Broken heart syndrome-like psychosomatic dysregulation in knee osteoarthritis: a bidirectional analysis of pain-stress coupling

Aavrati Rastogi; Roop B. Kalia; Anindya Das; Mukesh Bairwa

doi:10.18203/issn.2455-4510.IntJResOrthop20263914

Authors

Aavrati Rastogi Department of Orthopedics, AIIMS, Rishikesh, Uttarakhand, India https://orcid.org/0000-0002-8985-3143
Roop B. Kalia Department of Orthopedics, AIIMS, Rishikesh, Uttarakhand, India https://orcid.org/0000-0002-3418-5942
Anindya Das Department of Psychiatry, AIIMS, Rishikesh, Uttarakhand, India https://orcid.org/0000-0002-0500-7805
Mukesh Bairwa Department of Internal Medicine, AIIMS, Rishikesh, Uttarakhand, India https://orcid.org/0000-0002-8974-5775

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20263914

Keywords:

Knee osteoarthritis, Psychosomatic dysregulation, Pain-stress coupling, Anxiety, Depression

Abstract

Background: A prominent chronic musculoskeletal condition that is linked to pain, disability, and a lower quality of life is knee osteoarthritis (KOA). A biopsychosocial paradigm, which holds that psychological factors have a major impact on pain perception and functional limitation, is supported by emerging research. This model suggests a reciprocal relationship between emotional and physical health. Objective of the study was to evaluate gender-based variations across radiographic severity classes and to look into the relationship between pain intensity, functional impairment, and psychological distress in people with KOA.

Methods: A cross-sectional observational study was conducted among 108 patients diagnosed with KOA. The WOMAC (modified CRD Pune version) was used to assess clinical severity, while the GAD-7 and PHQ-9 were used to assess anxiety and depressive symptoms. Pain-stress correlations were evaluated using Pearson's correlation, and male and female participants with Kellgren-Lawrence (K/L) grades II and III were compared using independent-samples t-tests.

Results: Clinically significant patterns were found despite the lack of statistical significance (p>0.05). Increased psychological discomfort, especially depressive symptoms, was linked to higher WOMAC scores. In female participants, there was a somewhat favorable correlation between the severity of symptoms and depression (r=0.374, p=0.333), but anxiety exhibited mild correlations in both sexes. Pain, stiffness, function, and overall WOMAC ratings did not differ significantly based on sex across K/L grades (all p>0.05). These results point to a clinically significant connection between emotional discomfort and pain burden.

Conclusions: According to the study, there might be a reciprocal relationship between psychological distress and chronic pain, supporting a biopsychosocial view of KOA. Routine rehabilitation that incorporates psychological evaluation may improve patient results and encourage more thorough, patient-centered care.

References

Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019;393(10182):1745-59.

Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis. JAMA. 2021;325(6):568-78.

Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016;157(8):1588-9.

Tan BY, Goff A, Lang KV, Tham SYY, Zu DSKM, Munro YL, et al. Psychosocial factors in knee osteoarthritis: scoping review of evidence and future opportunities. Osteoarthritis Cartilage. 2024;32(10):1327-38.

Bayrak G, Alkan H. Factors influencing pain intensity in knee osteoarthritis: a cross-sectional biopsychosocial perspective. BMC Musculoskelet Disord. 2025;26(1):196.

Sharma A, Kudesia P, Shi Q, Gandhi R. Anxiety and depression in patients with osteoarthritis: impact and management challenges. Open Access Rheumatol. 2016;8:103-13.

Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Aging. 2016;45(2):228-35.

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3):S2-15.

Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors. Br J Anaesth. 2019;123(2):e273-83.

Bayrak G, Alkan H. Factors influencing pain intensity in knee osteoarthritis: a cross-sectional biopsychosocial perspective. BMC Musculoskelet Disord. 2025;26(1):196.

Rastogi A, Kalia RB, Meena PK. Unmasking the hidden struggle: anxiety and depression in the recovery of osteoarthritis of the knee. Int J Res Med Sci. 2026;14(3):612.

Pojala CV, Moga MA, Pojala CE, Roman NA, Necula RD, Toma SI, et al. Integrative phenotyping of knee osteoarthritis: linking WOMAC cut-offs, Kellgren-Lawrence grades, and cluster analysis for personalized care. Life. 2025;15(10):1542.

Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al. Osteoarthritis: new insights. Part 1: The disease and its risk factors. Ann Intern Med. 2000;133(8):635-46.

Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL III. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447-85.

Sagara M, Majjad A, Taoubane L, Bezza A. High prevalence of depression in symptomatic knee osteoarthritis: a cross-sectional study on risk factors and therapeutic implications. BMC Musculoskelet Disord. 2025;27(1):89.