teaching of patients undergoing total hip replacement surgery. Int J Nurs Stud 31:135-

142, 1994
ED

127. Savvas SM, Gibson SJ: Overview of pain management in older adults. Clin Geriatr
PT

Med 32:635-650, 2016

128. Seers K, Crichton N, Tutton L, Smith L, Saunders T: Effectiveness of relaxation for

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postoperative pain and anxiety: randomized controlled trial. J Adv Nurs 62:681-688, 2008

129. Sjöling M, Nordahl G, Olofsson N, Asplund K: The impact of preoperative

AC

information on state anxiety, postoperative pain and satisfaction with pain management.

Patient Educ Couns 51:169-176, 2003

130. Skolasky RL, Maggard AM, Li D, Riley LH, Wegener ST: Health behavior change

counseling in surgery for degenerative lumbar spinal stenosis. Part I: Improvement in

37
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rehabilitation engagement and functional outcomes. Arch Phys Med Rehabil 96:1200-

1207, 2015

131. Smith ML, Glass GV, Miller TI: The benefits of psychotherapy, Baltimore, Johns

Hopkins University Press, 1980

132. Søgaard R, Bünger CE, Laurberg I, Christensen FB: Cost-effectiveness evaluation of

an RCT in rehabilitation after lumbar spinal fusion: A low-cost, behavioural approach is

T
cost-effective over individual exercise therapy. Eur Spine J 17:262-271, 2008

IP
133. Sommer M, De Rijke JM, Van Kleef M, Kessels AG, Peters ML, Geurts JW, Gramke

CR
HF, Marcus MA: The prevalence of postoperative pain in a sample of 1490 surgical

inpatients. European journal of anaesthesiology. 25:267-274, 2008

134. US
Spalding NJ: A comparative study of the effectiveness of a preoperative education
AN
programme for total hip replacement patients. Br J Occup Ther 58:526-531, 1995

135. Stenekes MW, Geertzen JH, Nicolai JPA, De Jong BM, Mulder T: Effects of motor
M

imagery on hand function during immobilization after flexor tendon repair. Arch Phys

Med Rehabil 90:553-559, 2009

ED

136. Sterne JA, Egger M: Regression methods to detect publication and other bias in meta-
PT

analysis. In: Rothstein HR, Sutton AJ, Borenstein M (eds): Publication Bias in Meta-

analysis: Prevention, Assessment, and Adjustments. Chichester, John Wiley & Sons Ltd,
CE

2005, pp 99-110

137. Tappen RM, Whitehead D, Folden SL, Hall R: Effect of a video intervention on
AC

functional recovery following hip replacement and hip fracture repair. Rehabil Nurs

28:148-153, 2003

138. Thomas KM, Sethares KA: Is guided imagery effective in reducing pain and anxiety

in the postoperative total joint arthroplasty patient?. Orthop Nurs 29:393-39, 2010

38
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139. Toume M: Intervention and evaluation of preadmission patient education for patients

underdoing [sic] total hip arthroplasty. Journal of Japan Academy of Nursing Science

24:24-32, 2004

140. Tristaino V, Lantieri F, Tornago S, Gramazio M, Carriere E, Camera A: Effectiveness

of psychological support in patients undergoing primary total hip or knee arthroplasty: A

controlled cohort study. J Orthop Traumatol 17:1-11, 2016

T
141. Turk DC, Swanson KS, Tunks, ER: Psychological approaches in the treatment of

IP
chronic pain patients – when pills, scalpels, and needles are not enough. Can J Psychiatry

CR
53:213-223, 2008

142. Utrillas-Compaired A, Basilio J, Tebar-Martínez AJ, Asúnsolo-Del Barco Á: Does

US
preoperative psychologic distress influence pain, function, and quality of life after TKA?.
AN
Clin Orthop Relat Res 472:2457-2465, 2014

143. van den Akker-Scheek I, Zijlstra W, Groothoff JW, van Horn JR, Bulstra SK, Stevens
M

M: Groningen orthopaedic exit strategy: Validation of a support program after total hip or

knee arthroplasty. Patient Educ Couns 65:171-179, 2007

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144. Vranceanu AM, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D:

PT

Psychological factors predict disability and pain intensity after skeletal trauma. J Bone

Joint Surg Am 96:e20, 2014

CE

145. Wang TJ, Chang CF, Lou MF, Ao MK, Liu CC, Liang SY, Tung HH: Biofeedback

relaxation for pain associated with continuous passive motion in Taiwanese patients after
AC

total knee arthroplasty. Res Nurs Health 38:39-50, 2015

146. Watts G: A brief cognitive therapy intervention to reduce the fear of falling and

enhance daily living amongst older adults undergoing rehabilitation after hip fracture

[PhD dissertation]. Bangor: University of Wales, 1999

39
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147. Wilkie DJ: Nursing management: Pain. In: Lewis SM, Heitkemper MM, Dirksen SR

(eds): Medical surgical nursing assessment and management of clinical problems. St.

Louis, MO, Mosby, 2000, pp 126–153

148. Willens JS: Pain management. In: Smeltzer SC, Bare BG (eds): Brunner & Suddarth‘s

textbook of medical surgical nursing. Philadelphia, PA, Lippincott Williams & Wilkins,

2006, pp 216–248

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149. Wilson RA: A randomized controlled trial of an individualized education intervention

IP
for symptom management following total knee arthroplasty [PhD Dissertation]. Toronto:

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University of Toronto 2011

150. Wilson SL: Effects of relaxation on postoperative pain in patients with total knee

US
arthroplasty [PhD dissertation]. Toledo: Medical College of Ohio,1998
AN
151. Wong EML, Chair SY, Leung DY, Wai-Chi Chan S: Can a brief educational

intervention improve sleep and anxiety outcomes for emergency orthopaedic surgical
M

patients?. Contemp Nurse 47:132-143, 2014

152. Wong EML, Chan SWC, Chair SY: Effectiveness of an educational intervention on
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levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma. J Adv
PT

Nurs. 66:1120-1131, 2010

153. Woolf AD, Pfleger B: Burden of major musculoskeletal conditions. Bulletin of the
CE

World Health Organization, 81:646-656, 2003

154. Wu CL, Raja SN: Treatment of acute postoperative pain. Lancet 377: 2215-2225,
AC

2011

155. Xie LQ, Deng YL, Zhang JP, Richmond CJ, Tang Y, Zhou J: Effects of progressive

muscle relaxation intervention in extremity fracture surgery patients. Western J Nurs Res

38:155-168, 2016

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156. Yeh ML, Chen HH, Liu PH: Effects of multimedia with printed nursing guide in

education on self-efficacy and functional activity and hospitalization in patients with hip

replacement. Patient Educ Couns 57:217-224, 2005

157. Yin B, Goldsmith L, Gambardella R: Web-based education prior to knee arthroscopy

enhances informed consent and patient knowledge recall: a prospective, randomized

controlled study. J Bone Joint Surg Am 97:964-971, 2015

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158. Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W: Patient

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education before hip or knee arthroplasty lowers length of stay. J Arthroplasty 25:547-

CR
551, 2010

159. Zaffagnini S, Russo RL, Muccioli GMM, Marcacci M: The Videoinsight® method:

US
Improving rehabilitation following anterior cruciate ligament reconstruction—a
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preliminary study. Knee Surg Sports Traumatol Arthrosc 21:851-858, 2013
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Figure legends

Figure 1. Flow diagram of retrieved studies; RCT: randomized controlled trial; ICTRP:

International Clinical Trials Registry Platform; k: number of published articles in subgroups

Figure 2. Meta-analysis of the effect of psychosocial interventions on the outcome of

postoperative pain.

notes: N int: number of patient in the intervention group; N con: number of patients in the

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control group; CBI: cognitive or behavioral intervention; RE Model: Random Effect Model;

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k: number of published articles in subgroups

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Figure 3. Meta-analysis of the effect of psychosocial interventions on the outcome of

analgesic use.

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notes: N int: number of patient in the intervention group; N con: number of patients in the
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control group; CBI: cognitive or behavioral intervention; RE Model: Random Effect Model;

k: number of published articles in subgroups

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Figure 4. Meta-analysis on the outcome of preoperative anxiety comparing patients who had

psychosocial intervention with those who did not have any.

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notes: N int: number of patient in the intervention group; N con: number of patients in the
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control group; RE Model: Random Effect Model; k: number of published articles in

subgroups
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Figure 5. Meta-analysis of the effect of psychosocial interventions on the outcome of

postoperative anxiety.
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notes: N int: number of patient in the intervention group; N con: number of patients in the

control group; CBI: cognitive or behavioral intervention; RE Model: Random Effect Model;

k: number of published articles in subgroups

Figure 6. Meta-analysis of the effect of psychosocial interventions on the outcome of quality

of life.

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notes: N int: number of patient in the intervention group; N con: number of patients in the

control group; CBI: cognitive or behavioral intervention; RE Model: Random Effect Model;

k: number of published articles in subgroups

Figure 7. Meta-analysis of the effect of psychosocial interventions on the outcome of

recovery comparing patients who had psychosocial intervention with those who did not have

any.

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notes: N int: number of patient in the intervention group; N con: number of patients in the

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control group; CBI: cognitive or behavioral intervention; RE Model: Random Effect Model;

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k: number of published articles in subgroups

Figure 8. Risk of bias summary of included studies

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Records identified through database search Reviewer nominated records

(total k =16756) (k = 1)
Pubmed (k = 8805)
PsycINFO (k = 5348)
CINAHL (k = 1907)
ProQuest Dissertations & Theses (k = 455)
ICTRP Clinical Trials Search Portal (k=242)

Records irrelevant to topic:

Publication not containing psychological

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intervention or orthopedic surgery (k = 16 347)

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Not relevant publication type:
Records relevant to topic (k = 410) Editorial, review, commentary,

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letter, theoretical paper, news,
research protocol, case report,
etc. (k = 90)

Relevant publication type, records

US Systematic reviews relevant to
topic (k = 9)
Duplicate publications of the
same study (k = 131)
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selected for full text evaluation
(k = 180)
Full-text or data required to
assess eligibility not available
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(k = 2)

Excluded based on study characteristics:

Full text assessed for
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Non-prospective studies (k = 18)

eligibility (k = 178) Studies with no standard care or attention
control conditions (k = 28)
Studies on pediatric population (k = 8)
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Did not report outcome of interest (k = 20)

Studies included in Combination of psychological and non-
systematic review (k = 89) psychological interventions (k = 14)
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Study design changed mid-study (k= 1)

Excluded from quantitative summary:

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No relevant outcome in the time period of

Studies included in interest (k = 4)
quantitative review Non-RCTs (k = 23)
(k = 62)

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Table legends

Table 1. Time period of interest

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Table 2. Characteristics of included randomized controlled trials
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Table 1. Time period of interest

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Outcome Time period of interest Sensitivity analysis at

Postoperative pain Immediately after surgery until Day of the surgery1, days 1 to 7, days
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one month after surgery 8 to 30

Postoperative Immediately after surgery until Day of the surgery, days 1 to 7, days 8
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analgesic use one month after surgery to 30

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Preoperative One month before surgery until Days -30 to -8, days -7 to -1, day of

anxiety immediately before surgery the surgery pre-operation

1
In this study, by day of the surgery we refer to the rest of the day remaining after the surgical procedure was
completed.

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Postoperative Immediately after surgery until Day of the surgery, days 1 to 7, days 8

anxiety one month after surgery to 30

Quality of life One week after surgery until 6 First three months, months four to six

months after surgery

Recovery Immediately after surgery until Days 1 to 14, days 15 to 3 months

6 months after surgery post-surgery, months four to six

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Table 2. Characteristics of included randomized controlled trials

Article follow-up Joint

study type n Intervention timing outcomes time range replacement Electiveness Severity
Abramson (1998)1 dissertation 43 cbt after poa, rec 6,7 JR elective major
3
Akhavan (2008) dissertation 55 cbt after rec 8 JR elective major
4
Alexander (1982) dissertation 30 ed before au, poa, rec 5,6 not JR elective both
before &
Antall, et al. (2004)7 journal art. 12 rel after pp, au, poa, rec 5,6,7 JR elective major
c (rel+cbt);
Appler (1982)9 dissertation 60 rel before au, pra, poa, rec 2,5,6 not known not known both
Ayral, et al, (2002)12 journal art. 112 ed before pp, pra 3,4 not JR elective minor

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Bellelli, et al. (2010)15 journal art. 60 cbt after rec 8 partly both major
c

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Berge, et al. (2004)16 journal art. 40 (ed+cbt+rel) before - - JR elective major
17
Berger (1992) dissertation 60 c (cbt+rel) after pp, poa, rec 5,7,8 not JR both major
c before &

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Best (1981)18 dissertation 80 (ed.+em+cbt) after au, poa, rec 4,5,6 not JR acute major
Biau, et al. (2015)20 journal art. 199 ed before pp, au, rec 4,5,6 JR elective major
21
Bondy, et al. (1999) journal art. 134 ed before pra 3 JR elective major

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24
Burns, et al. (2007) journal art. 170 cbt after pp, rec 7,8,10 partly acute major
25
Butler, et al. (1996) journal art. 80 ed before pra, poa, rec 3,6,7 JR elective major
before &
Ceccio (1984)27 journal art. 20 rel after pp, au, poa 4 not known acute major
AN
32
Clari, et al. (2015) journal art. 219 ed after pp, poa, rec 7,8 not JR elective major
Clode-Baker, et al. pp, pra, poa, qol,
(1997)34 journal art. 78 ed before rec 2,5,6,7,9 JR elective major
35
Cooke, et al. (2015) journal art. 82 c (cbt+rel) before pp, au, pra, poa 2,4,5,7 JR elective major
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36
Cupal, et al. (2001) journal art. 30 rel after rec 10 not JR not known major
37
Daltroy, et al. (1998) journal art. 112 ed before pp, au, poa, rec 5,6 JR elective major
before &
Diaz, et al. (2005)39 journal art. 230 c (rel+sug) after pp, pra, poa 3,4,5 partly elective major
ED

Doering, S., Behensky,

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et al. (2000) journal art. 100 ed before rec 8 JR elective major
Doering, S.,
Katzlberger, F., et al. pp, au, pra, poa,
(2000)41 journal art. 100 ed before rec 3,5,6 JR elective major
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Durso-Cupal (1997) dissertation 20 c (rel+cbt) after rec 10 not JR not known major
47
Farlinger (2001) dissertation 38 ed before pp, au 5 not JR elective major
Forward, et al. before &
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(2015)49 journal art. 225 rel after pp, pra, poa 3,4,5 JR elective major
50
Fraval, et al. (2015) journal art. 211 ed before pra 3 partly elective major
Frost (2004)52 journal art. 26 cbt after qol, rec 10 JR elective major
Gambatesa, et al.
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(2013)53 journal art. 40 cbt after pp, poa, qol, rec 5,6,7,9 not known acute major
before &
Gavin, et al. (2006)57 journal art. 49 rel after pp, au 4,5 not JR elective major
Giraudet-Le Quintrec, pp, au, pra, poa,
et al. (2003)58 journal art. 100 ed before rec 3,4,5,6,7 JR elective major
Hørdam, et al. (2010)67 journal art. 161 cbt after qol 9 JR elective major
Jacobson et al. before &
(2016)71 journal art. 58 sug after pp, qol, rec 7,8,9,10 JR elective major
72
Janzen (2007) dissertation 31 ed before - - partly elective major
Johansson, et al.
(2007)75 journal art. 123 ed before rec 6 JR elective major
Jones, D., Duffy, M.
E., et al. (2011)77 journal art. 102 ed after poa, qol 5,9 not JR elective major
Langford, et al.
(2015)90 journal art. 26 c (ed+cbt) after qol, rec 10 not known acute major

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Lehrl, et al. (2012)92 journal art. 32 cbt after rec 6 JR elective major
93
Lilja, et al. (1998) journal art. 50 ed before pp, pra, poa 2,4,5 JR elective major
Maddison, et al.
(2012)98 journal art. 21 cbt after poa, rec 7,1 not JR elective major
before &
Mayer, et al. (2004)101 journal art. 24 cbt after rec 6 JR elective major
Mayich, et al. (2013)102 journal art. 40 ed after rec 8 not JR acute major
McGregor, et al.
(2004)105 journal art. 39 ed before pp, qol, rec 6,7,8,9 JR elective major
Monticone, et al.
(2014)107 journal art. 130 cbt after pp, qol, rec 7,8,9 not JR elective major
O'Connor et al.
(2016)111 journal art. 53 ed before pra 3 JR elective major
O'Halloran, et al.
(2015)112

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journal art. 30 cbt after - - partly acute major
115
Parsons (2011) dissertation 250 ed before pra 1 JR elective major

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before &
Peebhoy (2000)116 dissertation 160 c (cbt+rel) after pp, poa, qol, rec 4,5,6,8,9,10 JR elective major
117
Pellino, et al. (1998) journal art. 74 ed before au, rec 5,6 partly elective both

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118
Pellino, et al. (2005) journal art. 65 rel after pp, au, poa 5 JR elective major
before &
124
Rolving et al. (2016) journal art. 96 cbt after pp, au, rec 5,6 not JR elective major
Rolving, et al. before &
(2015)125

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journal art. 90 cbt after rec 8,1 not JR elective major
Santavirta, et al.
(1994)126 journal art. 60 ed before rec 8 JR elective major
before &
Seers, et al. (2008)128 journal art. 118 rel after pp, poa 5 JR elective major
AN
129
Sjöling, et al. (2003) journal art. 60 ed before pp, au, pra, rec 2,5,6 JR elective major
Søgaard, et al.
(2008)132 journal art. 60 cbt after - - not JR elective major
Stenekes, et al.
(2009)135 journal art. 25 cbt after rec 6,8 not JR acute major
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unpublished
Szeverényi, et al. research before &
(2014)* data 95 sug during au, rec 5,6 JR elective major
van den Akker-Scheek,
et al. (2007)143 journal art. 103 ed after qol, rec 8,9,10 JR elective major
ED

145
Wang, et al. (2015) journal art. 66 rel after pp, au 5 JR elective major
Watts (1999)146 dissertation 18 cbt after rec 8 not known acute major
149
Wilson (1998) dissertation 34 rel after pp, au 4,5 JR elective major
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150
Wilson (2011) dissertation 143 ed before pp, au, rec 5,6 JR elective major
155
Xie, et al. (2016) journal art. 84 rel after poa, rec 7,8 not JR acute major
157
Yin, et al. (2015) journal art. 55 ed before pra, poa 3,5 not JR elective major
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Zaffagnini, et al.
(2013)159 journal art. 106 sug after qol, rec 8,9 not JR elective major

n: total number of participants; journal art.: journal article; timing: timing of the psychological intervention; JR:
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joint replacement; 1: Days -8 to -30 pre surgery; 2: Days -7 to -1 pre surgery; 3: Day of surgery, pre surgery; 4:
Day of surgery, post surgery; 5: Days 1 to 7 post surgery; 6: Days 1 to 14 post surgery; 7: Days 8 to 30 post
surgery; 8: Days 15 to 3 month post surgery; 9: 1-3 months post surgery; 10: 4-6 months post surgery; pp:
Postoperative pain; au: Analgesic use; pra: Preoperative anxiety; poa: Postoperative anxiety; qol: Quality of life;
rec: Recovery; ed: patient education; cbt: cognitive behavioral techniques; rel: relaxation techniques; hy:
hypnosis; sug: therapeutic suggestion; em: emotion-focused intervention; c: combined (in brackets the
components of the combination);
*unpublished research data

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Supplement legends

Supplement 1. PRISMA checklist

Supplement 2. Search terms

Supplement 3. List of excluded studies with reasons for exclusion

Supplement 4. Characteristics of non-randomized controlled trials

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Supplement 5. Intervention and group characteristics

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Supplement 6. Conflict of interest and funders of included studies

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Supplement 7. Total dataset and sensitivity analyses results summary

Supplement 8. Meta regressions summary table

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Supplement 9. Narrative description of the results of the eligible non-randomized controlled
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studies

Supplement 10. Risk of bias for each included study

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Supplement 11. Funnel plot for the outcome of postoperative pain showing no publication

bias.
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Supplement 12. Funnel plot for the outcome of analgesic use indicating small publication
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bias.

Supplement 13. Funnel plot for the outcome of preoperative anxiety showing no publication
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bias.

Supplement 14. Funnel plot for the outcome of postoperative anxiety indicating small
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publication bias.

Supplement 15. Funnel plot for the outcome of quality of life indicating small publication

bias.

Supplement 16. Funnel plot for the outcome of recovery indicating small publication bias.

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