Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

Immediate preoperative outcomes of pain

neuroscience education for patients undergoing
total knee arthroplasty: A case series

Adriaan Louw PT, PhD, Kory Zimney PT, DPT, Jordan Reed PT, DPT, Merrill
Landers PT, DPT, PhD & Emilio J. Puentedura PT, DPT, PhD

To cite this article: Adriaan Louw PT, PhD, Kory Zimney PT, DPT, Jordan Reed PT, DPT, Merrill
Landers PT, DPT, PhD & Emilio J. Puentedura PT, DPT, PhD (2019) Immediate preoperative
outcomes of pain neuroscience education for patients undergoing total knee arthroplasty: A case
series, Physiotherapy Theory and Practice, 35:6, 543-553, DOI: 10.1080/09593985.2018.1455120

To link to this article: https://doi.org/10.1080/09593985.2018.1455120

Published online: 28 Mar 2018.

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PHYSIOTHERAPY THEORY AND PRACTICE
2019, VOL. 35, NO. 6, 543–553
https://doi.org/10.1080/09593985.2018.1455120

RESEARCH REPORT

Immediate preoperative outcomes of pain neuroscience education for patients

undergoing total knee arthroplasty: A case series
Adriaan Louw PT, PhDa, Kory Zimney PT, DPTb, Jordan Reed PT, DPTc, Merrill Landers PT, DPT, PhDd,
and Emilio J. Puentedura PT, DPT, PhDd
a
International Spine and Pain Institute, Story City, IA, USA; bDepartment of Physical Therapy, School of Health Sciences, University of South
Dakota, Vermillion, SD, USA; cRehabilitation Services, Spencer Hospital, Spencer, IA, USA; dDepartment of Physical Therapy, School of Allied
Health Sciences, University of Nevada Las Vegas, Las Vegas, NV, USA

ABSTRACT ARTICLE HISTORY

Background: Standard preoperative education for total knee arthroplasty (TKA) has been shown Received 1 February 2017
to have no effect on postoperative outcomes. This may be because such education programs fail Accepted 21 October 2017
to educate patients about pain. Pain neuroscience education (PNE) focuses on teaching people Revised 28 August 2017
more about pain from a neurobiological and neurophysiological perspective. Design and setting: KEYWORDS
Case Series. Aim: To determine the immediate effects, if any, of providing PNE before TKA surgery Arthroplasty; knee
on patient self-report measures. Participants: Twelve patients (female = 10) prior to TKA for knee osteoarthritis; pain
osteoarthritis (OA). Intervention: Preoperative educational session by a physical therapist on the Education; preoperative
neuroscience of pain, accompanied by an evidence-based booklet. Main outcome measures: education
Comparison of pre- and post-PNE self-report measures on knee pain (NPRS), Pain
Catastrophization Scale (PCS), fear of movement (TSK), and beliefs about TKA; as well as three
physical performance measures – knee flexion active range of motion, 40 m self-paced walk, and
pressure pain threshold (PPT). Results: Immediately following the PNE, patients had statistically
significant lower TSK scores, increased PPT, and improved beliefs about their upcoming surgery.
There were no significant changes in knee pain, function, or flexion active range of motion.
Conclusions: Results appear to suggest that immediately after PNE, patients scheduled for TKA
had statistically significant changes in fear of movement, decreased sensitivity to pain and
positive shifts in their beliefs about their future knee surgery. Larger trials with control/compar-
ison groups are warranted to determine the true effects of preoperative PNE for patients about to
undergo TKA.

Introduction much success in alleviating pain and disability asso-

ciated with severe knee OA, several studies have
Osteoarthritis (OA) is reported as the most common
shown that as many as one in five patients still
joint disease worldwide and affects more than 26
experience significant pain and disability after their
million people in North America (Kopec et al,
knee replacement (Baker et al, 2007; Kennedy et al,
2007). The prevalence of OA continues to rise expo-
2006).
nentially with various epidemiological studies report-
Persistent pain is complex and often a blend of
ing an expected doubling of the prevalence of OA
various biological, physiological, social, and psycholo-
over the next 2 decades (Cross et al, 2014). The
gical factors (Moseley, 2007). Recent research into per-
increasing prevalence has been tied to the aging glo-
sistent pain surrounding individuals undergoing TKA
bal population, decreased activity and obesity (Cross
has centered on psychological risk factors, including
et al, 2014). Total knee arthroplasty (TKA) is a com-
pre-surgical scores on measures of pain catastrophizing,
monly performed surgical procedure designed to alle-
pain-related fear of movement, and depression, which
viate knee pain and improve function in individuals
has shown to be predictive of heightened pain and
with severe knee OA. In 2010 the United States
disability following replacement surgery (Brander,
Center for Disease Control reported that there were
Gondek, Martin, and Stulberg, 2007; Edwards et al,
719,000 TKA performed and it is expected these
2009). Given the increased awareness of these psycho-
numbers will double by 2020 (Williams, Wolford,
logical factors’ importance in recovery following TKA,
and Bercovitz, 2015). Even though TKA has yielded
various preoperative educational approaches have been

CONTACT Emilio J. Puentedura, PT, DPT, PhD louie.puentedura@unlv.edu Department of Physical Therapy, School of Allied Health Sciences,
University of Nevada Las Vegas, 4505 Maryland Parkway, Box 453029, Las Vegas, NV 89154-3029
© 2018 Taylor & Francis
544 A. LOUW ET AL.
developed with the intent to assist patients with their
surgical experience and subsequent recovery (Beaupre,
Lier, Davies, and Johnston, 2004; McDonald et al,
2014). In 2004 and 2005, two systematic reviews eval-
uated the efficacy of preoperative education for total
knee and hip arthroplasty (Johansson et al, 2005;
McDonald, Hetrick, and Green, 2004). These reviews
reported results on 20 randomized controlled trials
involving over 2000 patients undergoing hip and/or
knee arthroplasty and showed that preoperative educa-
tion had a positive effect on preoperative anxiety levels
and patient knowledge, but no changes to postoperative
outcomes, including pain, range of motion (ROM),
function or length of hospital stay, when compared to
“usual care” (Johansson et al, 2005; McDonald, Hetrick,
and Green, 2004). Since the two reviews, several rando-
mized controlled trials have been published, showing
little or no effect of preoperative education addressing
postoperative impairments (Beaupre, Lier, Davies, and
Johnston, 2004; Ferrara et al, 2008; Vukomanovic,
Popovic, Durovic, and Krstic, 2008).
One possible reason why these preoperative educa-
tional sessions have yielded little to no benefit for
patients undergoing arthroplasty may be the lack of
education specifically in regards to pain. Most educa-
tion programs used in orthopedic patient populations
utilized anatomical and biomechanical models for
addressing pain (Brox et al, 2008; Maier-Riehle and
Harter, 2001; Moseley, 2004), which not only has
shown limited efficacy (Brox et al, 2008; Koes, Van
Tulder, Van Der Windt, and Bouter, 1994; Maier-
Riehle and Harter, 2001), but may even increase patient
fears, anxiety and stress, thus negatively impact their
outcomes (Maier-Riehle and Harter, 2001). Specific to
preoperative education, most programs focus on pro-
cedural information and are limited in teaching people
more about their pain (Louw, Diener, Butler, and
Puentedura, 2013). Several studies have shown that
pain is a significant issue following many orthopedic
procedures and surgeries (Niskanen and Strandberg,
2005; Pitimana-Aree et al, 2005; Sinatra, Torres, and
Bustos, 2002). Persistent levels of postoperative pain
and the limited effect of medication addressing post-
operative pain have led researchers to investigate ways
to positively impact postoperative pain control after
these surgeries (Fingleton et al, 2015; Meier et al,
2008). In fact, a recent systematic review of preopera-
tive education for TKA, Louw, Diener, Butler, and
Puentedura (2013) showed only one study to date hav-
ing an immediate postoperative impact on pain; a study
that specifically addressed pain education (McDonald,
Freeland, Thomas, and Moore, 2001).
In recent years, a new type of education has gained
considerable interest, and is referred to as pain neu-
roscience education (PNE) (Louw, Diener, Butler,
and Puentedura, 2011; Louw, Diener, Landers, and
Puentedura, 2014; Nijs, Van Houdenhove, and
Oostendorp, 2010). PNE is an educational strategy
used by physical therapists that focuses on teaching
people more about the neurobiological and neuro-
physiological processes involved in their pain experi-
ence (Meeus et al, 2010; Moseley, 2002). Current best
evidence regarding musculoskeletal pain provides
strong support for PNE to positively influence pain
ratings, dysfunction, fear-avoidance, pain catastro-
phization, limitations in movement, pain knowledge,
and healthcare utilization (Louw, Diener, Butler, and
Puentedura, 2011; Louw, Zimney, Puentedura, and
Diener, 2016). Specific to surgery, a PNE program
was recently developed and tested on patients under-
going lumbar surgery for radiculopathy (Louw,
Butler, Diener, and Puentedura, 2013; Louw,
Diener, Landers, and Puentedura, 2014; Louw,
Diener, and Puentedura, 2015). The purpose of the
preoperative PNE program was to teach patients
more about pain from a neurobiological and neuro-
physiological perspective, with the intent to help
them understand their pain after surgery (Louw,
Butler, Diener, and Puentedura, 2013). At 1-year
follow-up, patients spent 45% less on healthcare and
rated their surgical experience far superior compared
to patients not receiving PNE prior to surgery, even
though similar pain and disability levels were found
(Louw, Diener, Landers, and Puentedura, 2014).
Furthermore, it has been established that patients
with high pain catastrophization and presence of
central sensitization are ideally suited for PNE
(Louw, Zimney, Puentedura, and Diener, 2016; Nijs
et al, 2011). In line with the PNE research, it is now
well established that many patients with knee OA
present with high levels of pain catastrophization
(Baert et al, 2016), as well as signs of central sensiti-
zation (Baert et al, 2016; Lluch Girbes, Nijs, Torres-
Cueco, and Lopez Cubas, 2013). Considering this
information, there is a potential need to develop
and test a preoperative PNE program for patients
undergoing TKA. This case series aims to report on
the immediate effects related to pain, physical func-
tion, catastrophization, fear of movement, and beliefs
about surgery following a preoperative PNE program
for patients with knee OA awaiting TKA. These
potential immediate effects may provide insight into
the pre-operative subsection of the entire TKA
experience.

Methodology
Patient descriptions and examinations
Internal review board approval was obtained from the
University of Nevada Las Vegas and all patients pro-
vided written informed consent to participate in the
study. This case series comprises data from a sample
of consecutive patients with knee OA awaiting TKA at
Spencer Hospital (IA) that were scheduled for a pre-
operative educational class prior to surgery. All patients
were scheduled to attend a mandatory preoperative
TKA education program which covered: anatomy of
the knee joint and information about the joint replace-
ment surgery (i.e. what to expect when they were
admitted for surgery, what to expect immediately after
surgery, pain medications, and postoperative rehabilita-
tion/physical therapy). The patients were scheduled to
meet as a group (usually 10–12 patients per group) to
receive their standard preoperative TKA education pro-
gram and they were invited to participate in this case
series study before they received their standard educa-
tion program.
Inclusion criteria were that patients had to: (1) be
scheduled to have a TKA and their standard preopera-
tive TKA education program; (2) indicate their will-
ingness to participate in the study; and (3) ability to
read and understand English, as the study included the
use of an educational booklet. Because all potential
participants for this study had been screened and
cleared for their orthopedic surgery, the only exclusion
criterion was an unwillingness to participate in the
study.
Self-report outcome measures
Prior to PNE and after completion of the consent and
demographic intake forms, patients were asked to com-
plete self-report surveys related to knee pain, function,
fear avoidance, pain catastrophization, fear of move-
ment, and their beliefs about surgical outcome.
Knee pain (numeric pain rating scale – NPRS)
Knee pain was measured with the use of the NPRS, as
has been used in various PNE studies (Louw, Diener,
Landers, and Puentedura, 2014; Moseley, 2002, 2003).
A change of 2.1 points has been reported as the mini-
mal detectable change (MDC) (Cleland, Childs, and
Whitman, 2008).
Function (WOMAC)
Function (at baseline only) was assessed with the
WOMAC, an assessment of pain; disability and joint
stiffness in knee OA consisting of 24 questions. The
PHYSIOTHERAPY THEORY AND PRACTICE 545
WOMAC measures five items for pain (score range
0–20), two for stiffness (score range 0–8), and 17 for
functional limitation (score range 0–68) (Beaupre, Lier,
Davies, and Johnston, 2004; Ferrara et al, 2008).
Therefore, total scores range from 0 to 96 and a percen-
tage score can be calculated with higher score/percentage
indicating greater disability. Physical functioning ques-
tions cover everyday activities, such as stair use, standing
up from a sitting or lying position, standing, bending,
walking, getting in and out of a car, shopping, putting on
or taking off socks, lying in bed, getting in or out of a
bath, sitting, and heavy and light household duties. The
WOMAC has been shown to have good test–retest relia-
bility, construct validity, and excellent internal consis-
tency (Basaran, Guzel, Seydaoglu, and Guler-Uysal,
2010). Because we did not anticipate immediate changes
in function following PNE, the WOMAC was assessed at
baseline only to describe the case sample.
Pain catastrophization (PCS)
The PCS is a self-report questionnaire that assesses
inappropriate coping strategies and catastrophic think-
ing about pain and injury. The PCS has been used in
previous PNE studies (Moseley, 2004; Moseley, Hodges,
and Nicholas, 2004) and demonstrates strong construct
validity, reliability and stability (Sullivan, Bishop, and
Pivak, 1995). The PCS utilizes a 13-item, 5-point Likert
scale with higher scores indicating elevated levels of
catastrophizing. Previous studies utilizing the PCS
have shown a median score of 18 for healthy indivi-
duals and in patients with pain, the PCS is generally
higher (Sullivan, Bishop, and Pivak, 1995). The MDC
for the PCS is reported to be 9.1 points (George,
Valencia, and Beneciuk, 2010).
Fear of movement (Tampa scale of kinesiophobia –
TSK)
To evaluate the participant’s pain-related fear of move-
ment and (re)injury the TSK was used (Hapidou et al,
2012). Each item is scored on a four-point Likert-type
scale that ranges from strongly agree [1] to strongly
disagree [4]. Total scores range from 17 to 68, and
higher scores indicate more fear of movement and/or
(re)injury. Construct and predictive validity along with
good internal consistency and reliability for pain
related fear (Roelofs et al, 2004; Swinkels-Meewisse
et al, 2003). For chronic pain, the MDC is reported to
be 5.6 points (Hapidou et al, 2012).
Beliefs regarding TKA
The 12 patients scheduled for TKA were also asked to
rate their level of agreement on a 10-point scale
(strongly disagree [0]–strongly agree [10]) with 6
546 A. LOUW ET AL.
statements regarding TKA. The statements were used
in a similar PNE study for lumbar surgery and adapted
for TKA (Louw, Diener, Landers, and Puentedura,
2014; Louw, Diener, and Puentedura, 2015): (1) “I feel
prepared and ready to have knee surgery”; (2) “I am
afraid of the upcoming knee surgery”; (3) “I know what
to expect after the knee surgery”; (4) “Knee pain after
the surgery is expected”; (5) “I can control the amount
of pain I may experience after the surgery”; and (6)
“The knee surgery will fix my pain”.
All self-report outcome measures (except the
WOMAC) were repeated immediately following the
PNE so they could be compared to pre-PNE scores.
Physical measures
Prior to, and immediately after the preoperative PNE,
three physical measures were collected: (1) knee flexion
active ROM; (2) 40 m walk test; and (3) pressure pain
thresholds (PPT).
Knee flexion active ROM
Active knee flexion ROM was assessed with a standard
goniometer with the patient in a seated position. To
ensure consistency of pre- and post-PNE measure-
ments, skin marks were placed for the goniometric
measurements. There is good evidence for the reliabil-
ity and validity of goniometric knee ROM measure-
ments (Beaupre, Lier, Davies, and Johnston, 2004).
Physical function (40 m self-paced walk test
[SPWT])
To establish a performance-based assessment of physical
function for a patient with knee OA, the 40 m SPWT
was used (Dobson et al, 2013). In a recent study, the
Osteoarthritis Research Society International, based on
the consensus of 138 clinical and scientific experts
recommended the 40 m SPWT as one of the key physical
performance tests with people with knee OA (Dobson
et al, 2013). The SPWT assesses the time it takes to walk
40 m quickly and safely without overexerting oneself.
The time it takes to cover a specified distance is recorded
in seconds. Walking velocity for males (m/s) has been
reported as 1.14 and females as 0.89 (Kennedy et al,
2002). Additionally, each patient’s heart rate and blood
pressure were measured to establish safety for the 40 m
SPWT.
Nerve sensitivity (PPT)
To assess the sensitivity of the nervous system, pres-
sure algometry was used. PPT followed standardized
protocols (Fernandez-de-las-Penas et al, 2009;
Fernandez-de-Las-Penas et al, 2010) and was mea-
sured in pounds (lbs/in2) using a digital pressure-
pain algometer. The algometer had a 1 cm2 round
rubber tip that was placed over the three previously
determined points of: (1) the web space of the domi-
nant hand; (2) posterior midline of the knee set for
TKA; and (3) posterior midline of the non-operative
knee. Before applying pressure, the examiner
instructed each participant: “I am going to begin
applying pressure to your skin. I want you to tell
me the moment the sensation changes from comfor-
table pressure to slightly unpleasant pain”. Pressure
was then applied at a rate of 5 Newton’s/s. The
examiner stopped applying pressure and recorded
the measurement when the participants said “now”.
Three consecutive PPT measurements were taken at
each point with 20 s rest in between each measure-
ment and the mean of the three trials was used for
analysis. In patients with knee OA, the MDC for PPT
has been reported as 1.53 lbs and the standard error
of measurement as 0.66 lbs (Mutlu and Ozdincler,
2015).
All pre- and post-PNE outcome measures and phy-
sical measures were supervised and performed by inde-
pendent physical therapists, blinded to the exact
purpose of the study.
Intervention: preoperative pain neuroscience
education
The 30-min PNE program used in this study was an
adaptation of the program developed for lumbar sur-
gery (Louw, Butler, Diener, and Puentedura, 2013;
Louw, Diener, Landers, and Puentedura, 2014). The
educational material and content used in the spine
surgery study were altered to reflect knee pain, knee
OA, and TKA (Louw, 2015). The educational program
was designed to be delivered by a physical therapist in
group sessions to patients prior to their TKA. The
group format was used in this study, instead of one-
to-one individualized education, to conform to the
hospital and orthopedic surgeons’ normal educational
protocol. Patients also received a patient booklet con-
taining the same information provided during the live
lecture program. The primary focus of the preoperative
PNE program was to help patients re-conceptualize
their knee and leg pain as an increase in nerve sensi-
tivity and up-regulation of the peripheral and central
nervous system, at the same time defocusing attention
from nociceptive input via the tissues from the affected
areas. The PNE message thus aimed to reduce anxiety
and uncertainty, and promote positive expectations and
beliefs.
 PHYSIOTHERAPY THEORY AND PRACTICE 547

The PNE program was designed to include: prepared Table 1. Demographics for the 12 patients scheduled to
pictures (Meeus et al, 2010; Moseley, 2004; Moseley, undergo total knee arthroplasty (TKA).
Hodges, and Nicholas, 2004; Van Oosterwijck et al, Characteristic Results
● Female n = 10 (83.3%)
2011); examples (Meeus et al, 2010; Moseley, Hodges, ● Age Mean = 68.6 ± 8.7 years
and Nicholas, 2004; Van Oosterwijck et al, 2011); and Median = 70.1
metaphors (Van Oosterwijck et al, 2011). The sensitivity (range = 49.1–79.9)
● Primary reason for TKA Pain = 6 (50%)
of the nervous system, metaphorically described as an Weakness = 3 (25%)
alarm system (Van Oosterwijck et al, 2011), accompanied Decreased function and
mobility = 3 (25%)
with drawings of action potentials (Moseley, 2004; Van ● Duration of knee pain Mean = 6.8 ± 0.9 years
Oosterwijck et al, 2011) was used to describe: peripheral Median = 3.8 (range = 0.5–
32.0)
sensitization (Moseley, 2004; Moseley, Hodges, and ● Which knee is receiving the TKA? Left = 7 (58.3%)
Nicholas, 2004; Van Oosterwijck et al, 2011); central ● Previous TKA? No = 100%
● Other prior orthopedic surgeries? (Yes/No) Yes = 9 (75%)
sensitization (Moseley, 2004; Moseley, Hodges, and Overall satisfaction rated as
Nicholas, 2004; Van Oosterwijck et al, 2011); and plasti- 78%
● Disability (Western Ontario and McMaster Mean = 53 ± 11.5
city of the nervous system (Moseley, Hodges, and Universities Osteoarthritis Index) (0–96) Median = 54.0
Nicholas, 2004; Van Oosterwijck et al, 2011). The 30- (range = 30.0–72.0)
● Current knee pain (0–10) Mean = 4.3(±2.6
min group PNE lecture was provided in the form of a Median = 5.0 (0.0–8.0)
PowerPoint presentation by one of the authors, and ● Pain catastrophization (0–52) Mean = 15.6 ± 0.5
Median = 7.0 (range = 1.0–
patients were able to ask questions during, as well as 51.0)
after the presentation. The presentation was given prior ● Tampa Scale of Kinesiophobia (17–68) Mean = 41.7 ± 5.2
Median = 42.0
to the typical hospital preoperative education class cover- (range = 31.0–54.0)
ing procedural information pertaining to the TKA. ● Pressure pain thresholds (pounds/in.2) TKA Knee
mean = 11.3 ± 8.3
Median = 9.5 (range = 1.0–
25.2)
Data analysis Non-operative Knee
mean = 13.9 ± 5.8
All data were analyzed using SPSS version 22.0 (IBM Median = 12.9 (range = 4.2
to 25.3)
SPSS Statistics for Windows, Version 22.0. Armonk, Dominant Hand
NY: IBM Corp) with α = 0.05. To determine if the mean = 11.8 ± 6.7
30-min PNE group sessions had any immediate effects Median = 10.7
(range = 2.5–22.7)
on preoperative TKA patients, the pre- and post-mea- ● Knee range of motion (degrees) Mean = 111 ± 14.3
surements were analyzed using Wilcoxon Signed Ranks Mean = 112.5
(range = 75.0–132.0)
Tests. Non-parametric analyses were used due to the ● 40 m walk test (s) Mean = 48.4 ± 10.8
small sample size. Median = 47.6
(range = 32.2–70.1)

Results
Patients
There were 12 patients (10 female; average age
68.6 years) scheduled to undergo TKA surgery. The
average duration of knee pain was 6.8 years (range
0.5–32) for the cohort. Their total disability rating for
pain, stiffness, and physical function was rated as 53
out of 96 on the WOMAC and an average knee pain of
4.3 out of 10 on a NPRS. Patient demographics of the
study sample can be found in Table 1.
measurements, p = 0.081. There was a statistically sig-
nificant decrease in mean TSK scores from the pre- to
post-measurement, p = 0.036; however, the mean dif-
ference did not meet the MDC of 5.6 and was therefore
not clinically significant. Patients also exhibited an
increased tolerance for PPT on the surgical knee and
dominant hand pre- to post-education, ps ≤ 0.026
(Figure 1). Scores after PNE were not statistically dif-
ferent from the pre-scores for knee flexion ROM mea-
surements or for walking test, p = 0.352 and p = 0.075,
respectively.

Pain-related outcomes
There was no significant difference between the pre and
post pain measurements, p = 0.119 (see Table 2 for
medians and interquartile ranges). Likewise, there was
no difference between the pre and post PCS
Self-reported beliefs
“I know what to expect after TKA” and “I can control
the amount of post-operative pain” were both signifi-
cantly different after the PNE, ps ≤ 0.010 (Table 3).
548 A. LOUW ET AL.

Table 2. Medians and interquartile ranges with associated p value for each of the outcome measures. In contrast to the p values
reported here, the power values were derived from parametric analyses.
Pre PNE Post PNE p values Power
Numeric Pain Rating Scale (0–10) 5.0 3.5 0.119 0.307
IQR = 2.3–6.8 IQR = 1.0–5.0
Range (0.0–8.0) Range (0.0–7.0)
Pain Catastrophization Scale (0–52) 7.0 7.0 0.081 0.372
IQR = 3.3–27.8 IQR = 3.3–15.8
Range (1.0–51.0) Range (0.0–36.0)
Tampa Scale of Kinesiophobia (17–68) 42.0 39.0 0.036*† 0.651
IQR = 38.5–44.0 IQR = 36.0–42.5
Range (31.0–54.0) Range (31.0–46.0)
Knee flexion active range of motion (degrees) 112.5 114.5 0.352 0.117
IQR = 108.3–118.8 IQR = 105.8–118.8
Range (75.0–132.0) Range (76.0–134.0)
40 meter self-paced walk test (s) 47.6 44.7 0.075 0.486
IQR = 43.1–56.4 IQR = 36.1–54.9
Range (32.2–70.1) Range (31.2–61.2)
Pressure pain threshold of TKA knee (pounds/in.2) 9.5 13.7 0.015* 0.824
IQR = 4.8–18.3 IQR = 9.0–24.0
Range (1.0–25.2.0) Range (4.7–25.2)
Pressure pain threshold of non-TKA knee (pounds/in.2) 12.9 15.2 0.480 0.141
IQR = 9.7–17.2 IQR = 9.6–20.1
Range (4.2–25.3) Range (4.7–25.2)
Pressure pain threshold of the hand (pounds/in.2) 10.7 13.0 0.026* 0.440
IQR = 6.5–17.9 IQR = 8.1–20.8
Range (2.5–22.7) Range (2.5–23.0)
*Statistical significance p < .05.
†
Did not exceed minimal detectable change (MDC) for outcome measure.

None of the other self-reported beliefs changed signifi-
cantly after the PNE, ps ≥ 0.223.
Discussion
This case series aimed to report on the immediate
effects of a 30-min preoperative PNE program for
patients awaiting TKA. The results of the case series
suggest that immediately after a PNE session, patients
preparing for their surgery experienced an immediate
local and widespread increase in PPT, suggesting
decreased sensitivity to a painful stimulus.
Additionally, patients exhibited a statistically, but not
clinically significant decrease in pain-related fear of
movement and had a positive shift in various beliefs
regarding their impending surgery. Taken together,
these results suggest that PNE may produce an immedi-
ate positive impact on patients prior to TKA. Another
novel implementation of PNE in this case series was the
use of a group session for PNE, compared to an indi-
vidual session. While there has been limited research
on the utilization of group education with PNE, two
studies have shown effectiveness for pain ratings
(Moseley, 2003; Pires, Cruz, and Caeiro, 2015) and
one also found effectiveness for function/disability
(Moseley, 2003). Certainly, most research has been
directed toward individual sessions (Louw, Zimney,
Puentedura, and Diener, 2016). There is little doubt
that the effectiveness of PNE is based on the depth of
understanding and knowledge absorbed by the patient,
and an argument could be made that this would be
difficult to assure in a 30-min group session. However,
the effectiveness of group delivery does require further
research because of the cost-savings when compared to
one-to-one individual educational instruction. Current
evidence suggests that direct individualized verbal
interaction with a therapist has been found to be the
superior delivery method (Louw, Diener, Butler, and
Puentedura, 2011; Louw, Zimney, Puentedura, and
Diener, 2016). This is thought to be so because it allows
for a more personalized discussion about the patient’s
pain experience and for any specific questions a patient
might have to be thoroughly addressed. Conversely, the
group format does allow for more social interaction
and discussion of pain as a shared experience, and
this too may be of benefit to patients. In this study,
questions from the patients in each group were highly
encouraged and there were no restrictions on time to
ensure all questions were adequately addressed.
One important finding pertains to the increased PPT
thresholds at the TKA knee site, as well as a distal site
at the dominant hand. Pain pressure algometry is com-
monly used to assess the sensitivity of the nervous
system (Fernandez-de-las-Penas et al, 2009;
Fernandez-de-Las-Penas et al, 2010) and it is postulated
that local-only (i.e. at the site of the injury or disease
state) sensitivity is associated with peripheral sensitiza-
tion, whereas local and remote pressure sensitivity is
associated with central sensitivity (Nijs, Van
 PHYSIOTHERAPY THEORY AND PRACTICE 549

Figure 1. Changes in median PPT values after PNE (* indicates statistically significant improvement) (Scale 0–30 in pounds/in.2).

Table 3. Medians and interquartile ranges with associated p values for each of the self-reported beliefs.
Pre Post p values
I feel prepared and ready for the TKA 0.5 0.58 0.223
IQR = 0.0–3.9 IQR = 0.0–1.8
Range (0.0–6.0) Range (0.0–6.0)
I am afraid of the upcoming TKA 8.0 8.5 0.547
IQR = 5.0–10.0 IQR = 4.6–10.0
Range (4.0–10.0) Range (2.0–10.0)
I know what to expect after the TKA 5.0 1.0 0.005*
IQR = 1.3–6.9 IQR = 0.0–2.8
Range (0.0–7.0) Range (0.0–3.5)
Knee pain after TKA is to be expected 1.0 1.0 0.680
IQR = 0.0–1.8 IQR = 0.1–1.0
Range (0.0–3.0) Range (0.0–5.0)
I can control the amount of post-operative pain 3.0 1.0 0.010*
IQR = 2.0–5.0 IQR = 0.0–1.0
Range (0.0–5.0) Range (0.0–3.0)
The TKA will fix my pain 0.8 1.0 0.886
IQR = 0.0–3.8 IQR = 0.3–2.8
Range (0.0–5.0) Range (0.0–3.0)
*Statistical significance p < .05.

Houdenhove, and Oostendorp, 2010). The results of
this study suggest a potential widespread change in
sensitivity, which is in line with current beliefs that
central sensitization may play a significant role in
knee OA pain (Baert et al, 2016; Lluch Girbes, Nijs,
Torres-Cueco, and Lopez Cubas, 2013). After the 30-
min PNE session, there was an increase of PPT at the
TKA knee and dominant hand exceeding the MDC
(1.53 lbs). There is a growing body of evidence suggest-
ing that in a subgroup of patients with knee OA
(particularly those with moderate to severe sympto-
matic OA) (King et al, 2013), the clinical picture may
be dominated by sensitization of central nervous sys-
tem pain pathways (i.e. altered central pain modula-
tion) rather than by structural dysfunctions causing
nociceptive pain (Lluch Girbes, Nijs, Torres-Cueco,
and Lopez Cubas, 2013). In a recent systematic review,
it was shown that pre-surgical altered central pain
modulation, especially widespread pain sensitization,
predicts more pre-surgical and ultimately, post-surgical
550 A. LOUW ET AL.
pain (Baert et al, 2016). The systematic review recom-
mended that surgeons be attentive for patients with
signs of altered central pain modulation before surgery
as they might be at risk for unfavorable post-surgical
outcomes. Furthermore, the authors concluded that a
broader therapeutic approach aiming to desensitize the
central nervous system can be adapted in these patients.
The 30-min PNE session applied in this case series
resulted in an immediate increase in PPT, or calming
of the central nervous system, and may be seen part of a
“broader therapeutic approach” (Baert et al, 2016).
In addition to the PPT, after the preoperative PNE
program there were significant reductions in various
beliefs regarding post-surgical expectations. This may
be important, since satisfaction with TKA has been
shown to strongly correlate with patient expectations
(Noble, Conditt, Cook, and Mathis, 2006).
Additionally, various cognitions, including pain cata-
strophization and fear of movement have been shown
to powerfully impact the outcome of TKA
(Hirschmann, Testa, Amsler, and Friederich, 2013;
Riddle, Wade, Jiranek, and Kong, 2010). Although
changes in PCS did not reach statistical significance
in this study and TSK did, but it failed to meet the
MDC, this study of PNE shows that such an approach
may in fact be able to address these issues in larger
powered trials and the call for standardized preopera-
tive screening and subsequent treatment of these fac-
tors should become part of the preoperative work-up
in orthopedic practice (Hirschmann, Testa, Amsler,
and Friederich, 2013; Riddle, Wade, Jiranek, and
Kong, 2010). The findings of this study regarding
shifting expectations with PNE concur with the PNE
for spine surgery study and its potential to alter the
course of recovery (Louw, Diener, Landers, and
Puentedura, 2014).
The fact that pain did not change significantly con-
curs with the complexity of pain, current evidence for
central sensitization (Baert et al, 2016), as well as pre-
vious PNE studies (Louw, Diener, and Puentedura,
2015). Given the anatomical changes associated with
knee OA, it was not surprising that physical measures
such as walking and knee flexion ROM did not change
significantly (Baert et al, 2014). The fact that PCS did not
change significantly was surprising, given its sizeable
shift in the PNE study for spine surgery (Louw, Diener,
and Puentedura, 2015). In fact, various PNE studies have
shown high levels of PCS may in fact be strong predic-
tors of the success of a PNE approach (Louw, Zimney,
Puentedura, and Diener, 2016). One possible reason may
be the fact that in the spine surgery study, the mean PCS
score of the patients prior to PNE was 25.4, whereas for
this TKA study it was lower at 15.6.
Several limitations exist for this case series. Case series
by design do not utilize a comparison or control group
and the true effect of PNE compared to other interven-
tions, or no intervention, cannot be known. The fact that
the PNE had to be delivered in a group format and was
limited to 30 min, to minimize disruption of the standar-
dized preoperative TKA protocol at the hospital, may also
have been a limitation of the study. Delivering PNE in a
group format is considered to be more cost effective and
needs further study, but the 30-min format may have been
too short a time for participants in the group. In addition,
the small number of participants means that some of the
outcomes, despite the apparent differences in central ten-
dency (i.e. NPRS, knee flexion, 40 m self-paced walk test,
PPT of the non-TKA knee), were underpowered
(Table 2), which means that there is an increased like-
lihood of making a Type II error. Another limitation is
that only one measurement, PPT, was used to investigate
potentially central sensitized state of the subjects.
Additional central sensitization measurements of tem-
poral summation or conditioned pain modulation were
not utilized in this case series. Additionally, the majority
of patients in this case series (83%) were female, and this
should be taken into account.
Implications
Current preoperative educational approaches for TKA
have a positive effect on preoperative anxiety levels and
patient knowledge, but no significant effect on post-
operative outcomes like pain, ROM, function or length
of hospital stay. This may be because these education
approaches have not specifically addressed the patient’s
understanding of pain.
Adding PNE to the preoperative education of patients
undergoing TKA resulted in less sensitivity of the nervous
system and improved beliefs about their surgery, which
are implicated in affecting outcomes. Future studies invol-
ving larger sample sizes and control or comparison
groups may find some effect on other outcome measures
like pain, ROM, function or length of hospital stay.
Conclusion
To the best of our knowledge, this is the first preoperative
PNE study for TKA. After PNE, patients scheduled for
TKA experienced a reduction in PPT and shifted various
beliefs regarding surgery; all of which are implicated in
affecting TKA outcomes. Some measures did not change,
such as pain ratings, pain catastrophization, and knee
ROM. Larger trials with matched non-PNE (usual care)
populations are needed to determine the true effects of
PNE for TKA.

Declaration of interest
The authors declare no conflict of interest.
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