Preoperative severe pain, decreased function, and high anxiety levels increase preoperative anxiety in patients who underwent primary total knee arthroplasty

Preoperative severe pain, decreased function, and high anxiety levels increase preoperative anxiety in patients who underwent primary total knee arthroplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Preoperative severe pain, decreased function, and high anxiety levels increase preoperative anxiety in patients who underwent primary total knee arthroplasty Ki-Bong Park, Young Dae Jeon, Sang-Gon Kim, Jae-Hwan Park This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4287153/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Patients experience clinically significant anxiety from the time they are recommended to undergo total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of a preoperative intervention regarding anxiety levels in patients undergoing TKA for knee osteoarthritis (OA) and to evaluate whether patient characteristics affect the effectiveness of the intervention according to anxiety level. This retrospective observational study recruited 89 patients who underwent TKA under general anesthesia for knee OA. The preoperative intervention comprised rehabilitation education and an interview with an orthopedic surgeon regarding surgical preparation status. The State-Trait Anxiety Inventory (STAI) was administered before and after the preoperative intervention. The mean STAI score significantly improved after the intervention. The proportion of patients with clinically meaningful state anxiety (CMSA) also significantly decreased after the intervention. There were no significant differences in demographic and social factors between the two groups. However, the patients whose CMSA status did not improve experienced severe pain, poor functional scores, and high anxiety scores. For patients undergoing TKA, the implementation of a patient-specific intervention, which consists of preoperative rehabilitation education and a surgeon interview, helps reduce preoperative anxiety. However, these interventions may not be effective in patients who present with severe pain, poor functional status, or high anxiety levels before surgery. Thus, higher levels of intervention for anxiety may be necessary. Health sciences/Health care Health sciences/Medical research osteoarthritis total knee arthroplasty preoperative anxiety intervention pain Figures Figure 1 Figure 2 Introduction Total knee arthroplasty (TKA) is a common procedure performed to alleviate knee pain; more often than not it is caused by osteoarthritis (OA) [1]. Patients scheduled to undergo TKA are known to experience clinically significant anxiety from the moment they are recommended to undergo surgery [2]; therefore, anxiety intervention is required before surgery. Currently, enhanced recovery after surgery protocols emphasize perioperative therapeutic strategies employed by surgeons and anesthesiologists, as well as the increased importance of preoperative patient education and interdisciplinary collaboration [3]. Preoperative education reduces perioperative anxiety by modifying the patient’s postoperative expectations [4], and preoperative muscle strengthening and flexibility exercises aid in rapid recovery post-surgery [5]. Additionally, preoperative education and rehabilitation can reduce pain and improve patient satisfaction after TKA [6,7]. Despite various perioperative interventions, some patients proceed with surgery because of significant anxiety. However, no research has been done on the characteristics of patients who are anxious due to a non-response to perioperative interventions [8,9,10]. By analyzing the characteristics of patients who do not respond to interventions such as preoperative rehabilitation or education, it may be possible to select patients who require a higher level of intervention, such as consulting a psychiatrist or taking anti-anxiety medications [11,12,13,14]. This study aimed to evaluate the effectiveness of patient-specific interventions in patients who underwent primary TKA. The primary endpoint was to evaluate changes in anxiety state before and after the intervention, and the secondary endpoint was to compare the characteristics of the group whose anxiety state did not significantly improve after the intervention with those of the improved group. Methods Participants and inclusion criteria This retrospective observational study recruited participants who underwent general anesthesia and TKA for knee OA between June 2023 and January 2024. This study consecutively enrolled patients aged >60 years old with moderate or severe OA. Patients with rheumatoid arthritis, osteonecrosis, post-traumatic OA, a history of psychiatric disorders, or those who underwent second-stage bilateral TKA were excluded from this study. Patient-specific preoperative intervention Figure 1 illustrates the perioperative process from the decision to perform surgery to the day of admission. After deciding to perform surgery, the first STAI-X survey was conducted immediately at the outpatient clinic (T1). Subsequently, a clinical nurse specialist explained the preparation process for the surgery, hospital life from admission to discharge, and general information regarding TKA surgery, general anesthesia, and complications the patient and guardian may experience. Preoperative rehabilitation education was provided twice a week in the 4 th and 3 rd weeks before surgery. A professional physical therapist initiated quadriceps strengthening exercises preoperatively and taught rehabilitation methods postoperatively, including wearing an extension brace, active range of motion exercises, continuous passive motion devices, and walking using a walker. Two weeks before surgery, the patient met with a surgeon who had performed TKA before. The surgeon in charge explained the overall preparation process for the patient’s surgery; preoperative consultations, such as the opinion of the cardiologist on angina pectoris or the opinion of the nephrologist on chronic renal failure; and the level of risk of general anesthesia for each disease. Two weeks later, the patients were hospitalized and the second STAI-X survey was conducted (T2). Primary outcome: anxiety The preoperative anxiety status was measured using the State-Trait Anxiety Inventory (STAI)-X before the intervention [15]. The STAI-X consists of 20 questions with a total score ranging from 20 to 80, with higher scores indicating greater anxiety. Clinically meaningful state anxiety (CMSA) was defined as a total score of 52. One orthopedic surgeon administered the two surveys. The first and second surveys were administered immediately before starting the intervention and on the day of hospitalization for surgery, respectively. Secondary outcome: subgroup analysis Patients with preoperative CMSA status were divided into a group that improved to a non-CMSA status (improved group) and a group that showed no change in CMSA status after the intervention (non-improved group). Age, sex, comorbidities, range of motion, knee OA grade, and deformity angle were examined as demographic characteristics, whereas religion and education level were examined as social characteristics. The American Society of Anesthesiologists physical status (ASA-PS), numeric rating scale, Tegner activity scale, Knee Society Score (KSS), and Western Ontario and McMaster Universities (WOMAC) scores were evaluated to determine the preoperative pain and function level. Statistical analysis Continuous variables are presented as means with standard deviations. Categorical variables were compared using the Chi-square test or Fisher’s exact test, and continuous variables were compared using the Student’s t-test, as appropriate. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 28 (IBM Corp., Armonk, NY, USA). Statistical significance was set at P < 0.05. Ethics This retrospective study was conducted with the approval of the Institutional Review Board (IRB) of our institution (IRB No. 2024-01-015-002) and was performed according to the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants. Results Table 1 summarizes the demographic characteristics of the participants. All variables were normally distributed. Eighty-nine patients were enrolled in this study: 68 women (76.4%) and 21 men (23.6%) with a mean age of 72.1 years (range, 60–87 years). Levels of preoperative anxiety The mean STAI score significantly decreased from 46.5 points before the intervention to 37.4 points after the intervention ( P < 0.001; Figure 2), and the proportion of patients with a CMSA status significantly decreased from 36.0% before the intervention to 14.6% after the intervention ( P < 0.001; Table 2). Preoperative CMSA and non-CMSA groups No significant differences in the epidemiological, sociological, or functional characteristics were observed between the two groups, barring diabetes (Table 3). The proportion of patients with diabetes as a comorbidity was significantly higher in the CMSA group (50.0%) than in the non-CMSA group (17.5%; P = 0.001). The mean STAI before the intervention was significantly higher in the CMSA group (60.8 points) than in the non-CMSA group (38.4 points; P < 0.001). The mean STAI score after the intervention was also significantly higher in the CMSA group (52.0 points) than in the non-CMSA group (29.2 points; P < 0.001). Subgroup analysis of the improved and non-improved groups Table 4 presents a comparison of the characteristics of the group that improved from CMSA to non-CMSA status and the non-improved group after the patient-specific intervention. The preoperative pain scale score was significantly higher in the non-improved group (7.2 points) than in the improved group (4.9 points; P < 0.001). The Tegner activity level was significantly lower in the non-improved group (2.2 points) than in the improved group (2.7 points; P = 0.007). The preoperative knee function scores, KSS and WOMAC score, in the non-improved group were 41.8 and 43.7 points, respectively, which were significantly worse than the 57.8 and 46.9 points in the improved group ( P = 0.03 and 0.04, respectively). Additionally, the preoperative STAI score was significantly higher in the non-improved group than in the improved group (65.3 points vs. 57.8 points, P = 0.002). Discussion The most important finding of this study is that patient-specific intervention consisting of individual interviews and rehabilitation education of patients undergoing primary TKA significantly improved the STAI score. Furthermore, this study indicated that severe pain and decreased function contribute to the non-improvement of preoperative anxiety, despite patient-specific interventions. Timing of intervention A previous study [22] reported that 38% of patients experienced the highest level of anxiety when the surgeon recommended TKA in an outpatient clinic. Despite suffering from chronic knee pain for a long time, the treatment process in the outpatient clinic proceeded very quickly; that is, patients who received their updated OA diagnosis were recommended TKA as the last treatment method and were asked to decide on the date of surgery within a few minutes. These findings may be sufficient to induce anxiety among geriatric patients in outpatient clinics. Therefore, interventions to improve patients’ anxiety levels between the time of TKA and hospitalization for surgery are recommended. Preoperative outpatient interviews with surgeons Overseeing preoperative outpatient appointments may reduce anxiety. One study reported that anesthesiologists explained different anesthetic options before surgery and provided counseling on anxiety related to anesthesia and surgery [16]. Previous studies on surgery-related anxiety have similarly reported that trust in medical staff is worthwhile in helping patients overcome preoperative anxiety [2,17,18]. Therefore, in this study, the final interview with the patient was designed to be conducted by the surgeon who would perform the surgery, who comprehensively explained the results of all tests performed for the surgery and answered the patient’s questions related to the surgery and hospitalization. Effectiveness of preoperative intervention Preoperative intervention improves not only patient anxiety but also postoperative outcomes. Medina-Garzon [19] evaluated the effectiveness of a nursing intervention with three sessions of motivational interviewing to reduce preoperative anxiety in patients who underwent TKA and reported that anxiety levels improved after the intervention. Ho et al. [20] introduced a patient-specific integrated education program into the TKA clinical pathway and reported that anxiety status improved after the intervention regarding STAI scores during hospitalization. This study evaluated anxiety levels before and after intervention in the same patients and indicated that anxiety levels significantly decreased after intervention compared with those before intervention. Preoperative education improves surgical outcomes in patients who underwent TKA [7,20,21,22,23]. Although preoperative education is embedded in the consent process, it is unclear whether it offers benefits regarding anxiety reduction over usual care [24]. A systematic review and meta-analysis [23] conducted to determine the efficacy of preoperative education and/or exercise on postoperative outcomes in patients undergoing TKA reported significant improvements in function, quadriceps strength, and length of stay. However, the trials included in that systematic review differed, in that, they evaluated whether preoperative education affected postoperative anxiety, whereas this study evaluated whether preoperative intervention affected preoperative anxiety. Demand for a high level of intervention Olsen et al. [25] reported that more severe preoperative pain (OR = 1.34) and more severe anxiety symptoms (OR = 1.14) were associated with an increased likelihood of moderate-to-severe pain five years after TKA, and more severe anxiety symptoms (OR = 1.25) were also associated with an increased likelihood of moderate-to-severe pain-related functional impairment five years after TKA. From this, it can be assumed that preoperative pain, preoperative functional status, and preoperative anxiety level are interrelated. Similarly, this study indicated that patients with severe pain, decreased function, and high anxiety levels did not respond to preoperative interventions consisting of rehabilitation education and additional interviews with surgeons. Therefore, other interventions, such as psychotherapy or pharmacotherapy, may be required for non-responsive patients. Previous studies [26,27] have evaluated the efficacy of pharmacotherapy 6 months before cervical spine surgery in patients with a history of anxiety or depression and reported that pretreatment for affective disorders significantly improved clinical outcomes. Wang et al. [28] reported that postoperative pain improved when duloxetine was administered to centrally sensitized patients who underwent TKA, so it can be expected that the administration of a similar anti-anxiety drug would not only improve pain but also improve perioperative anxiety. Strengths and weaknesses of this study This study differs from others, in that, it provides an opportunity for patients to receive a comprehensive explanation of the benefits and risks of surgery as well as the results of each department’s assessment of anesthesia risk, from the physician performing the surgery. To the best of our knowledge, this is the first study to evaluate the effectiveness of a surgeon-directed preoperative intervention in reducing preoperative anxiety in patients undergoing TKA, regarding changes in STAI and the proportion of patients with CMSA. Moreover, this study established that the characteristics of patients whose CMSA status did not improve despite preoperative intervention suggested the need for appropriate additional intervention. This study had certain limitations. First, the sample size was small; only geriatric patients who underwent TKA for knee OA at a single institution were included. Additionally, the generalizability of the findings may be limited. Second, it was not possible to determine which of the two programs, rehabilitation education or surgeon interviews, was more effective in reducing patient anxiety. Third, we assessed the characteristics of non-responders using demographic, social, and clinical factors. However, we could not evaluate various factors that could not be verified with objective numbers such as rapport with staff, previous experience or knowledge of surgical procedures, personal characteristics, and susceptibility to stressful situations. Finally, this study did not evaluate whether the participants whose anxiety levels improved before TKA experienced improvements in their postoperative pain or functional scores. In cases of total joint replacement, patients who receive preoperative education reportedly exhibit greater mobility in the immediate postoperative period and a shorter length of stay [22]. Therefore, mid- to long-term follow-up evaluations of the participants are necessary to evaluate differences in postoperative outcomes. Conclusions For patients undergoing TKA, the implementation of a patient-specific intervention, which consists of preoperative rehabilitation education and a surgeon interview, helps reduce preoperative anxiety. However, these interventions may not be effective in patients who present with severe pain, poor functional status, or high anxiety levels before surgery. Thus, higher levels of intervention for anxiety may be necessary. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Ulsan University Hospital (No. 2024-01-015-002). And written informed consent was obtained from all subjects and/or their legal guardian(s). Consent for publication Consent for publication was obtained from each participant in this study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Author’s contributions K.-B. Park: conception, study design, and manuscript writing and revision. Y.D. Jeon: collection of data, data analysis, interpretation, and manuscript writing. S.-G. Kim: collection of data, data analysis, interpretation, and manuscript writing. J.-H. Park: collection of data, data analysis, and manuscript writing. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Park SH, Jung KH, Chang SW, Jang SM, Park KB. Trends in knee surgery research in the official journal of the Korean Knee Society during the period 1999-2018: a bibliometric review. Knee Surg. Relat. Res. 32 ,28 (2020). Jung KH, Park JH, Ahn JW, Park KB. Surgery-related anxiety on geriatric patients undergoing total knee arthroplasty: a retrospective observational study. BMC Musculoskelet. Disord. 24, 161 (2023). Riga M, Altsitzioglou P, Saranteas T, Mavrogenis AF. Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery. SICOT. J . 9 ,E1 (2023). Lawrence C. 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Demographics of the entire study population Variables N = 89 Sex Female: Male 68 (76.4): 21 (23.6) Age, years 72.1 (60–87) Height, cm 155.9 (142.9–175.4) Weight, kg 66.3 (47.8–97.9) Body mass index, kg/m 2 27.2 (21.6–39.1) Hypertension (+: -) 68 (76.4): 21 (23.6) Diabetes (+: -) 26 (29.2): 63 (70.8) Rage of motion, ° Extension -6.4 (-12.2–0) Flexion 124 (85–140) Hip-Knee-Ankle axis, ° 7.6 (1.2–17.7) Data are presented as N (%) or mean (range). Table 2. Average preoperative anxiety score before and after intervention and proportion of patients with clinically meaningful anxiety Pre-intervention Post-intervention P value STAI score 46.5 (23–79) 37.4 (20–75) < 0.001 Patients with CMSA 32 (36.0) 13 (14.6) < 0.001 Data are presented as mean (range) or N (%). CMSA: clinically meaningful state anxiety Table 3. Comparison between the patient group with preoperative CMSA status and the group with non-CMSA status CMSA group (n = 32) Non-CMSA group (n = 57) P value Demographics Age, year 73.4 71.3 0.07 Female ratio 26 (81.3) 42 (73.7) 0.43 Body mass index, kg/m 2 27.9 26.7 0.13 Hypertension + 28 (87.5) 40 (70.2) 0.07 Diabetes + 16 (50.0) 10 (17.5) 0.001 Social Religion (+: -) 22 (68.8): 10 (21.2) 34 (59.6): 23 (40.4) 0.39 Education level 0.17 None 3 (9.4) 2 (3.5) Elementary school 16 (50.0) 26 (45.6) Middle school 9 (28.1) 11 (19.3) > High school 4 (12.5) 18 (31.6) Functional status (mean) ASA-PS 2.4 2.5 0.81 Numeric rating scale 6.1 5.3 0.08 Tegner activity level 2.4 2.3 0.62 Knee Society Score 50.6 48.1 0.54 WOMAC score 51.1 46.9 0.33 STAI score Preintervention 60.8 38.4 < 0.001 Postintervention 52.0 29.2 < 0.001 Data are presented as mean (range) or N (%). CMSA: clinically meaningful state anxiety; ASA-PS: The American Society of Anesthesiologists physical status; WOMAC: Western Ontario and McMaster Universities; STAI: State-Trait Anxiety Inventory. Table 4. Comparison of characteristics of the group that improved to non-CMSA status after intervention with the non-improved group Improved group (n = 19) Non-improved group (n = 13) P value Demographics Age, year 74.6 71.8 0.23 Female ratio 16 (84.2) 10 (76.9) 0.67 Body mass index, kg/m 2 28.1 27.7 0.74 Hypertension + 16 (84.2) 12 (92.3) 0.63 Diabetes + 10 (52.6) 6 (46.2) 0.72 Social Religion (+: -) 15 (79.0): 7 (53.9): 0.13 Education level 0.31 None 1 (5.3) 2 (15.4) Elementary school 11 (57.9) 5 (38.5) Middle school 6 (31.6) 3 (23.1) > High school 1 (5.3) 3 (23.1) Functional status (mean) ASA-PS 2.5 2.3 0.23 Numeric rating scale 4.9 7.2 < 0.001 Tegner activity level 2.7 2.2 0.007 Knee Society Score 56.6 41.8 0.03 WOMAC score 46.1 43.7 0.04 STAI score Pre-intervention 57.8 65.3 0.002 Post-intervention 46.9 59.5 < 0.001 Data are presented as N (%) or mean (range). ASA-PS: The American Society of Anesthesiologists physical status; CMSA: clinically meaningful state anxiety; WOMAC: Western Ontario and McMaster Universities; STAI: State-Trait Anxiety Inventory. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4287153","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":296855340,"identity":"9cdc2d65-cdc2-483f-bc78-732858ae44a1","order_by":0,"name":"Ki-Bong Park","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACCQkQecAGyALSD0AcHuK0pEG0JJCg5TAJWiRn9x78XHHmfOKG2w1sEgl/7PIYeM4+wKtFWuZcsuSZG7cTN9w5wCaR2JZczMDbboBXi5xEjoFkwweglhsJQC0NzIkN/Gz4HQbUYvyz4cM5iJaEP/WEtUhL5JhJNtw4ANXCdjixgbcNvxbJOefSLBvOJBvPvJHYbJHYdjyxjecYfi0St3sP32w4ZifbdyP54I0Pf6oT+3nS8GtBigbGBjBFwCcoWkbBKBgFo2AU4AAAo6BKJa2r/dMAAAAASUVORK5CYII=","orcid":"","institution":"Ulsan University Hospital, University of Ulsan College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ki-Bong","middleName":"","lastName":"Park","suffix":""},{"id":296855341,"identity":"8c0ea185-1afc-461f-96e9-a5c330ddf269","order_by":1,"name":"Young Dae Jeon","email":"","orcid":"","institution":"Ulsan University Hospital, University of Ulsan College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Young","middleName":"Dae","lastName":"Jeon","suffix":""},{"id":296855342,"identity":"ef062afd-7cf9-4bbb-bc4b-037208e4f8a4","order_by":2,"name":"Sang-Gon Kim","email":"","orcid":"","institution":"Ulsan University Hospital, University of Ulsan College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sang-Gon","middleName":"","lastName":"Kim","suffix":""},{"id":296855343,"identity":"38476bfa-bb95-496c-ad0b-8713f001e467","order_by":3,"name":"Jae-Hwan Park","email":"","orcid":"","institution":"Ulsan University Hospital, University of Ulsan College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jae-Hwan","middleName":"","lastName":"Park","suffix":""}],"badges":[],"createdAt":"2024-04-18 10:43:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4287153/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4287153/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55763525,"identity":"b3e45916-f762-4b0c-ab3b-af3fa62f7037","added_by":"auto","created_at":"2024-05-02 19:42:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":459200,"visible":true,"origin":"","legend":"\u003cp\u003ePerioperative process from the decision to perform surgery to admission day.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4287153/v1/a3363263e76649632e469c09.jpg"},{"id":55763523,"identity":"ab07b7df-6b67-4d81-b753-16a84e2a38e7","added_by":"auto","created_at":"2024-05-02 19:42:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":328307,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of preoperative anxiety level before total knee arthroplasty. (a) Pre-intervention evaluation. (b) Post-intervention evaluation.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4287153/v1/b9bb9af70b3265999d588425.jpg"},{"id":61384531,"identity":"9a12d204-1069-4d6e-91a8-64c83cf004ee","added_by":"auto","created_at":"2024-07-30 06:44:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1387895,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4287153/v1/5e80b41a-a796-4356-b62f-54749060ba41.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative severe pain, decreased function, and high anxiety levels increase preoperative anxiety in patients who underwent primary total knee arthroplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA) is a common procedure performed to alleviate knee pain; more often than not it is caused by osteoarthritis (OA) [1]. Patients scheduled to undergo TKA are known to experience clinically significant anxiety from the moment they are recommended to undergo surgery [2]; therefore, anxiety intervention is required before surgery.\u003c/p\u003e\n\u003cp\u003eCurrently, enhanced recovery after surgery protocols emphasize perioperative therapeutic strategies employed by surgeons and anesthesiologists, as well as the increased importance of preoperative patient education and interdisciplinary collaboration [3]. Preoperative education reduces perioperative anxiety by modifying the patient\u0026rsquo;s postoperative expectations [4], and preoperative muscle strengthening and flexibility exercises aid in rapid recovery post-surgery [5]. Additionally, preoperative education and rehabilitation can reduce pain and improve patient satisfaction after TKA [6,7].\u003c/p\u003e\n\u003cp\u003eDespite various perioperative interventions, some patients proceed with surgery because of significant anxiety. However, no research has been done on the characteristics of patients who are anxious due to a non-response to perioperative interventions [8,9,10]. By analyzing the characteristics of patients who do not respond to interventions such as preoperative rehabilitation or education, it may be possible to select patients who require a higher level of intervention, such as consulting a psychiatrist or taking anti-anxiety medications [11,12,13,14].\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the effectiveness of patient-specific interventions in patients who underwent primary TKA. The primary endpoint was to evaluate changes in anxiety state before and after the intervention, and the secondary endpoint was to compare the characteristics of the group whose anxiety state did not significantly improve after the intervention with those of the improved group.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants and inclusion criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study recruited participants who underwent general anesthesia and TKA for knee OA between June 2023 and January 2024. This study consecutively enrolled patients aged \u0026gt;60 years old with moderate or severe OA. Patients with rheumatoid arthritis, osteonecrosis, post-traumatic OA, a history of psychiatric disorders, or those who underwent second-stage bilateral TKA were excluded from this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient-specific preoperative intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 illustrates the perioperative process from the decision to perform surgery to the day of admission. After deciding to perform surgery, the first STAI-X survey was conducted immediately at the outpatient clinic (T1). Subsequently, a clinical nurse specialist explained the preparation process for the surgery, hospital life from admission to discharge, and general information regarding TKA surgery, general anesthesia, and complications the patient and guardian may experience. Preoperative rehabilitation education was provided twice a week in the 4\u003csup\u003eth\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e weeks before surgery. A professional physical therapist initiated quadriceps strengthening exercises preoperatively and taught rehabilitation methods postoperatively, including wearing an extension brace, active range of motion exercises, continuous passive motion devices, and walking using a walker. Two weeks before surgery, the patient met with a surgeon who had performed TKA before. The surgeon in charge explained the overall preparation process for the patient\u0026rsquo;s surgery; preoperative consultations, such as the opinion of the cardiologist on angina pectoris or the opinion of the nephrologist on chronic renal failure; and the level of risk of general anesthesia for each disease. Two weeks later, the patients were hospitalized and the second STAI-X survey was conducted (T2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrimary outcome: anxiety\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe preoperative anxiety status was measured using the State-Trait Anxiety Inventory (STAI)-X before the intervention [15]. The STAI-X consists of 20 questions with a total score ranging from 20 to 80, with higher scores indicating greater anxiety. Clinically meaningful state anxiety (CMSA) was defined as a total score of 52. One orthopedic surgeon administered the two surveys. The first and second surveys were administered immediately before starting the intervention and on the day of hospitalization for surgery, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSecondary outcome: subgroup analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with preoperative CMSA status were divided into a group that improved to a non-CMSA status (improved group) and a group that showed no change in CMSA status after the intervention (non-improved group). Age, sex, comorbidities, range of motion, knee OA grade, and deformity angle were examined as demographic characteristics, whereas religion and education level were examined as social characteristics. The American Society of Anesthesiologists physical status (ASA-PS), numeric rating scale, Tegner activity scale, Knee Society Score (KSS), and Western Ontario and McMaster Universities (WOMAC) scores were evaluated to determine the preoperative pain and function level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables are presented as means with standard deviations. Categorical variables were compared using the Chi-square test or Fisher\u0026rsquo;s exact test, and continuous variables were compared using the Student\u0026rsquo;s t-test, as appropriate. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 28 (IBM Corp., Armonk, NY, USA). Statistical significance was set at \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was conducted with the approval of the Institutional Review Board (IRB) of our institution (IRB No. 2024-01-015-002) and was performed according to the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 summarizes the demographic characteristics of the participants. All variables were normally distributed. Eighty-nine patients were enrolled in this study: 68 women (76.4%) and 21 men (23.6%) with a mean age of 72.1 years (range, 60\u0026ndash;87 years).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLevels of preoperative anxiety\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean STAI score significantly decreased from 46.5 points before the intervention to 37.4 points after the intervention (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001; Figure 2), and the proportion of patients with a CMSA status significantly decreased from 36.0% before the intervention to 14.6% after the intervention (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001; Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePreoperative CMSA and non-CMSA groups\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo significant differences in the epidemiological, sociological, or functional characteristics were observed between the two groups, barring diabetes (Table 3). The proportion of patients with diabetes as a comorbidity was significantly higher in the CMSA group (50.0%) than in the non-CMSA group (17.5%; \u003cem\u003eP\u003c/em\u003e = 0.001). The mean STAI before the intervention was significantly higher in the CMSA group (60.8 points) than in the non-CMSA group (38.4 points; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). The mean STAI score after the intervention was also significantly higher in the CMSA group (52.0 points) than in the non-CMSA group (29.2 points; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubgroup analysis of the improved and non-improved groups\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 presents a comparison of the characteristics of the group that improved from CMSA to non-CMSA status and the non-improved group after the patient-specific intervention. The preoperative pain scale score was significantly higher in the non-improved group (7.2 points) than in the improved group (4.9 points; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). The Tegner activity level was significantly lower in the non-improved group (2.2 points) than in the improved group (2.7 points; \u003cem\u003eP\u003c/em\u003e = 0.007). The preoperative knee function scores, KSS and WOMAC score, in the non-improved group were 41.8 and 43.7 points, respectively, which were significantly worse than the 57.8 and 46.9 points in the improved group (\u003cem\u003eP\u003c/em\u003e = 0.03 and 0.04, respectively). Additionally, the preoperative STAI score was significantly higher in the non-improved group than in the improved group (65.3 points vs. 57.8 points, \u003cem\u003eP\u003c/em\u003e = 0.002).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of this study is that patient-specific intervention consisting of individual interviews and rehabilitation education of patients undergoing primary TKA significantly improved the STAI score. Furthermore, this study indicated that severe pain and decreased function contribute to the non-improvement of preoperative anxiety, despite patient-specific interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTiming of intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA previous study [22] reported that 38% of patients experienced the highest level of anxiety when the surgeon recommended TKA in an outpatient clinic. Despite suffering from chronic knee pain for a long time, the treatment process in the outpatient clinic proceeded very quickly; that is, patients who received their updated OA diagnosis were recommended TKA as the last treatment method and were asked to decide on the date of surgery within a few minutes. These findings may be sufficient to induce anxiety among geriatric patients in outpatient clinics. Therefore, interventions to improve patients\u0026rsquo; anxiety levels between the time of TKA and hospitalization for surgery are recommended.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePreoperative outpatient interviews with surgeons\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverseeing preoperative outpatient appointments may reduce anxiety. One study reported that anesthesiologists explained different anesthetic options before surgery and provided counseling on anxiety related to anesthesia and surgery [16]. Previous studies on surgery-related anxiety have similarly reported that trust in medical staff is worthwhile in helping patients overcome preoperative anxiety [2,17,18]. Therefore, in this study, the final interview with the patient was designed to be conducted by the surgeon who would perform the surgery, who comprehensively explained the results of all tests performed for the surgery and answered the patient\u0026rsquo;s questions related to the surgery and hospitalization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEffectiveness of preoperative intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative intervention improves not only patient anxiety but also postoperative outcomes. Medina-Garzon [19] evaluated the effectiveness of a nursing intervention with three sessions of motivational interviewing to reduce preoperative anxiety in patients who underwent TKA and reported that anxiety levels improved after the intervention. Ho et al. [20] introduced a patient-specific integrated education program into the TKA clinical pathway and reported that anxiety status improved after the intervention regarding STAI scores during hospitalization. This study evaluated anxiety levels before and after intervention in the same patients and indicated that anxiety levels significantly decreased after intervention compared with those before intervention. Preoperative education improves surgical outcomes in patients who underwent TKA [7,20,21,22,23]. Although preoperative education is embedded in the consent process, it is unclear whether it offers benefits regarding anxiety reduction over usual care [24]. A systematic review and meta-analysis [23] conducted to determine the efficacy of preoperative education and/or exercise on postoperative outcomes in patients undergoing TKA reported significant improvements in function, quadriceps strength, and length of stay. However, the trials included in that systematic review differed, in that, they evaluated whether preoperative education affected postoperative anxiety, whereas this study evaluated whether preoperative intervention affected preoperative anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDemand for a high level of intervention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOlsen et al. [25] reported that more severe preoperative pain (OR = 1.34) and more severe anxiety symptoms (OR = 1.14) were associated with an increased likelihood of moderate-to-severe pain five years after TKA, and more severe anxiety symptoms (OR = 1.25) were also associated with an increased likelihood of moderate-to-severe pain-related functional impairment five years after TKA. From this, it can be assumed that preoperative pain, preoperative functional status, and preoperative anxiety level are interrelated. Similarly, this study indicated that patients with severe pain, decreased function, and high anxiety levels did not respond to preoperative interventions consisting of rehabilitation education and additional interviews with surgeons. Therefore, other interventions, such as psychotherapy or pharmacotherapy, may be required for non-responsive patients. Previous studies [26,27] have evaluated the efficacy of pharmacotherapy 6 months before cervical spine surgery in patients with a history of anxiety or depression and reported that pretreatment for affective disorders significantly improved clinical outcomes. Wang et al. [28] reported that postoperative pain improved when duloxetine was administered to centrally sensitized patients who underwent TKA, so it can be expected that the administration of a similar anti-anxiety drug would not only improve pain but also improve perioperative anxiety.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengths and weaknesses of this study\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study differs from others, in that, it provides an opportunity for patients to receive a comprehensive explanation of the benefits and risks of surgery as well as the results of each department\u0026rsquo;s assessment of anesthesia risk, from the physician performing the surgery. To the best of our knowledge, this is the first study to evaluate the effectiveness of a surgeon-directed preoperative intervention in reducing preoperative anxiety in patients undergoing TKA, regarding changes in STAI and the proportion of patients with CMSA. Moreover, this study established that the characteristics of patients whose CMSA status did not improve despite preoperative intervention suggested the need for appropriate additional intervention.\u003c/p\u003e\n\u003cp\u003eThis study had certain limitations. First, the sample size was small; only geriatric patients who underwent TKA for knee OA at a single institution were included. Additionally, the generalizability of the findings may be limited. Second, it was not possible to determine which of the two programs, rehabilitation education or surgeon interviews, was more effective in reducing patient anxiety. Third, we assessed the characteristics of non-responders using demographic, social, and clinical factors. However, we could not evaluate various factors that could not be verified with objective numbers such as rapport with staff, previous experience or knowledge of surgical procedures, personal characteristics, and susceptibility to stressful situations. Finally, this study did not evaluate whether the participants whose anxiety levels improved before TKA experienced improvements in their postoperative pain or functional scores. In cases of total joint replacement, patients who receive preoperative education reportedly exhibit greater mobility in the immediate postoperative period and a shorter length of stay [22]. Therefore, mid- to long-term follow-up evaluations of the participants are necessary to evaluate differences in postoperative outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor patients undergoing TKA, the implementation of a patient-specific intervention, which consists of preoperative rehabilitation education and a surgeon interview, helps reduce preoperative anxiety. However, these interventions may not be effective in patients who present with severe pain, poor functional status, or high anxiety levels before surgery. Thus, higher levels of intervention for anxiety may be necessary.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Ulsan University Hospital (No. 2024-01-015-002). And written informed consent was obtained from all subjects and/or their legal guardian(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was obtained from each participant in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor\u0026rsquo;s contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eK.-B. Park: conception, study design, and manuscript writing and revision. Y.D. Jeon: collection of data, data analysis, interpretation, and manuscript writing. S.-G. Kim: collection of data, data analysis, interpretation, and manuscript writing. J.-H. Park: collection of data, data analysis, and manuscript writing. All authors read and approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePark SH, Jung KH, Chang SW, Jang SM, Park KB. Trends in knee surgery research in the official journal of the Korean Knee Society during the period 1999-2018: a bibliometric review. \u003cem\u003eKnee Surg. Relat. Res.\u003c/em\u003e \u003cstrong\u003e32\u003c/strong\u003e,28 (2020).\u003c/li\u003e\n\u003cli\u003eJung KH, Park JH, Ahn JW, Park KB. 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Assoc.\u003c/em\u003e \u003cstrong\u003e60\u003c/strong\u003e,909-915 (2022).\u003c/li\u003e\n\u003cli\u003eNam HS, Yoo HJ, Ho JPY, Kim YB, Lee YS. Preoperative education on realistic expectations improves the satisfaction of patients with central sensitization after total knee arthroplasty: a randomized-controlled trial. \u003cem\u003eKnee Surg. Sports Traumatol. Arthrosc.\u003c/em\u003e \u003cstrong\u003e31\u003c/strong\u003e,4705-4715 (2023).\u003c/li\u003e\n\u003cli\u003eAytekin E, Sukur E, Oz N, Telatar A, Eroglu Demir S, Sayiner Caglar N, Ozturkmen Y, Ozgonenel L. The effect of a 12 week prehabilitation program on pain and function for patients undergoing total knee arthroplasty: A prospective controlled study. \u003cem\u003eJ. Clin. Orthop. Trauma.\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e,345-349 (2019).\u003c/li\u003e\n\u003cli\u003eShawahna R, Jaber M, Maqboul I, Hijaz H, Tebi M, Ahmed NA, Shabello Z. Prevalence of preoperative anxiety among hospitalized patients in a developing country: a study of associated factors. \u003cem\u003ePerioper. Med (Lond).\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e,47 (2023)\u003c/li\u003e\n\u003cli\u003eBedaso A, Mekonnen N, Duko B. Prevalence and factors associated with preoperative anxiety among patients undergoing surgery in low-income and middle-income countries: a systematic review and meta-analysis. \u003cem\u003eBMJ Open\u003c/em\u003e. \u003cstrong\u003e12\u003c/strong\u003e,e058187 (2022)\u003c/li\u003e\n\u003cli\u003eLiu Q, Li L, Wei J, Xie Y. Correlation and influencing factors of preoperative anxiety, postoperative pain, and delirium in elderly patients undergoing gastrointestinal cancer surgery. \u003cem\u003eBMC Anesthesiol.\u003c/em\u003e \u003cstrong\u003e23\u003c/strong\u003e,78 (2023).\u003c/li\u003e\n\u003cli\u003eRizzo MG Jr, Costello JP 2nd, Luxenburg D, Cohen JL, Alberti N, Kaplan LD. Augmented Reality for Perioperative Anxiety in Patients Undergoing Surgery: A Randomized Clinical Trial. \u003cem\u003eJAMA Netw. Open.\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e,e2329310 (2023).\u003c/li\u003e\n\u003cli\u003eK\u0026uuml;hlmann AYR, de Rooij A, Kroese LF, van Dijk M, Hunink MGM, Jeekel J. Meta-analysis evaluating music interventions for anxiety and pain in surgery. \u003cem\u003eBr. J. Surg.\u003c/em\u003e \u003cstrong\u003e105\u003c/strong\u003e,773-783 (2018).\u003c/li\u003e\n\u003cli\u003ePeng F, Peng T, Yang Q, Liu M, Chen G, Wang M. Preoperative communication with anesthetists via anesthesia service platform (ASP) helps alleviate patients' preoperative anxiety. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cstrong\u003e10\u003c/strong\u003e,18708 (2020).\u003c/li\u003e\n\u003cli\u003eGraf S, Feldmann H, Hunold LS, Steinkraus KC, Nasir N, Michalski CW, D\u0026ouml;rr-Harim C, H\u0026uuml;ttner FJ. Use of virtual reality in port implantation to reduce perioperative anxiety and pain: protocol for a randomised controlled pilot trial at a single German university hospital (VIP-trial; DRKS00028508). \u003cem\u003eBMJ Open.\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e,e074738 (2023).\u003c/li\u003e\n\u003cli\u003eCollimore KC, McCabe RE, Carleton RN, Asmundson GJ. Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters. \u003cem\u003eJ. Anxiety Disord.\u003c/em\u003e \u003cstrong\u003e22\u003c/strong\u003e,1021-1028 (2008).\u003c/li\u003e\n\u003cli\u003eRaghavan G, Shyam V, Murdoch JAC. A survey of anesthetic preference and preoperative anxiety in hip and knee arthroplasty patients: the utility of the outpatient preoperative anesthesia appointment. \u003cem\u003eJ. Anesth.\u003c/em\u003e \u003cstrong\u003e33\u003c/strong\u003e,250\u0026ndash;256 (2019).\u003c/li\u003e\n\u003cli\u003eLee CC, Cha JR, Park JH, Kim MS, Park KB. Surgery-related anxiety regarding arthroscopic meniscectomy under general anesthesia: a retrospective observational study. \u003cem\u003eBMC Musculoskelet. Disord\u003c/em\u003e. \u003cstrong\u003e19\u003c/strong\u003e,24(1):980 (2023).\u003c/li\u003e\n\u003cli\u003eJung KH, Park JH, Song JY, Han JW, Park KB. State-Anxiety in Geriatric Patients Undergoing Surgical Treatment for Femoral Neck or Intertrochanteric Fractures. Geriatr. Orthop. Surg. Rehabil. \u003cstrong\u003e12\u003c/strong\u003e,21514593211063320 (2021).\u003c/li\u003e\n\u003cli\u003eMedina-Garz\u0026oacute;n M. Effectiveness of a nursing intervention to diminish preoperative anxiety in patients programmed for knee replacement surgery: preventive controlled and randomized clinical trial. \u003cem\u003eInvestig. Educ. Enferm. \u003c/em\u003e\u003cstrong\u003e37\u003c/strong\u003e,e07 (2019).\u003c/li\u003e\n\u003cli\u003eHo CJ, Chen YT, Wu HL, Huang HT, Lin SY. The effects of a patient-specific integrated education program on pain, perioperative anxiety, and functional recovery following total knee replacement. \u003cem\u003eJ. Pers. Med.\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e,719 (2022).\u003c/li\u003e\n\u003cli\u003eAtabaki S, Haghani S, Dorri S, Farahani MA. The effect of rehabilitation education on anxiety in knee replacement patients. \u003cem\u003eJ. Educ. Health Promot.\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e,115 (2020).\u003c/li\u003e\n\u003cli\u003eJones ED, Davidson LJ, Cline TW. The Effect of Preoperative Education Prior to Hip or Knee Arthroplasty on Immediate Postoperative Outcomes. \u003cem\u003eOrthop. Nurs.\u003c/em\u003e \u003cstrong\u003e41\u003c/strong\u003e,4-12 (2022).\u003c/li\u003e\n\u003cli\u003eMoyer R, Ikert K, Long K, Marsh J. The Value of Preoperative Exercise and Education for Patients Undergoing Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. \u003cem\u003eJBJS Rev.\u003c/em\u003e \u003cstrong\u003e5\u003c/strong\u003e,e2 (2017).\u003c/li\u003e\n\u003cli\u003eMcDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. \u003cem\u003eCochrane Database Syst. Rev.\u003c/em\u003e \u003cstrong\u003e5\u003c/strong\u003e,CD003526 (2014).\u003c/li\u003e\n\u003cli\u003eOlsen U, Sellevold VB, Gay CL, Aamodt A, Lerdal A, Hagen M, Dihle A, Lindberg MF. Factors associated with pain and functional impairment five years after total knee arthroplasty: a prospective observational study. \u003cem\u003eBMC Musculoskelet. Disord.\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e,22 (2024).\u003c/li\u003e\n\u003cli\u003eAdogwa O, Elsamadicy AA, Cheng J, Bagley C. Pretreatment of Anxiety Before Cervical Spine Surgery Improves Clinical Outcomes: A Prospective, Single-Institution Experience. \u003cem\u003eWorld Neurosurg.\u003c/em\u003e \u003cstrong\u003e88\u003c/strong\u003e,625-630 (2016).\u003c/li\u003e\n\u003cli\u003eElsamadicy AA, Adogwa O, Cheng J, Bagley C. Pretreatment of Depression Before Cervical Spine Surgery Improves Patients' Perception of Postoperative Health Status: A Retrospective, Single Institutional Experience. \u003cem\u003eWorld Neurosurg.\u003c/em\u003e \u003cstrong\u003e87\u003c/strong\u003e,214-219 (2016).\u003c/li\u003e\n\u003cli\u003eWang S, Wang W, Shao L, Ling J. Efficacy and safety of duloxetine for postoperative pain after total knee arthroplasty in centrally sensitized patients: study protocol for a randomized controlled trial. \u003cem\u003eBMC Musculoskelet. Disord. \u003c/em\u003e\u003cstrong\u003e22\u003c/strong\u003e,316 (2021).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographics of the entire study population\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eN = 89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Female: Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e68 (76.4): 21 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eAge, years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e72.1\u0026nbsp;(60\u0026ndash;87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHeight, cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e155.9 (142.9\u0026ndash;175.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eWeight, kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e66.3 (47.8\u0026ndash;97.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e27.2 (21.6\u0026ndash;39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension (+: -)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e68 (76.4): 21 (23.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes (+: -)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e26 (29.2): 63 (70.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eRage of motion,\u0026nbsp;\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Extension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e-6.4 (-12.2\u0026ndash;0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Flexion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e124 (85\u0026ndash;140)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003eHip-Knee-Ankle axis,\u0026nbsp;\u0026deg;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e7.6 (1.2\u0026ndash;17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as N (%) or mean (range).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eAverage preoperative anxiety score before and after intervention and proportion of patients with clinically meaningful anxiety\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.62063227953411%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003ePre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003ePost-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.62063227953411%\" valign=\"top\"\u003e\n \u003cp\u003eSTAI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e46.5\u0026nbsp;(23\u0026ndash;79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e37.4\u0026nbsp;(20\u0026ndash;75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.62063227953411%\" valign=\"top\"\u003e\n \u003cp\u003ePatients with CMSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e32 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e13 (14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.126455906821963%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean\u0026nbsp;(range) or\u0026nbsp;N (%).\u003c/p\u003e\n\u003cp\u003eCMSA: clinically meaningful state anxiety\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eComparison between the patient group with preoperative CMSA status and the group with non-CMSA status\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\"\u003e\n \u003cp\u003eCMSA group (n = 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\"\u003e\n \u003cp\u003eNon-CMSA group (n = 57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eAge, year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e73.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e71.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eFemale ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e26 (81.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e42 (73.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e28 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e40 (70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e16 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e10 (17.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eReligion (+: -)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e22 (68.8): 10 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e34 (59.6): 23 (40.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Elementary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e16 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e26 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Middle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e11 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt; High school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e18 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eFunctional status (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eASA-PS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eNumeric rating scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eTegner activity level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eKnee Society Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e50.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e48.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eWOMAC score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e46.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eSTAI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Preintervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e60.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e38.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Postintervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e52.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e29.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean (range) or N (%).\u003c/p\u003e\n\u003cp\u003eCMSA: clinically meaningful state anxiety; ASA-PS: The American Society of Anesthesiologists physical status; WOMAC: Western Ontario and McMaster Universities; STAI: State-Trait Anxiety Inventory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eComparison of characteristics of the group that improved to non-CMSA status after intervention with the non-improved group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\"\u003e\n \u003cp\u003eImproved group (n = 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\"\u003e\n \u003cp\u003eNon-improved group (n = 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u0026nbsp;\u003c/em\u003evalue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eDemographics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eAge, year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e74.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e71.8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eFemale ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e16 (84.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e10 (76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e16 (84.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e12 (92.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes +\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e10 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eReligion (+: -)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e15 (79.0):\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e7 (53.9):\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Elementary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e11 (57.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; Middle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e6 (31.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026gt; High school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e1 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eFunctional status (mean)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eASA-PS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eNumeric rating scale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eTegner activity level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eKnee Society Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e56.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e41.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eWOMAC score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e46.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e43.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003eSTAI score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Pre-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e57.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.69983416252073%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Post-intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e46.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.850746268656717%\" valign=\"top\"\u003e\n \u003cp\u003e59.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.598673300165837%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as N (%) or mean (range).\u003c/p\u003e\n\u003cp\u003eASA-PS: The American Society of Anesthesiologists physical status; CMSA: clinically meaningful state anxiety; WOMAC: Western Ontario and McMaster Universities; STAI: State-Trait Anxiety Inventory.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"osteoarthritis, total knee arthroplasty, preoperative, anxiety, intervention, pain ","lastPublishedDoi":"10.21203/rs.3.rs-4287153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4287153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePatients experience clinically significant anxiety from the time they are recommended to undergo total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of a preoperative intervention regarding anxiety levels in patients undergoing TKA for knee osteoarthritis (OA) and to evaluate whether patient characteristics affect the effectiveness of the intervention according to anxiety level.\u003c/p\u003e\n\u003cp\u003eThis retrospective observational study recruited 89 patients who underwent TKA under general anesthesia for knee OA. The preoperative intervention comprised rehabilitation education and an interview with an orthopedic surgeon regarding surgical preparation status. The State-Trait Anxiety Inventory (STAI) was administered before and after the preoperative intervention.\u003c/p\u003e\n\u003cp\u003eThe mean STAI score significantly improved after the intervention. The proportion of patients with clinically meaningful state anxiety (CMSA) also significantly decreased after the intervention. There were no significant differences in demographic and social factors between the two groups. However, the patients whose CMSA status did not improve experienced severe pain, poor functional scores, and high anxiety scores.\u003c/p\u003e\n\u003cp\u003eFor patients undergoing TKA, the implementation of a patient-specific intervention, which consists of preoperative rehabilitation education and a surgeon interview, helps reduce preoperative anxiety. However, these interventions may not be effective in patients who present with severe pain, poor functional status, or high anxiety levels before surgery. Thus, higher levels of intervention for anxiety may be necessary.\u003c/p\u003e","manuscriptTitle":"Preoperative severe pain, decreased function, and high anxiety levels increase preoperative anxiety in patients who underwent primary total knee arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-02 19:42:01","doi":"10.21203/rs.3.rs-4287153/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a4626b5-fd05-4817-8e93-9ec571cfec95","owner":[],"postedDate":"May 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":31311453,"name":"Health sciences/Health care"},{"id":31311454,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2024-07-30T06:36:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-02 19:42:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4287153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4287153","identity":"rs-4287153","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}