Preventing Persistent Post-Surgical Pain and Dysfunction (PrePARE)

Preventing Persistent Post-Surgical Pain and Dysfunction in At-Risk Veterans: Effect of a Brief Behavioral Intervention

Primary Aim: To examine the superior efficacy of ACT versus Attention Control (AC) on postoperative pain intensity and functioning in at-risk Veterans undergoing TKA. Changes in pain intensity and functioning from baseline to 6 weeks, 3 months and 6 months post-TKA will be compared. Level of pain intensity will be measured using the Brief Pain Inventory (BPI) Pain Severity Subscale and level of functioning will be measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living and Quality Of Life Subscales.

Secondary Aims: A) To examine the superior efficacy of ACT versus AC on the severity of anxiety and depressive symptoms and improvements in coping skills. Changes from baseline to 6 weeks, 3 months and 6 months post-TKA will be compared. Anxiety and depressive symptoms will be measured with the Hamilton Rating Scales (Ham-A and Ham-D, respectively). Coping skills (i.e. Pain Acceptance and Engagement in Values-Based Behavior) will be measured with the Chronic Pain Acceptance Questionnaire and the Chronic Pain Values Inventory. B) To evaluate whether decreases in distress-based symptoms and increases in coping skills mediate changes in pain and functioning at 6 months in Veterans receiving ACT. Changes in anxiety symptoms, depressive symptoms, pain acceptance and engagement in values-based behavior from baseline to 6 weeks and 3 months will be used as potential mediators for changes in pain and functioning at 6 months.

Exploratory Aim: Describe the pharmacological and non-pharmacological strategies Veterans are using to manage pain and their perceived helpfulness. This will provide insights into the effects of the current opioid restrictions on pain management strategies. These strategies & their perceived helpfulness will be assessed using the Pain Management Strategies Survey at baseline, 6 weeks, 3, and 6 months.

Study Overview

• Status: Completed
• Conditions: Depression; Pain; Anxiety; Arthroplasty, Replacement, Knee; Veterans; Function
• Intervention / Treatment: Other: Attention Control (AC); Behavioral: Acceptance and Commitment Therapy (ACT)

Detailed Description

Persistent post-surgical pain (PPSP) is a common and debilitating problem following surgery.1 Orthopedic surgeries, such as Total Knee Arthroplasty (TKA), are consistently associated with high postoperative pain, putting patients at risk for PPSP.2, 3 In fact, TKA has the highest rate of PPSP at 6 months (49%) when compared to a variety of surgeries.4 Pain that persists beyond the expected period of healing serves little or no useful purpose and can be devastating to one's sense of well-being. Notably, pain severity is highly correlated with adverse effects on physical functioning, recovery and quality of life, including negative impacts on sleep, mood, daily activities, cognitive functions and social life.2, 5-13 PPSP is also highly correlated with prolonged opioid use following surgery. When pain and addiction are present, the patient's level of desperation rises, medical and psychiatric illness severity increases, and there is greater utilization of health care services.

Strong and consistent evidence indicates that patients with high levels of pain, anxiety and/or depressive symptoms (distress) prior to surgery are at risk for PPSP.5, 14-23 Notably, Veterans are at a particularly high risk for post-surgical problems because 80% experience some level of psychological distress prior to surgery and 50% report experiencing pain on a regular basis.9, 24 Furthermore, surgery presents a unique set of circumstances in which the precise timing of the physical insult and ensuing pain are known in advance. 25 It is, therefore, possible and critical that these risk factors be attended to in order to improve postoperative pain management and disrupt processes responsible for the transition from acute to chronic pain.

As proof of concept, co-PIs Rakel and Dindo completed an R34-funded study evaluating the feasibility and potential efficacy of an intensive 1-day Acceptance and Commitment Therapy (ACT) workshop for preventing PPSP and prolonged opioid use following orthopedic surgery in at-risk Veterans. ACT is trans-diagnostic, with effectiveness across a range of conditions, including chronic pain, depression, and anxiety.16-18 The brief, 1-day format was used to optimize treatment adherence and chances for dissemination into clinical settings. Results were promising. 100% of the Veterans attending, completed the 1-day intervention. Compared to controls, Veterans randomly assigned to ACT reported a larger decrease in pain intensity 3 months post-TKA and reached pain and opioid cessation criteria sooner. Importantly, Veterans reporting larger changes in behavioral engagement (targeted mediator of ACT) exhibited significantly larger decreases in pain and opioid use. This application builds on these promising preliminary findings using a rigorous design to establish the unique effects of ACT beyond attention and explore mediators of treatment response.

In the context of the current opioid epidemic, it is also important for us to better understand how changes in opioid prescribing patterns are influencing postoperative pain management strategies. It is likely that complaints of pain will increase, putting patients at higher risk for PPSP and impaired functioning. Early reports suggests that patients are looking for substitute sources of pain relief, such as rogue Fentanyl powder and Gabapentin.26, 27 Using a multi-site, double-blind, two-arm, parallel, randomized controlled trial with Veterans at-risk for PPSP post-TKA, the following aims will be addressed:

Primary Aim: To examine the superior efficacy of ACT versus Attention Control (AC) on postoperative pain intensity and functioning in at-risk Veterans undergoing TKA. Changes in pain intensity and functioning from baseline to 6 weeks, 3 months and 6 months post-TKA will be compared. Level of pain intensity will be measured using the BPI Pain Severity Subscale and level of functioning will be measured using the KOOS Activities of Daily Living and Quality Of Life Subscales.

Secondary Aims: A) To examine the superior efficacy of ACT versus AC on the severity of anxiety and depressive symptoms and improvements in coping skills. Changes from baseline to 6 weeks, 3 months and 6 months post-TKA will be compared. Anxiety and depressive symptoms will be measured with the Hamilton Rating Scales (Ham-A and Ham-D, respectively). Coping skills (i.e. Pain Acceptance and Engagement in Values-Based Behavior) will be measured with the Chronic Pain Acceptance Questionnaire and the Chronic Pain Values Inventory. B) To evaluate whether decreases in distress-based symptoms and increases in coping skills mediate changes in pain and functioning at 6 months in Veterans receiving ACT. Changes in anxiety symptoms, depressive symptoms, pain acceptance and engagement in values-based behavior from baseline to 6 weeks and 3 months will be used as potential mediators for changes in pain and functioning at 6 months.

Exploratory Aim: Describe the pharmacological and non-pharmacological strategies Veterans are using to manage pain and their perceived helpfulness. This will provide insights into the effects of the current opioid restrictions on pain management strategies. These strategies & their perceived helpfulness will be assessed using the Pain Management Strategies Survey at baseline, 6 weeks, 3, and 6 months.

This project builds on promising preliminary data and has the potential to translate what is known about effective treatments of chronic pain to prevent poor surgical outcomes. It incorporates an interdisciplinary approach to the care of Veterans that attends to major risk factors of postoperative sequelae that significantly impact Veterans' quality of life and healthcare utilization. Using an effective, highly accepted and deployable intervention increases the clinical usefulness of these results which may be extended in the future to the many other conditions leading to chronic pain in both Veterans and Civilians.

• Study Type: Interventional
• Enrollment (Actual): 402
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Iowa
    • Iowa City, Iowa, United States, 52242
      • Iowa City VAMC

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• scheduled for unilateral total knee arthroplasty (TKA)
• identified to be "at-risk" at the enrollment visit (i.e. worst pain ≥7 on BPI (severe pain) OR worst pain ≥3 (moderate pain) on BPI PLUS anxiety symptoms ≥6 on the Anxiety Subscale of the Depression, Anxiety and Stress Scale [DASS-21] or ≥10 on the Stress Subscale of the Depression, Anxiety and Stress Scale [DASS-21] OR depressive symptoms ≥7 on Depression Subscale of the Depression, Anxiety and Stress Scale [DASS-21] OR >20 on the Pain Catastrophizing Scale [PCS].

Exclusion Criteria:

• inability to complete study forms/procedures because of a language/literacy barrier;
• bipolar or psychotic disorder
• history of brain injury
• cognitive impairment (determined by score of <21 [high school or above] or <20 [< high school] on the Veterans Affairs Saint Louis University Mental Status [SLUMS] exam)
• ACT therapy within the past year
• inability to attend workshop prior to surgery

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Attention Control (AC); The primary purpose of this workshop is to provide attention and education to participants. Topics of discussion will include: a) the pathophysiology of postoperative pain and how it differs from preoperative pain, b) the role of contextual factors (e.g., depressive or anxiety symptoms, expectation) on the experience of pain, d) the role of inflammation in pain and healing, e) types of pain medications and other pain relief strategies provided following surgery, and f) goals of pain medications. Additionally, deep (diaphragmatic) breathing strategies will be taught and a progressive muscle relaxation exercise will be performed in the workshop at strategic times to maintain Veteran engagement.	Other: Attention Control (AC); Information on any other coping practices will be omitted. The group facilitators will present one topic at a time, using the Pain Manual, and the participants will discuss and reflect about issues and experiences related to each topic. If necessary, the group facilitators will raise specific discussion questions to facilitate group dialogue and participant involvement.
Experimental: Acceptance and Commitment Therapy (ACT); The ACT intervention will include: 1) Acceptance and Mindfulness Training emphasizing new ways of managing troubling thoughts, feelings, and physical sensations (e.g., learning how to recognize, and develop cognitive distance from, unhelpful thoughts such as "I can't take this pain anymore" or "This is unfair") and learning how to willingly face experiences that cannot be changed; and 2) Behavioral Change Training involving a) teaching patients how to recognize ineffective patterns of behavior and habits, b) exploring and setting life goals and goals related to mental and physical health, and c) promoting effective and committed actions to achieve these goals despite the urge to do otherwise. The workshop will also include information on pain and pain control post-TKA.	Behavioral: Acceptance and Commitment Therapy (ACT); Overall, the goal of the ACT intervention is to cultivate psychological flexibility: to help Veterans respond to life events in ways which do not exacerbate difficulties or restrict engagement in meaningful activities. It increases patients' awareness of behaviors that exacerbate the pain (such as struggling with it) and recognition of avoidance strategies that interfere with life engagement.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Intensity	Pain will be measured using the Brief Pain Inventory (BPI) Scale: 0-10, with higher scores meaning worse pain	6 weeks postop, 3 months postop and 6 months postop
Function	Knee Injury and Osteoarthritis Outcome Score (KOOS), Activities of Daily Living (ADL) subscore. Scale: 0-100, with lower scores indicating poorer function.	6 weeks postop, 3 months postop, and 6 months postop

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Anxiety	Depression, Anxiety and Stress Scale (DASS-21), Anxiety subscale. Range: 0-21 Lower scores indicate less severe anxiety	6 weeks postop, 3 months postop, and 6 months postop
Depressive Symptoms	Depression, Anxiety and Stress Scale (DASS-21), Depression subscale Scale: 0-21 Lower scores indicate less severe depression	6 weeks postop, 3 months postop, and 6 months postop
Level of Pain Acceptance	Chronic Pain Acceptance Questionnaire (CPAQ) Scale: 0-120 Higher score indicates higher level of pain acceptance	6 weeks postop, 3 months postop, and 6 months postop
Level of Success in Engagement in Values-Based Behavior	Chronic Pain Values Inventory Scale: 0-5 Lower score indicates suffering while higher score is associated with better concurrent and future functioning.	6 weeks postop, 3 months postop, and 6 months postop
Number of Participants Using Pain Management Strategies	Pain Management Strategies Survey Survey of use of pharm and non-pharm pain relief strategies. No score. We are reporting on the number of participants who completed the survey.	3 months postop and 6 months postop

Collaborators and Investigators

• Sponsor: University of Iowa
• Collaborators: Baylor College of Medicine; National Institute of Nursing Research (NINR); Iowa City Veterans Affairs Medical Center
• Investigators: Principal Investigator: Barbara Rakel, PhD, University of Iowa

Publications and helpful links

General Publications

• Shanahan ML, Zimmerman B, Rodrigues M, Green D, Embree J, Buckwalter J, Garvin L, Hadlandsmyth K, Smith T, Rakel B, Dindo L. Intersectional pain disparities and resilience in veterans with chronic pain. Health Psychol. 2026 Jan;45(1):123-135. doi: 10.1037/hea0001555.
• Dindo L, Hadlandsmyth K, Garvin L, Marchman J, Zimmerman MB, Buckwalter JA 4th, Green DM, Wollaeger JK, Strayer A, Kim KS, Liu W, Embree J, Rodrigues M, Rakel BA. ACT for postsurgical pain and dysfunction in at-risk veterans: Multisite, double-blind, cluster RCT. J Psychosom Res. 2025 Nov;198:112393. doi: 10.1016/j.jpsychores.2025.112393. Epub 2025 Sep 24.

Study record dates

Study Major Dates

• Study Start (Actual): July 29, 2019
• Primary Completion (Actual): July 30, 2023
• Study Completion (Actual): January 30, 2024

Study Registration Dates

• First Submitted: May 24, 2019
• First Submitted That Met QC Criteria: May 24, 2019
• First Posted (Actual): May 29, 2019

Study Record Updates

• Last Update Posted (Actual): May 6, 2026
• Last Update Submitted That Met QC Criteria: April 15, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Neurologic Manifestations; Mental Disorders; Behavioral Symptoms; Pathological Conditions, Signs and Symptoms; Behavior; Signs and Symptoms; Pain; Anxiety Disorders; Depression; Behavior Therapy; Psychotherapy; Behavioral Disciplines and Activities; Cognitive Behavioral Therapy; Acceptance and Commitment Therapy
• Other Study ID Numbers: 201812794; 1R01NR017610-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Data generated from this application will be shared with members of the research team (i.e., PIs and investigators) to address alternative research questions that were not included in the original application but that can be addressed from the data generated and are of particular interest to the research team members. These data will also be shared through publications, as appropriate. This sharing will be fostered and coordinated by the PIs in a manner that is consistent with NIH policy and human subject's protection including Privacy Rules. Finally, data from the study will be archived and stored at the University of Iowa, College of Nursing on a secure server for future use by other researchers outside the research team. The data manager, in collaboration with the project director, will be responsible for the archiving of these data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No