Acute postoperative pain impact trajectories and factors contributing to trajectory membership.

BACKGROUND: Ongoing postoperative pain assessments are vital to optimizing pain management and attenuating the development of poor health outcomes after surgery. This study aimed to characterize acute multidimensional trajectories of pain impact on physical function, sleep, mood, and stress and to examine clinical characteristics and demographics associated with trajectory membership. Additionally, this study compared levels of pain intensity and prescription opioid use at 2 weeks and 1 month postoperatively across acute symptom trajectories. METHODS: Participants (N = 285) undergoing total knee arthroplasty, total hip arthroplasty, and spinal fusion procedures were recruited for this multisite prospective observational study. Longitudinal, joint k-means clustering was used to identify trajectories based on pain impact on activity, sleep, mood, and stress. RESULTS: Three distinct pain impact trajectories were observed: Low (33.7%), Improving (35.4%), and Persistently High (30.9%). Participants in the Persistently High impact trajectory reported pain interfering moderately to severely with activity, sleep, mood, and stress. Relative to other trajectories, the Persistently High impact trajectory was associated with greater postoperative pain at 1 month postoperatively. Preoperatively, participants in the Persistently High impact trajectory reported worse Pain Catastrophizing Scale scores and PROMIS Pain Interference, PROMIS Anxiety, and PROMIS Social Isolation scores than did participants presenting with other trajectories. No statistical differences in opioid use were observed across trajectories. CONCLUSIONS: Variation in acute postoperative pain impact on activity, sleep, mood, and stress exists. Given the complex nature of patients' postoperative pain experiences, understanding how psychosocial presentations acutely change throughout hospitalization could assist in guiding clinicians' treatment choices and risk assessments.

Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures.

BACKGROUND: Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery. METHODS: Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships. RESULTS: Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters. CONCLUSIONS: These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.

Discrete and Dynamic Postoperative Pain Catastrophizing Trajectories Across 6 Months: A Prospective Observational Study.

OBJECTIVES: To investigate pain catastrophizing presentations up to 6 months postoperatively and subsequent changes in pain intensity and physical function. DESIGN: Prospective observational multisite study. SETTING: Two tertiary care facilities between 2016 and 2019. PARTICIPANTS: Adult patients (N=348) undergoing a mastectomy, thoracic surgery, total knee or hip arthroplasty, spinal fusion, or major abdominal surgery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain Catastrophizing Scale scores, Defense and Veterans Pain Rating Scale, average pain intensity, and Patient Reported Outcomes Measurement Information System (PROMIS) physical function. RESULTS: Four pain catastrophizing trajectories were identified in 348 surgical patients during the 6 months of postoperative recovery: stable, remitting, worsening, and unremitting. Linear mixed-effects models found that the unremitting trajectory was associated with higher pain intensity over time. The average pain intensity of participants in the remitting trajectory was estimated to decrease at a faster rate over the 6 months after surgery than pain of other trajectories, despite participants reporting high preoperative Pain Catastrophizing Scale and pain scores. Worsening and unremitting trajectories were associated with reduced physical function. Preoperative average pain intensity scores were not associated with postoperative physical function scores, nor were participants' preoperative physical function scores associated with average pain intensity scores postoperatively. Prolonged hospitalization, smoking, and preoperative opioid prescriptions were associated with the unremitting trajectory. CONCLUSIONS: Findings suggest that preoperative pain catastrophizing scores alone may not be adequate for estimating long-term patient-reported outcomes during postoperative rehabilitation. Pain catastrophizing has a dynamic presentation and is associated with changes in pain intensity and physical function up to 6 months postoperatively. Routine assessments can inform the delivery of early interventions to surgical patients at risk of experiencing a pain catastrophizing trajectory associated with suboptimal outcomes during rehabilitation.