Knee osteoarthritis pain worsens depression | Depression worsens knee osteoarthritis pain

There is a lot of research being published on the effects of depression on knee pain. In much of the research, investigators say that doctors are not in tune with these problems in their patients and their scoring systems for documenting depression may not be accurate. The one common thread that appears in many of the studies is that the knee pain patient suffering from depression needs to be offered treatments that give them hope and have a good personal support system.

A study lead by the University of Southern California looked further into behavioral modification in knee and hip osteoarthritis patients with depression. In the very simplest terms, behavioral modification in patients with depression is training in how to replace pessimistic/catastrophizing thoughts, with thoughts that are more optimistic.

  • The goal of this research was to see:
    • which osteoarthritis patients would benefit from behavioral modification and
    • those who would not benefit as much and
    • to identify these patients so they could be helped.

The researchers noted that based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified as targets for potential moderators.

Trial outcome variables (the factors that would influence all the patients regardless of age or weight for example, included pain, fatigue, self-efficacy (a belief in one’s own ability to succeed), quality of life, catastrophizing, and use of pain medication.

The researchers identified the 5 key factors that would influence successful or non-successful treatment outcomes in patients with osteoarthritis:

  1. The ability to cope with pain
  2. The patient expectation for treatment response
  3. radiographically assessed disease severity (The researchers looked at the MRIs of knee and hip osteoarthritis to determine severity of the disease)
  4. age, and
  5. education.

Surprisingly they found that levels of depression at baseline were not associated with treatment response. So if a patient had less severe depression or more severe depression, their test outcome would be the same.

  • Patients with interpersonal problems (lack of family support or poor marital or relationship status) associated with pain coping did not benefit much from the treatment.
  • Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited.
  • Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. (My note: The worse the osteoarthritis was, the better the patient responded. Read into this what you will, but this is another example of an MRI showing severity of disease that did not effect the patient’s positive response. In other words – the MRI is saying the patient should be much worse than they are).
  • Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.1

What is one to make of this research?

  • Patients with osteoarthritis and depression need strong family support, if not availability, patient needs to be optimistic in his/her own ability to have successful treatment. This can be a difficult chore for some.
  • Patients who are told of the severity of his/her knee or hip osteoarthritis based on their MRI should more believe what their  own body is telling them. In most cases the MRI is saying they are worse than they feel.
  • If treatment is begun with optimism, and optimistic thoughts outweigh pessimistic thoughts, the greater the chance for alleviation of symptoms.

“It is becoming increasingly evident that structural changes alone do not account for all musculoskeletal pain”

Let’s go further into the complex MRI discussion.

Doctors from the Benha University School of Medicine in Egypt wrote in the European journal of rheumatology of how depression may make knee pain significantly worse than it should be, at least significantly worse than an MRI suggests.

In the research we cited above, the MRI suggested that the patient’s pain should be worse, in this research the MRI is suggesting that the patient’s pain should be less. The patients in the above study had worse MRI and less pain, the patients as we will see in this study, had “better” MRIs and more pain. This is of course the inherent problem of MRIs, they do not always tell the true story.

These are the learning points from the Egyptian research:

  • “Knee osteoarthritis can lead to psychosocial deterioration in addition to physical inability, which makes it difficult to interpret the source of the patients’ complaints. It is becoming increasingly evident that structural changes alone do not account for all musculoskeletal pain.”
    • In other words, depression makes the knee diagnosis much more challenging.
  • The Egyptian doctors say this is especially true in cases of Baker’s cysts, osteophytes (bone spurs), and high Body Mass Index (overweight/obesity) which have a great impact on the pain and disability associated with osteoarthritis. Depression might be the culprit behind the discrepancy between MRI or ultrasound findings and the patients’ clinical score.

At the University of Maryland, doctors examined depressive symptoms clearly associated with increases in pain and functional limitations in knee osteoarthritis patients. Publishing in the journal Clinical rheumatology, this research construct was to determine if depression severity accelerated problems of knee osteoarthritis and document it by radiographic and clinical assessments. They could not find evidence  that depressive symptoms have a detectable effect on changes in radiographic disease severity in knee osteoarthritis.

Are doctors asking patients the right questions to get the best determination of the patient’s depression challenges

Writing in the medical journal Disability and rehabilitation, researchers in the United Kingdom are suggesting that people with chronic knee pain and hip osteoarthritis may benefit from “Acceptance commitment therapy,” a form of psychotherapy and behavioral modification. They hope this treatment would be especially hopeful in people who have significant pain. Such as those in the above study whose MRIs suggested that they should not have the severe pain they are suffering from.

As a side note, the researchers also questioned whether accepted depression and physiological scoring systems, such as the Rasch-transformed and standard scales were accurate in assessing these patients.3 In other words, were doctors asking patients the right questions to get the best determination of the patient’s depressive challenges?

In another study, the same group of researchers writing in the medical journal Disability and rehabilitation examined the type of questionnaires that should be offered to patients with knee osteoarthritis to determine levels of hopelessness and depression.

Here is what they wrote:

  • “These findings indicate that questionnaires need to be checked for their ability to measure psychological constructs in the clinical groups to which they will be applied.”
    • For people with osteoarthritis, the state-trait anxiety inventory is an acceptable measure of anxiety
      • The state-trait anxiety inventory measures acute worry (STATE is a transient anxiety, one that will go away. TRAIT is chronic anxiety, “worrying too much,” about something that does not need that level of worry, catastrophizing thoughts).
    • The revised FATIGUE SEVERITY SCALE is an acceptable measure of fatigue with removal of items 1 and 2.
      • 1. My motivation is lower when I am fatigued. (Question should be removed as not helpful)
      • 2. Exercise brings on my fatigue. (Question should be removed as not helpful)
      • 3. I am easily fatigued.
      • 4. Fatigue interferes with my physical functioning.
      • 5. Fatigue causes frequent problems for me.
      • 6. My fatigue prevents sustained physical functioning.
      • 7. Fatigue interferes with carrying out certain duties and responsibilities.
      • 8. Fatigue is among my most disabling symptoms.
      • 9. Fatigue interferes with my work, family, or social life.
    • the Beck Depression Inventory seeks to come up with a cumulative scoring system to determine
      • Score 0–13: minimal depression
      • Score 14–19: mild depression
      • Score 20–28: moderate depression
      • Score 29–63: severe depression.
      • The researchers did not find this scoring system helpful to patients with knee osteoarthritis.
  • The feeling of helplessness can be measured using the  the  arthritis helplessness index. This index asked patients to rate the following statements by 1 strongly disagreeing, 2 disagreeing, 3 agreeing, or 4 strongly agreeing. Here is an example of the questions:
    • My arthritis is controlling my life
    • Managing my arthritis is largely my own responsibility.
    • I can reduce my arthritis pain by staying calm and relaxed.
    • When I manage my personal life well my arthritis does not flare up as much.
    • I have considerable ability to control my arthritis pain.
    • No matter what I do, or how hard I try, I just can’t seem to get relief from my arthritis pain.



In the above studies from 2016 and 2017, doctors tried to come up with plans treating a symptom of knee pain, that is depression.

In 2009, our team published in the Journal of Prolotherapy our findings on healing knee pain. This is what we wrote:

This observational study was the first to show Prolotherapy helps not only the physical components of unresolved knee complaints such as pain, stiffness, range of motion and crunching sensations, but also helps numerous quality of life functions including walking ability, sleep, athletic ability, activities of daily living, and feelings of depression and anxiety.

This study also showed that 15 months after their last Prolotherapy session, the vast majority of improvements continued.

In this study population, Prolotherapy reduced the patients’ subjective overall disability, medication usage, other pain therapy treatments needed, as well as depressed and anxious feelings.

Prolotherapy improved the patients walking and exercise ability, sleep, activities of daily living, and work situation. For the vast majority of the patients, Prolotherapy had a long lasting effect and changed their lives for the better.

You can read that complete study here Prolotherapy research for unresolved knee pain.

Are you a candidate for our non-surgical treatments? Ask our specialists:

  • Ross Hauser, MD | Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | David Woznica, MD

Contact us now!

1 Broderick JE, Keefe FJ, Schneider S, Junghaenel DU, Bruckenthal P, Schwartz JE, Kaell AT, Caldwell DS, McKee D, Gould E.  Cognitive behavioral therapy for chronic pain is effective, but for whom?. Pain. 2016 Sep 1;157(9):2115-23.

2 El Monaem SM, Hashaad NI, Ibrahim NH. Correlations between ultrasonographic findings, clinical scores, and depression in patients with knee osteoarthritis. European Journal of Rheumatology. 2017 Sep;4(3):205.

3 Clarke SP, Poulis N, Moreton BJ, Walsh DA, Lincoln NB. Evaluation of a group acceptance commitment therapy intervention for people with knee or hip osteoarthritis: a pilot randomized controlled trial. Disability and rehabilitation. 2017 Mar 27;39(7):663-70.

4 Lincoln N, Moreton B, Turner K, Walsh D. The measurement of psychological constructs in people with osteoarthritis of the knee: a psychometric evaluation. Disabil Rehabil. 2017 Feb;39(4):372-384. doi: 10.3109/09638288.2016.1146356. Epub 2016 Mar 17. [Pubmed]

5. Rathbun AM, Yau MS, Shardell M, Stuart EA, Hochberg MC. Depressive symptoms and structural disease progression in knee osteoarthritis: data from the Osteoarthritis Initiative. Clin Rheumatol. 2017 Jan;36(1):155-163. doi: 10.1007/s10067-016-3495-3. Epub 2016 Dec 12. [Pubmed]

4 Patel S, Heine PJ, Ellard DR, Underwood M. Group exercise and self-management for older adults with osteoarthritis: a feasibility study. Prim Health Care Res Dev. 2016 May;17(3):252-64. doi: 10.1017/S1463423615000389. [Pubmed]


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