The Journal of Pain, Vol 17, No 2 (February), 2016: pp 236-247

Available online at www.jpain.org and www.sciencedirect.com

The Influence of Chronic Pain on Postoperative Pain and Function

After Hip Surgery: A Prospective Observational Cohort Study
Joachim Erlenwein,* Michael Przemeck,y Astrid Degenhart,y Stefan Budde,z
Deborah Falla,* Michael Quintel,* Michael Pfingsten,* and Frank Petzke*
€ ttingen, Go
*Pain Clinic, Department of Anesthesiology, University Hospital, Georg-August-University of Go € ttingen,
Germany.
y
Department of Anesthesiology and Intensive Care, Annastift, Hannover, Germany.
z
Department of Orthopedic Surgery, Medical School Hannover, Hannover, Germany.

Abstract: Pre-existing or chronic pain is an established risk factor for severe postoperative pain. In
this prospective observational cohort study, we investigated whether a history of chronic pain,
beyond the presence of hip-related pain, affected other postoperative factors including early mobi-
lization, function, and psychological distress after hip surgery. Patients who underwent total hip
replacement surgery were observed from the preoperative day until the seventh postoperative
day. Before surgery, they were characterized by their pain history, pain intensity, function, and psy-
chological characteristics. Postoperatively, pain intensity was evaluated on day 1, 3, 5, and 7 and the
analgesic consumption was recorded for each of these days. Measures of function (functional ques-
tionnaire, ability to mobilize and to climb stairs, and range of hip motion) and psychological distress
were re-evaluated on day 7. A history of chronic pain was associated with slower postoperative
mobilization, poorer physical function, and greater psychological distress in addition to increased
postoperative pain intensity. The comorbidity of a chronic pain disorder resulted in greater pain in-
tensity after surgery, and also impeded postoperative rehabilitation. Identification of patients with
a chronic pain disorder is necessary preoperatively so that appropriate pain management and reha-
bilitation can be planned to facilitate recovery.
Perspective: Chronic pain, beyond the presence of hip-related pain, is associated with slower post-
operative mobilization, poorer physical function, and greater psychological distress after total hip
replacement surgery. Identification of patients with chronic pain and establishment of multiprofes-
sional perioperative management might improve postoperative rehabilitation of patients with
chronic pain.
ª 2016 by the American Pain Society
Key words: Acute pain, chronic pain, rehabilitation, hip joint replacement, psychosocial distress.

D
espite increased awareness of the need to ensure
effective postoperative pain management, pain
is still poorly managed in some areas.1,13,27
Pre-existing chronic pain, which is a common disease in
Western industrialized countries that affects up to
approximately 20% of the population, has been identi-
fied as a risk factor for severe postoperative
Received March 16, 2015; Revised October 13, 2015; Accepted October
25, 2015.
The study was supported solely by departmental funds.
The authors have no conflicts of interest to declare.
Address reprint requests to Joachim Erlenwein, MD, Pain Clinic,
Department for Anesthesiology, University Hospital Go € ttingen, Robert-
Koch-Str. 40, Go€ ttingen 37075, Germany. E-mail: joachim.erlenwein@
med.uni-goettingen.de
1526-5900/$36.00
ª 2016 by the American Pain Society
http://dx.doi.org/10.1016/j.jpain.2015.10.013
pain.4,16,18,23,31,34 Data from a large registry project on
the basis of 22,963 patients showed that patients with
pre-existing chronic pain reported greater postoperative
pain intensity, rated on a numeric rating scale (NRS),
compared with those without chronic pain. This was
evident across all age groups, in both sexes, and for pa-
tients who underwent most surgical procedures.17
Another study showed that patients with symptomatic
low back pain had poorer functional outcome and
limited or no improvement in mental health after total
knee arthroplasty.3
The occurrence of pre-existing chronic pain varies, and
depends on the age of the patients or the definition of
chronic pain (eg, 6 vs 3 months) and might be as great
as 70% in some surgical population groups.31,42,49
However, most studies that showed that severe
postoperative pain is more likely in patients with

236
Erlenwein et al
pre-existing or chronic pain classified patients on the basis
of their pain intensity (eg, on a NRS).17 Yet, 1-dimensional
ratings do not do justice to the multifactorial nature of
pain. In addition, chronic pain is often accompanied
with psychosocial comorbidities that could have a signifi-
cant effect on the perception of pain.14 Rather, assess-
ment of (postoperative) status in patients with chronic
pain should take into consideration multiple elements
of a patient’s presentation including their functional ca-
pacity. Specifically, the question arises whether patients
with pre-existing chronic pain are more likely to present
with greater functional limitations postoperatively.
The aim of this prospective observational cohort study
was to investigate whether the presence of additional
chronic pain disorders would affect postoperative
outcome in terms of pain intensity and early postopera-
tive rehabilitation. In addition to postoperative pain in-
tensity, the relevant functional outcomes for the
current study were postoperative mobilization and psy-
chological recovery in the early days after surgery. A sec-
ondary aim was to explore the association of
distinguishing characteristics between patients with
and without additional chronic pain, on the outcomes
pain and function. To avoid major differences in the
baseline status between groups (with and without addi-
tional chronic pain) we selected a cohort of patients who
underwent elective surgery for a hip joint replacement,
one of the most common surgeries in Western countries,
for the study population.
Methods
Patients and Protocol
All patients with osteoarthritis who underwent an
elective hip joint replacement at the Orthopedic Univer-
sity Hospital of the Medical School Hannover, Germany
between July 23 and October 18, 2013 (12.5 weeks)
were invited to participate. No upper age limit or sex
preference was applied, although patients had to be
older than 18 years of age. The patients had to have
the capacity to give consent at his or her own will. Insuf-
ficient knowledge of the German language to under-
stand the study information or the required
questionnaire package and dementia were exclusion
criteria. Patients with acute hip pain caused by necrosis
of the femur head, active drug abuse, and planned spinal
anesthesia were also excluded. In case of postoperative
delirium syndrome the subject was excluded.
Patients were usually admitted on the day before sur-
gery. After consent the pain history was taken followed
by completion of questionnaires. The functional testing
and pressure pain thresholds (PPTs) were assessed in
the afternoon of the preoperative day. Analgesic con-
sumption and pain intensity were assessed on postoper-
ative days 1, 3, 5, and 7. All patients were treated
according to the standardized pain management
protocol established and certified at the institution for
several years.12 The study was approved by the ethical
committees of the University Hospital of Go € ttingen
(No. 5/4/12) and the Medical School Hannover (No.
The Journal of Pain 237
1483-2012), and conducted according to the recommen-
dations of the Declaration of Helsinki.
Categorization of Groups
To ensure a fairly homogeneous sample of surgical pa-
tients with similar types of functional restrictions at the
outset, patients who underwent an elective hip joint
replacement were chosen as the study population. All
patients had chronic hip pain related to osteoarthritis
and related physical dysfunction. On the basis of their
pain history they were divided into 2 groups: patients
with chronic hip pain only (no additional chronic pain
[nCP]) and patients with hip pain and at least 1 other clin-
ically ascertained chronic (of at least 6 months duration)
pain entity, independent from osteoarthritis of the hip
(with additional chronic pain [CP]).
The categorization of groups was on the basis of the
pain history to allow a dichotomous categorization be-
tween patients with and without (additional) chronic
pain as in other studies (see the introductory section).
The more specific assessment and questionnaires in the
pain history were collected to compare both groups
with regard to differences on the basis of various aspects
of chronic pain, and to validate the clinically derived
dichotomous comparison.
Pain History
The patients’ pain history was assessed by 2 physicians
(J.E., A.D.) who used a standardized protocol on the basis
of the German Pain Questionnaire including localiza-
tion, duration, pain intensity, and temporal aspects of
pain of all pain sites.33 To support the pain history the
protocol included a body chart, and the patients were in-
structed to draw all of the areas they experienced pain
regardless of the severity. In addition, history of treat-
ment and analgesic consumption were assessed. The
overall severity of chronic pain was measured using the
Chronic Pain Grade (CPG; von Korff), which is used to
categorize the patient on the basis of pain intensity
and pain-related dysfunction into 1 of 5 levels (grade 0:
no pain, to grade 4: high disability or severely limiting).45
To assess the chronicity of the patient, data on the cur-
rent analgesic regimen and previous pain-related treat-
ments were collected and patients were classified with
the Mainz Pain Staging System (MPSS).43 Preoperative
hip pain intensity was assessed at the time of the inter-
view with an 11-point NRS. Furthermore, the maximum
and the average pain intensities over the past 3 months
were obtained using the same scale.
PPTs
On the preoperative day, the PPT—as an assessment
overall pain sensitivity—was measured once over 10 sites
(bilaterally over the thumb, lateral epicondylus, muscu-
lus (m.) trapezius, m. quadriceps femoris, and m. tibialis
anterior) using an electronic pressure algometer (Some-
dic Production, Stockholm, Sweden). The algometer
probe tip (1 cm2) was applied to each site and patients
were advised to indicate when they perceived pain for
the first time during pressure stimulation with slowly
238 The Journal of Pain
increasing intensity (50 kPa/s). Stimulation stopped with
the report of pain. The maximum pressure intensity
applied was 1000 kPa. Measurements were performed
by 2 research assistants (M.G.; S.B., see Acknowledg-
ments), who were trained before the study, in approxi-
mately equal shares. For the purpose of this analysis
the mean threshold over all 10 testing sites was calcu-
lated.
Postoperative Pain Assessment
The intensity of postoperative pain was assessed with
an 11-point NRS (from 0 = no pain to 10 = worst pain),
taken from the Qualita €tsverbesserung in der post-
operativen Schmerztherapie (quality improvement in
postoperative pain therapy) questionnaire, which is a
validated German outcome measurement instrument
for postoperative quality control. It includes a question
on pain intensity during movement, and the least and
worst pain over the past 24 hours. For these measures
of pain intensity a Cronbach a of .84 was calculated for
internal consistency.29,30
Analgesic Consumption
To allow comparisons, opioid doses were expressed as
oral morphine equivalent (conversion factor to
morphine: oxycodone .75, hydromorphone .13,
piritramid 1.5, fentanyl .01, tilidin/tramadol 10, bupre-
norphine .03, intravenous vs oral morphine 3:1). Presur-
gical opioid analgesic consumption was categorized
into 4 categories (no opioids, only as needed, daily
morphine equivalent < 30 mg and > 30 mg). The postop-
erative analgesic consumption was calculated for the in-
tervals from time of surgery including the first
postoperative day and the daily dosages for each mea-
sure time point (postoperative days 3, 5, and 7).
To compare nonopioid medication use, the Medication
Quantification Scale was used, which is a reliable and
validated method for quantifying medication use in
patients with chronic pain,28,48 and for which an inter-
rater reliability of r = .985 (P < .0001) was shown. It is
calculated for each analgesic on the basis of weights
assigned by medication class (acetaminophen 2.2, cox-2
inhibitors 2.3, metamizole 2.3, diclofenac and ibuprofen
and indomethacin 3.4) and dosage level (level 1 = sub-
therapeutic dosage and/or on demand, level 2 = < 50%
of the daily dosage, level 3 > 50%, and level 4 = over-
dosage). These scores were summed to provide a quanti-
tative index of total nonopioid medication usage
suitable for statistical analysis.
Function and Mobilization
Functional Questionnaire
The Western Ontario and McMaster Universities Oste-
oarthritis Index (WOMAC) was used to measure function
in daily life.2 It is a self-administered instrument,
validated in German, with total score and 3 subscales
(pain, stiffness, and physical function). Higher scores
reflect worse pain and function. The WOMAC is a reliable
and valid measure of function associated with osteoar-
Chronic Pain and Postoperative Pain and Function
thritis. It has been shown to be sensitive to changes in
function. The properties of the German version of the
WOMAC were evaluated in a recent study,50 and it was
shown that the instrument is a reliable and valid measure
for assessment of the symptoms and physical functional
disability (internal consistency of Cronbach a, with a
range of .80-.96). It was recorded the day before surgery
in the hospital routine assessment and in a modified
version (including only the possible activities that could
be undertaken on the ward) on the day 7 after surgery.50
Functional Tests
The ‘‘timed stand up and go’’ is a standardized test used
to measure individual mobilization36: the time taken to
stand up from a sitting position on an armchair, walk
3 meters, and return to sitting was measured. In addition,
the time taken to climb a flight of 10 stairs (16.5 cm high)
was measured. Both measured times were categorized
into 5 levels of mobility (1 = < 10 seconds, freely mobile;
2 = < 20 seconds, mostly independent; 3 = 20–29 seconds,
variable mobility; > 30 seconds, impaired mobility; and
5 = can not walk or fulfill the task).
Range of Motion
Range of motion of the hip was recorded with the pa-
tient in the supine position by 1 examiner (A.D.) who
using the neutral 0 method and a goniometer (baseline:
degrees of extension and/or flexion, rotation and abduc-
tion; and postoperative day 7: extension and/or flexion,
and abduction).
Functional Outcome of Postoperative Mobili-
zation
Because of the potential risk of hip dislocation, the
functional tests could not be repeated on the seventh
day postoperatively, thus, as an alternative, the progress
of the patient’s postoperative mobilization was re-
corded. The treating physiotherapist was asked to indi-
cate whether mobilization had included walking on
stairs by the seventh postoperative day (done vs not
done) and whether the physiotherapist considered the
patient able to walk on stairs on the seventh day after
surgery (yes vs no).
Depressive Symptoms, Anxiety, and
Stress
The Depression Anxiety Stress Scales (DASS) is a set of 3
self-reported scales designed to measure the negative
emotional states of depression, anxiety, and stress.5
Each of the 3 DASS scales contains 7 items. Subjects are
asked to use a 4-point severity or frequency scale to
rate the extent to which they had experienced each state
over the past week. Scores for depression, anxiety, and
stress are calculated by summing the scores for the rele-
vant items. The scales of the DASS have been shown to
have high internal consistency and to yield meaningful
discrimination in a variety of settings.6 It was recently
translated and validated in German.33
The Tampa Scale of Kinesiophobia (TSK) is a self-report
questionnaire developed to assess kinesiophobia, or fear
Erlenwein et al
of movement and/or (re)injury, which have been
confirmed as important predictors for the persistence
of pain-related disability.38 Results consist of a total
sum score ranging between 17 and 68. A high value on
the TSK indicates a high degree of kinesiophobia. The
psychometric properties of a German version of the TSK
were evaluated in a recent study,41 which showed it to
be a reliable and valid measure for assessment of the
fear of movement and/or (re)injury (internal consistency
of a = .73).
Somatization
The Patient Health Questionnaire (PHQ) can be used to
establish provisional diagnoses for selected disorders
included in the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition. It includes a scale to assess
somatization (PHQ-15). Subjects were asked to rate the
severity of 15 symptoms over the past 4 weeks as
0 (‘‘not bothered at all’’), 1 (‘‘bothered a little’’), or 2
(‘‘bothered a lot’’). Thus, the total PHQ-15 score could
range from 0 to 30 and scores of $ 5, $ 10, and $ 15
represent mild, moderate, and severe levels of somatiza-
tion, respectively. The reliability and validity of the PHQ-
15 are high in clinical and occupational health care
settings, and it has been validated for use in German.26
Cognitive Appraisal of Pain and
Catastrophizing
The Kiel Pain Inventory (KPI) is a well established tool
in German to assess various aspects of chronic pain.19
The Catastrophizing Thoughts Scale of the KPI, which
consists of 5 items that describe the threatening aspects
of pain (eg, ‘‘What will happen if the pain gets worse?’’).
The Thoughts of Help-/Hopelessness Scale consists of 9
items that focus on lack of hope and impossibility to
become pain-free (eg, ‘‘It’s not going to get any better.’’).
The Thought Suppression Scale of the KPI consists of 4
items (eg, ‘‘Pull yourself together!,’’ ‘‘Don’t make such a
fuss!’’) and describes attempts to suppress pain sensa-
tions, pain-related emotions, and thoughts.
In all scales, patients indicate on a 7-point Likert scale
(0 ‘‘never,’’ 6 ‘‘always’’) the extent to which they had
experienced those thoughts in the past 14 days when
they experienced pain. Results are summed for each scale
and divided by the number of questions of each scale.
Higher scores in each scale indicate a higher occurrence
of catastrophizing, help- or hopelessness and suppressive
thoughts. Cronbach a was .84 for the Catastrophizing
Thoughts Scale, .91 for Thoughts of Help-/Hopelessness
Scale, and .78 for the Thought Suppression Scale. The
KPI scales are well validated within cross-sectional as
well as in prospective studies.20,44
General Quality of Life
Finally, the General Quality of Life Health Survey
(SF-12) was used as a brief and reliable measure of overall
health status. It has a validated German version and has
been extensively applied in large population health sur-
veys including studies with chronic pain.54 The SF-12
Health Survey is a shorter version of the SF-36 Health
The Journal of Pain 239
Survey that uses just 12 questions to measure functional
health and wellbeing from the patient’s point of view.
Taking only 2 to 3 minutes to complete, the SF-12 is a
practical, reliable, and valid measure of physical and
mental health. Higher scores indicate better general
health. Values of internal consistency for both scales
(Cronbach a) in several studies were consistently > 70.6
Clinical Procedure
In the evening and the morning before the surgical
procedure, all patients were given 20 to 30 mg dipotas-
sium chlorazepat as premedication. General anesthesia
was performed according to clinical standards, induced
by remifentanil (1–1.5 mg/kg body weight [b.w.] over 3 mi-
nutes) and propofol (1–2 mg/kg b.w.). Orotracheal intu-
bation was facilitated with 0.5 mg/kg b.w. atracurium.
Anesthesia was maintained with sevoflurane 0.7 to 1.0
minimum alveolar concentration or propofol 3.5 to
4.5 mg/kg b.w. per hour, along with remifentanil 0.15
to 0.25 mg/kg/min. Depth of anesthesia was monitored us-
ing bispectral index electroencephalogram (BIS; Covi-
dien, Medtronic, Minneapolis, Minnesota). During the
final stage of the surgery (ie, the implantation of the
femoral shaft), 0.1 mg/kg b.w. piritramid and 15 mg/kg
b.w. metamizol (if contraindicated, an equal amount of
paracetamol) were administered intravenously. In the re-
covery area, patients received 10 to 20 mg slow-release
oxycodone orally (age and/or weight adapted: 10 mg if
weight < 60 kg and/or age > 70 years; all others: 20 mg)
and 600 mg ibuprofen. Pain was titrated with intrave-
nous piritramid until the intensity was # 3 on the NRS.
On the ward, oral slow-release oxycodone (twice per
day) and ibuprofen (3 times per day) were continued
(dosage according to the first dosage admitted in the re-
covery area) for the following days according to a stan-
dardized postoperative pain management protocol.
Briefly, this protocol consisted of routine pain measure-
ments taken 3 times daily. If the NRS was > 3 patients
were offered 1.3 to 2.6 mg oral hydromorphone (age-
and weight-adjusted) and pain intensity was assessed
after 60 minutes. If NRS remained > 3, a second hydro-
morphone dose was offered. If after a further 60 minutes
the pain persisted, a third dose of hydromorphone was
given, and the patient was physically examined by a
physician to rule out painful complications that would
require further action (eg, hematoma or acute thrombo-
phlebitis). Slow-release oxycodone was increased by
10 mg, when 3 doses of hydromorphone were given
within 24 hours. Whenever the patients’ chart revealed
that the pain intensity was < 3 over the past 24 hours,
slow-release oxycodone was reduced by 10 mg per dose.
Postoperative Physiotherapy
Mobilization after surgery followed a standardized
protocol. Full weight-bearing was permitted from the
first postoperative day. Physiotherapy on the first to
third postoperative day included passive and guided
active movements of the hip, sitting upright at the
edge of the bed and, walking a few steps to several me-
ters using a walker or crutches, according to the patients’
240 The Journal of Pain
capability. Over the following days, the walking distance
was increased, stair climbing was introduced as able, and
independent mobility was repeatedly encouraged.
Statistical Analysis
The analysis was performed with SPSS (IBM SPSS Statis-
tics for Windows, version 21.0; IBM Corp, Armonk, NY)
and Statistica version 10 (StatSoft, Tulsa, OK). Presented
percentages are rounded. Categorical variables are pre-
sented as percent and absolute number of patients or
as median with first and third quartile. Continuous vari-
ables are described using the mean and standard devia-
tion.
Group comparisons with ordinal variables were per-
formed with the Mann–Whitney U test. Continuous attri-
butes were all analyzed using the t-tests for independent
samples. The variance was tested and the t-test was
accordingly adjusted. The normality of the data was not
tested. The distribution of frequencies of dichotomous at-
tributes in groups was described using the Pearson c2 test.
Pre- and postoperative ordinal and continuous vari-
ables with significant differences between both groups
were analyzed in a multivariate analysis for each group
and outcome (pain intensity, daily function on the sev-
enth day). Cumulative pain intensity was calculated by
summing the daily reported pain intensity in each cate-
gory to avoid multiple pain outcomes.
The significance level of the comparative analysis and
of the multivariate testing was set at P < .05. Results of
single hypotheses were not adjusted for multiple testing.
Results
One hundred seventy-two patients were scheduled for
elective hip joint replacement surgery and screened to
participate within the recruitment period. Eleven pa-
tients declined participation, 10 could not be included
(3 took part in other studies, 1 was younger than 18 years
old, 1 did not speak German, 3 were hospitalized outside
of clinical routine and could not be measured preopera-
tively, 1 was an active drug abuser, 1 had dementia).
Eighteen patients had to be excluded because their sur-
gery was postponed; they had postoperative delirium
or acute (<6 months) hip pain attributed to femoral
head necrosis. Eight were excluded because of spinal
anesthesia.
Thus, 125 patients whose age ranged from 24 to
88 years (mean 6 SD: 63.2 6 12.7 years) were included
Table 1. Patient Characteristics
CHARACTERISTIC TOTAL (N = 125)
General characteristic
Women/men, % [n] 42/58 [52/73]
Age, y 63.2 6 12.7
Body mass index 28.1 6 5.4
Life quality (SF-12)
Physical health 30.0 6 7.4
Mental health 49.2 6 11.8
NOTE. Numerical variables are presented as mean 6 SD. Categorical variables are presented as percent and absolute number of patients.
Chronic Pain and Postoperative Pain and Function
in the analysis. Sixty-nine percent of the patients were
categorized as CP group (n = 86) and 31% as nCP
(n = 39). The characteristics of the included patients are
shown in Table 1. There were no significant differences
between groups regarding age or sex, however, body
mass index (BMI) differed between groups. Both groups
reported a normal average of mental quality of life
compared with a significantly reduced physical quality
on the SF-12 questionnaire and the scores were not
different between groups (Table 1).
Preoperative Pain and Pain Testing
There were no differences between groups for the
duration of hip or hip-related pain and its intensity.
With consideration of chronic hip pain and other pain
sites, patients with hip pain only suffered longer from
chronic pain.
Moreover, the level of preoperative consumption of
analgesics was comparable between groups. Because of
the categorization of the patients and because of the
more comprehensive applied medical treatment, CP pa-
tients had higher grades of chronicity (MPSS) but the
severity of the chronic pain (CPG) was comparable. There
were no differences in the pain sensitivity (PPT) between
groups (Table 2). However PPT was weakly and nega-
tively correlated with current hip pain intensity (total
r = .20; P = .028) and average hip pain intensity over
the past 3 months (r = .28; P = .004) for the whole pa-
tient sample.
Preoperative Functional Status and
Psychological Characteristics
No significant differences were observed for the
WOMAC or functional test scores (Table 3). There were
no differences in depressive symptoms, anxiety, or stress
on the preoperative day (relevant scores: nCP 5% and CP
6% for depression, nCP 10% and CP 7% for stress, nCP
15% and CP 11% for anxiety) and no differences in
pain-related fear of movement, catastrophizing,
helplessness, thought suppression, or the tendency of so-
matization (Table 4).
Postoperative Pain and Analgesic
Consumption
Patients in the CP group reported greater movement-
evoked pain and greater maximum pain intensity
compared with nCP patients on all days except for
NCP (N = 39) CP (N = 86) STATISTICAL ANALYSIS
46/54 [18/21] 39/61 [34/52] P = .558, c2 = .192
61.6 6 14.3 63.9 6 11.9 P = .350, T = .937
26.3 6 4.0 28.9 6 5.7 P = .012, T = 2.549
30.4 6 7.4 29.8 6 7.5 P = .713, T = .369
46.7 6 12.6 50.5 6 11.2 P = .106, T = 1.629
Erlenwein et al
day 1 (Fig 1). A tendency of greater postoperative opioid
consumption in the CP group (especially over the course
of the postoperative rehabilitation until the seventh day)
could be detected, but this difference was not statisti-
cally significant (Fig 1). There were no differences in non-
opioid consumption (Medication Quantification Scale:
day 1: P = .517, T = .649; day 3: P = .767, T = .297; day
5: P = .306, T = 1.029; and day 7: P = .405, T = .835).
Postoperative Function and Mobilization
Patients in the CP group needed more days until they
were mobilized on stairs and until they gained the ability
to climb stairs independently. They were also more
restricted in daily function (Table 3).
Postoperative Psychological Distress
Postoperatively, psychological distress decreased
overall, but CP patients reported higher levels of psycho-
logical distress than nCP patients. This was not related
to anxiety but rather stress and depressive mood
(Table 4).
The Journal of Pain 241
Association Between Pain and Function
Ordinal and continuous variables with differences be-
tween both groups were included into the multivariate
analysis for each group separately: For the outcome
‘‘physical function’’ (modified WOMAC), the analysis
included BMI, duration of chronic pain, MPSS, postoper-
ative stress and depression, maximal pain intensities on
days 3, 5, and 7, and pain intensities during movement
on days 3, 5, and 7. For the outcome ‘‘pain intensity’’
the analysis included function on day 7 (modified
WOMAC), BMI, duration of chronic pain, MPSS, postop-
erative stress, and depression.
The multivariate analysis showed that pain intensity,
reported by nCP patients on the seventh postoperative
day, was the only factor to influence their level of func-
tion on that day. In contrast, for CP patients, greater
motion-evoked pain on former days influenced function
on day 7. In this group, pain intensity reported on the
day of the functional measurement had no independent
influence on their functionality. Furthermore, for
CP patients, depressed mood and higher BMI were
also independent risk factors for limited function
(Table 5).

Table 2. Preoperative Pain Characteristics

CHARACTERISTIC TOTAL (N = 125) NCP (N = 39) CP (N = 86) STATISTICAL ANALYSIS
Hip pain intensity
At the time of the interview 5 (3–7) 5 (3–7) 5 (2.75–7) P = .703, Z = .381
Maximum during the past 3 mo 8 (7–9) 8 (8–9) 8,5 (7–9.25) P = .565, Z = .575
Average during the past 3 mo 5.5 (5–7) 5 (5–7) 6 (4–7) P = .979, Z = .027
Duration of chronic pain, % [n]
6–12 mo 9 [12] 20 [8] 5 [4] P < .001, Z = 3.897
1–2 y 13 [16] 20 [8] 9 [8]
2–5 y 21 [26] 26 [10] 19 [16]
>5 y 57 [71] 34 [13] 67 [58]
Duration of chronic hip pain, % [n]
6–12 mo 21 [26] 21 [8] 21 [18] P = .317, Z = 1.000
1–2 y 22 [28] 21 [8] 23 [20]
2–5 y 33 [41] 25 [10] 36 [31]
>5 y 24 [30] 33 [13] 20 [17]
MPSS (%) [n]
I 33 [41] 77 [30] 13 [11] P < .001, Z = 6.668
II 42 [53] 20 [8] 52 [45]
III 25 [31] 3 [1] 35 [30]
Chronic pain grade, % [n]
0 0 [0] 0 [0] 0 [0] P = .493, Z = .685
1 14 [17] 21 [8] 11 [9]
2 23 [29] 16 [6] 26 [23]
3 20 [25] 24 [10] 18 [15]
4 43 [54] 39 [15] 45 [39]
Pain sensitivity
Pain pressure threshold, kPA 377.9 6 179.4 383.5 6 205.1 375.5 6 168.2 P = .834, T = .210
Current pain medication, % [n]
Opioids
None 82 [103] 85 [33] 81 [70] P = .700, Z = 3.897
‘‘As required’’ 5 [6] 5 [2] 5 [4]
Daily dosage # 30 mg ME 10 [13] 5 [2] 13 [11]
Daily dosage > 30 mg ME 3 [3] 5 [2] 1 [1]
Nonopioids 60 [75] 51 [20] 64 [55] P = .237, c2 = 1.795

Abbreviation: ME, morphine equivalent.

NOTE. Numerical variables are presented as mean 6 SD. Variables on the Numeric Rating Scale are presented as mean and quartiles. Categorical variables are presented
as percent and absolute number of patients.
242 The Journal of Pain Chronic Pain and Postoperative Pain and Function
Table 3. Pre- and Postoperative Functional Status and Mobilization
CHARACTERISTIC TOTAL (N = 125) NCP (N = 39) CP (N = 86) STATISTICAL ANALYSIS
Preoperative
Timed up and go, % [n]
Score 1 21 [27] 21 [9] 21 [18] P = .475, Z = .715
Score 2 63 [79] 68 [26] 61 [53]
Score 3 13 [16] 11 [4] 15 [12]
Score 4 3 [3] 0 [0] 3 [3]
Score 5 0 [0] 0 [0] 0 [0]
Climbing stairs test, % [n]
Score 1 68 [85] 72 [27] 66 [58] P = .487, Z = .695
Score 2 15 [19] 14 [6] 16 [13]
Score 3 3 [3] 0 [0] 4 [3]
Score 4 0 [0] 0 [0] 0 [0]
Score 5 14 [18] 14 [6] 14 [12]
Functional questionnaire
WOMAC Score 158.2 6 58.8 145.4 6 69.5 165.1 6 52.0 P = .127, T = 1.440
Subscore: pain 51.1 6 21.0 53.0 6 17.9 46.9 6 26.5 P = .229, T = 1.219
Subscore: stiffness 53.9 6 23.3 49.1 6 25.3 56.0 6 22.2 P = .157, T = 1.427
Subscore: physical function 53.9 6 21.3 47.9 6 22.7 56.6 6 20.2 P = .054, T = 1.948
Range of motion (degrees)
Range extension/flexion 79.4 6 22.5 80.8 6 26.4 78.8 6 20.7 P = .647, T = .459
Maximum internal rotation in flexion 10.8 6 27.9 18.5 6 49.5 7.5 6 7.1 P = .882, T = 1.324
Maximum abduction 22.8 6 10.6 23.8 6 11.6 22.4 6 10.1 P = .481, T = .707
Postoperative
Functional questionnaire
WOMAC score (modified) 38.4 6 28.5 25.5 6 22.6 44.0 6 29.0 P < .001, T = 3.706
Subscore: pain (modified) 15.4 6 13.8 10.0 6 10.0 18.0 6 14.4 P = .001, T = 3.908
Subscore: physical function (modified) 22.9 6 18.2 15.9 6 15.3 26.0 6 18.6 P = .003, T = 2.818
Range of motion
Range extension/flexion 78.7 6 16 79.7 6 17.9 78.2 6 15.2 P = .644, T = .463
Maximum abduction 28.2 6 8.8 30.0 6 8.5 27.4 6 8.9 P = .137, T = 1.496
Maximum internal rotation in flexion - - - -
Mobilization by physiotherapists, % [n]
Active mobilization on stairs on day 7 55 [67] 70 [27] 49 [42] P = .022, c2 = 4.787
Ability to climb stairs on day 7 63 [75] 76 [30] 56 [48] P = .026, c2 = 4.529

NOTE. Numerical variables are presented as mean 6 SD. Categorical variables are presented as percent and absolute number of patients.

Conclusions In contrast to previous findings, pain did not continu-

Our results indicate that chronic pain is not only asso-
ciated with severe postoperative pain, but also with
poor physical function, delayed mobilization, and
mental recovery. Patients, who had other chronic pain
entities besides pain attributed to osteoarthritis of the
hip, had a prolonged mobilization. On the objective
assessment of goal obtainment according to the stan-
dardized mobilization plan, CP patients also reported
poorer subjective physical function postoperatively,
and had more psychological stress. This indicates that
chronic pain has a clinically relevant effect on postoper-
ative rehabilitation and needs to be considered more as a
comorbidity in treatment and care.
Pain Intensity
There were clinically relevant differences for pain in-
tensity during movement and maximum pain, but not
at rest. These findings are in line with other results,
which revealed that movement-related pain after sur-
gery is more relevant and better reflects differences be-
tween patients than pain at rest.46
ously decrease over the course of the first postoperative
week.17 After an early decrease, pain increased again in
both groups. This was associated with the progress of
mobilization and might be specific for musculoskeletal
surgery. Pain during movement only increased in CP pa-
tients and it remained stable and comparatively low in
nCP patients. This finding showed that the evaluation
of procedure-specific pain intensity only using unique se-
lective assessment lacks important information about
the course and thus has limited validity. However, it indi-
cates that different patient groups might have different
pain patterns with regard to certain risk factors and sur-
gical procedures.9,15,17 Although differences in
individual pain sensitivity have been linked to
postoperative pain intensity, pressure pain sensitivity
did not explain differences in our study.22,40,47 Taken
together this suggests that the temporal dimension of
pain (eg, time pattern of pain intensity in response to
recovery and mobilization) requires greater
consideration.
In contrast to the differences in pain intensity and to
findings of other studies, no difference in analgesic
Erlenwein et al The Journal of Pain 243
Table 4. Pre- and Postoperative Psychological Characteristics
CHARACTERISTIC TOTAL (N = 125) NCP (N = 39) CP (N = 86) STATISTICAL ANALYSIS
Preoperative
Psychological distress
DASS, subscale depression 3.7 6 3.9 3.6 6 4.0 3.7 6 3.9 P = .843, T = .199
DASS, subscale anxiety 1.9 6 2.4 1.9 6 2.6 1.9 6 2.3 P = .940, T = .076
DASS, subscale stress 5.4 6 4.3 5.4 6 4.9 5.4 6 4.1 P = .961, T = .049
Kinesophobia (TSK) 36.4 6 6.3 36.3 6 6.4 36.4 6 6.3 P = .978, T = .027
Somatisation (PHQ-15) 6.0 6 3.4 5.4 6 2.6 6.3 6 3.6 P = .177, T = 1.366
Cognitive appraisal of pain and catastrophizing
Helplessness (Thoughts of Help-/Hopelessness Scale) 2.1 6 1.7 2.2 6 1.8 2.1 6 1.7 P = .933, T = .367
Catastrophizing Thoughts scale 0.9 6 1.2 0.9 6 1.0 0.9 6 1.4 P = .717, T = .332
Thought Suppression scale 2.6 6 1.6 2.5 6 1.5 2.8 6 1.8 P = .460, T = .646
Postoperative
Psychological distress
DASS, subscale depression 2.2 6 3.2 1.5 6 2.1 2.6 6 3.6 P = .036, T = 2.120
DASS, subscale anxiety 2.1 6 2.5 1.6 6 1.6 2.3 6 2.7 P = .158, T = 1.422
DASS, subscale stress 3.2 6 3.7 2.2 6 2.7 3.6 6 4.0 P = .028, T = 2.232
Kinesiophobia (TSK) 35.0 6 6.0 33.7 6 5.2 35.2 6 6.3 P = .196, T = 1.300

NOTE. Data are presented as mean 6 SD except where otherwise noted.

consumption was observed.25,45 This might be because
the assessment of pain intensity for our study was
carried out independently from the routine
measurement by the ward staff, on which the
adaptation of analgesia was based. The study
assessment was related to the previous 24 hours,
whereas the routine measurements were used to
assess current pain. Thus, our results reflect a more
cumulated judgment of pain intensity, independent
of the actual triggers of provision of additional
analgesic medication.
Functionality
Previous studies have shown an association between
preoperative function and outcome after hip replace-
ment.24,37,53 Although mobility and hip-specific function
were not different in our study groups preoperatively,
postoperatively a significant functional difference
emerged. A history of chronic pain was associated with
delayed postoperative mobilization and poorer
function—reflected in the objective assessment by the
physiotherapists and the subjective evaluation by the pa-
tients themselves.
It remains unclear whether the intensity of pain inter-
feres with functional improvement or whether the
failure or delay to improve function maintains
pain.11,32 It might also be possible that specific
movement disorders related to other chronic pain
manifestations became apparent—which were
previously masked by the hip pain.
The results of the multivariate analysis showed that in
both groups, pain and function were associated albeit in
different ways. The analysis for independent predictors
showed that for nCP patients only the pain at the time
point of the functional assessment was related. In this
group, there seemed to be a direct relationship between
pain and function. In contrast, for CP patients,
movement-evoked pain rated on previous days as well
as depressive mood and BMI influenced their function
1 week after surgery. In addition, pain on the previous
days (in combination with other factors) had a much
lower level of explained variance than pain alone in
the nCP group, which indicated that the function of
the CP patients was influenced by multiple interacting
factors. Moreover, a negative amplification of pain
caused by delayed mobilization and slower resolution
of psychological distress might have contributed,
because it has been shown that successful and timely
mobilization has a positive effect on pain after endo-
prosthetic surgery.11,32 The poorer capacity for
mobilization in CP patients underlined the necessity to
improve postoperative recovery for these patients. This
requires a detailed assessment of chronic pain patients
beyond the consideration of a premedication with
opioids or a dichotomization of the presence of chronic
pain (yes vs no).
Psychological Function
The patient groups did not differ in their level of
anxiety or kinesiophobia. Although both features can
be associated with poorer postoperative function or
pain, they did not contribute to the difference in our
cohort.35,51 Overall, the values for affective distress
were rather low—only a few patients exceeded
cutoff values, which indicated the need for further
psychological exploration or the presence of possible
psychiatric comorbidity.33 Nevertheless, postopera-
tively the CP patients retained greater values for stress
and depressed mood. In the prediction analysis we
found a close relationship between ‘‘depressed
mood’’ and function and pain—but only for CP pa-
tients. This was supported by findings of earlier
studies, which identified depression as a risk factor
for severe postoperative pain, and also for functional
deficits.8,18,23,39 These findings suggest that
psychological factors should also be considered in
perioperative concepts, consistent with the
multimodal concept of chronic pain. This is in line
244 The Journal of Pain Chronic Pain and Postoperative Pain and Function

Figure 1. Postoperative pain intensity and analgesic consumption (nCP patients, white bars: n = 39; CP patients, gray bars: n = 86;
*P < .05, medians and quartiles are given). (A) Maximum pain; day 1: P = .169, Z = 1.377; day 3: P = .003, Z = 2.964; day 5:
P = .004, Z = 2.886; day 7: P = .02, Z = 2.321. (B) Pain during movement; day 1: P = .172, Z = 1.366; day 3: P = .032, Z = 2.245;
day 5: P = .009, Z = 2.616; day 7: P = .001, Z = 3.383. (C) Pain at rest; day 1: P = .966, Z = 0.43; day 3: P = .434, Z = 0.783; day 5:
P = .376, Z = .885; day 7: P = .620, Z = .496. (D) Opioid consumption during ‘‘first 48 hours’’: P = .682, T = .411; day 3: P = .814,
T = .236; day 5: P = .249, T = 1.158; day 7: P = .329, T = .980.

with the fact that psychological distress is also
associated with the progression from acute to
persistent and/or chronic postsurgical pain.10,21
Definition of Chronic Pain
Although the severity and chronicity of chronic pain
were recorded, the group allocation was on the basis
of the 1-dimensional temporal definition of pain
(>6 months).17 Thus, the definition of the ‘‘chronic pain
group’’ might be problematic. In studies on the role of
chronic pain on perioperative outcome, a multidimen-
sional approach should also be preferred—as recommen-
ded for studies on chronic postoperative pain.52
Nevertheless, in our analysis a comparison of postopera-
tive function according to severity or degree of chro-
nicity (CPG, MPSS) was not significantly different.
Reasons might be the inability of the CPG to differentiate

Table 5. Factors Associated With Worse Postoperative Pain Intensity and Worse Physical Function
OUTCOME GROUP R2 F P INDEPENDENT PREDICTORS
Movement-evoked pain* nCP .256 10.340 .003 Function
CP .258 12.841 <.001 Function, depression
Maximum pain* nCP .256 10.320 .003 Function
CP .210 9.838 <.001 Function, stress
Physical function (modified nCP .531 33.928 <.001 Maximum pain day 7
functional questionnaire 7th day) CP .374 14.526 <.001 Movement-evoked pain day 5,
depression, BMI

*Cumulative pain intensity was calculated over day 1, day 3, day 5, and day 7.
Erlenwein et al
between several chronic pain manifestations and the
static character of the MPSS.
Strengths
A strength of the present study was the simultaneous
consideration of the perioperative dynamics of clinical
psychological parameters up to the seventh postopera-
tive day. The comparison was made between 2 homoge-
neous groups, without extreme functional baseline
differences, as would be expected in a comparison of
chronic pain patients with a group without pre-existing
pain. The initial characterization showed no significant
functional differences. Also, there was no variability in
pain management because of regional analgesia as is
the case, for example, in total knee arthroplasty.7
Predictors for severe pain and less function could be
analyzed separately for both groups.
Limitations
Despite differences in pain intensity, there were no dif-
ferences in the amount of administered analgesics.
Although the measures reported were collected indepen-
dently of the measures used for pain management, this
might indicate that the treatment algorithm used re-
quires adaptation to optimize treatment of chronic pain
patients. However, the observation that patients with
chronic pain report greater postoperative pain is a univer-
sal finding in many studies.8,17,25,40 It is not clear if this
reflects deficits in pain management or intrinsic patient-
related factors, like differences in appraisal of pain.
Baseline function was examined using objective tests
and subjective questionnaires related to function. How-
ever, because of the risk of hip dislocation, the postoper-
ative re-examination was limited to questionnaire items
suitable at that time point and to external assessment by
physiotherapists.
Patients with isolated hip pain reported a longer
duration of hip pain, but no differences in affective
or functional baseline status could be found. This sup-
ports rather than contradicts the influence of addi-
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