Friends and family are a part of a person’s social support system which plays a pivotal role in the recovery process from surgeries such as a total knee replacement (TKR).
Friends and family offer people undergoing TKR surgeries personal and social support. Other forms of support they can help offer are emotional, informational, and clinical. In a mixed-method prospective cohort study, 515 adults with a primary or secondary diagnosis of osteoarthritis who were scheduled to undergo a primary TKR in British Columbia were recruited from mandatory presurgical total joint replacement education sessions.1 This study defined social support as the provision of aid and assistance in three categories. The first category is informational support where information on pain, pain management, and recovery trajectories was provided. The second category was clinical support which included pre-optimization and support from clinics and their surgeons and physiotherapists. The third category is personal support which included support provided by family, friends, and other TKR patients. Each participant completed a pre-surgery, self-administered, English-language questionnaire that asked about each kind of support. The participants also completed an additional survey 6 and 12 months post-TKR addressing post-TKR pain, functioning, and stiffness problems. When first sent home after the TKR, participants recounted needing personal support and assistance from their family and friends with daily activities such as turning over in bed, bathing, using the bathroom, and using stairs. Many participants needed family or friends to drive them to their post-surgery health appointments to meet informational support needs. Family and friends also helped meet patients’ emotional support needs by driving them to grocery stores and social activities and helping them prepare meals. Participants who reported having high social support expectations before surgery and had all their social support expectations met post-surgery, were also the same participants who had positive TKR outcomes. They had improvement in their post-TKR pain, had their major expectations and needs for support met during their TKR recovery, and believed that any future expectations and needs for support would be adequately met.
Another study shows similar results.2 Participants preparing to undergo TKR completed a baseline preoperative questionnaire and were later assessed six months after surgery using the Western Ontario McMaster Universities Arthritis Index (WOMAC). The WOMAC score is a joint-specific instrument for measuring clinical outcomes in patients treated for knee osteoarthritis. The score measures pain, joint stiffness, and physical function. Higher scores indicate greater difficulty. Participants with greater levels of social support, when compared to participants with lower levels of social support, reported better functionality post-TKR (social support β-2.24, 95% confidence interval [CI] [-5.55 – 1.06], p=0.10). Participants with greater levels of social support also reported having lower pain levels than participants with lower levels of social support post-TKR (social support β-0.86, 95% CI [-1.82 – 0.09], p=0.07). Participants with higher levels of social support also reported less joint stiffness than participants with lower levels of social support post-TKR (social support β- 0.17, 95% CI [-0.59 – 0.25], p=0.40). The point estimate shows the benefits of social support on pain, function, and joint stiffness even though these WOMAC scores were not statistically significant.
A systematic review that included studies that were prospective or retrospective and aimed to identify preoperative prognostic factors for pain, physical function, and/or quality of life had similar findings.3 All studies included in the systematic review included patients (n=13,247) who were suffering from osteoarthritis and underwent TKR. The sample size of all studies was at least 200 patients each and the follow-up period was at least one year. All studies included in this systematic review had to identify prognostic factors at baseline and report a statistical association (or lack of association) with the outcome. Data were quantified using the odds ratio which is a statistic that quantifies the strength of the association between the amount of social support a person has and post-TKR outcomes such as pain and physical functioning. A trend toward an association was observed in all the studies in the systematic review where the pain level was lower in those with social support from friends and family (mean odds ratio [OR] 1.167, 95% CI [0.98 –1.139] than in those without social support.
Friends and family can help improve physical function and pain after a TKR to allow for a faster recovery time. Theiss et al. conducted a study involving a plan-do-check-act methodology involving 1,722 people who had primary hip and knee replacement surgeries.4 The team conducting the study used the modified Groningen Orthopedic Social Support Scale (MGO-SSS) to measure levels of social support and then associated those social support levels with other patient outcomes, such as improved physical function and pain. Scores from the MGO-SSS were scaled from 0 (no support) to 100 (very high support). These were categorized into four levels: 0 – 32 (no/low support), 33 – 66 (moderate support), 67 – 89 (high support), and 90 – 100 (very high social support). The study found that the support of a family member or friend before, after, and during joint replacement surgery measurably impacts quality and outcomes. Patients with high and very high levels of social support (MGO-SSS scores 67 – 100) had shorter hospital stays, were more likely to be discharged to go home, more likely to meet ambulation and transfer-out-of-bed targets, and were overall more confident and ready to go home on discharge than patients with low or moderate levels of social support (MGO-SSS scores 0 – 66). The study included specific outcomes such as the expected length of stay at the hospital post-TKR. Patients with low levels of support had an average expected length of stay at the hospital of 4.3 days while patients with very high levels of support had an average expected length of stay in the hospital of three days (p<0.5). Nevertheless, the study reported that among the patients with lower levels of social support, 75% were discharged home after meeting ambulation goals for patients post-TKR compared to 96.2% of patients with very high levels of social support (p=0.001). Similarly, when patients were asked if they were confident to be discharged from the hospital to their home to continue their recovery process, 50.0% of patients with low or moderate levels of social support were confident in their support system at home to motivate and aid them with their continued recovery process, while 80.2% of patients with high or very high levels of social support were confident (p=0.007). Having appropriate support could help address post-TKR functioning which was identified as a significant challenge by several participants and allow for a faster recovery.
Social support appears to be important for overall well-being and is associated with less pain, increased function, and faster recovery from TKR compared to not having adequate support. Engaging socially with family and friends may be an important behavior as it appears to have a therapeutic effect on overall well-being.
References
- Goldsmith LJ, Suryaprakash N, Randall E, et al. The importance of informational, clinical and personal support in patient experience with total knee replacement: a qualitative investigation. BMC Musculoskelet Disord 2017; 18 (1): 127.
- Papakostidou I, Dailiana ZH, Papapolychroniou T, et al. Factors affecting the quality of life after total knee arthroplasties: a prospective study. BMC Musculoskelet Disord 2012; 13: 116.
- Harmelink KEM, Zeegers A, Hullegie W, et al. Are there prognostic factors for one-year outcome after total knee arthroplasty? a systematic review. J Arthroplasty 2017; 32 (12): 3840-3853.e3841.
- Theiss MM, Ellison MW, Tea CG, et al. The connection between strong social support and joint replacement outcomes. Orthopedics 2011; 34 (5): 357.
