Pain and satisfaction in hospitalized trauma patients: the importance of self-efficacy and psychological distress

Physical Trauma Patients with Symptoms of an Acute and Posttraumatic Stress Disorder: Protocol for an Observational Prospective Cohort Study

Background

Injury, medical treatment, and rehabilitation can have major impacts on patients’ wellbeing. About 25-33% of the patients experience an acute stress disorder (ASD) or a posttraumatic stress disorder (PTSD) after injury. ASD is a relatively new diagnosis. Therefore, knowledge about patients’ experiences, the course of ASD and PTSD, and who is at risk for developing ASD or PTSD is lacking.

Objective

The aims of this multi-method study are to explore patients’ experiences with injury (and their care) using a focus group study. Then, in the observational study, different courses of ASD, PTSD, and quality of life will be examined. In addition, this study will examine if these courses could be characterized by socio-demographic, clinical, and psychological variables. Consequently, a risk profile will be developed to determine which patients are at risk for developing ASD or PTSD during the 12 months after injury.

Methods

Trauma patients treated in the shock room (in 2015) of the Elisabeth-TweeSteden Hospital will share their experiences with injury in the focus group study. Open, axial, and selective coding will be used to analyze the data. Concerning the observational study, patients treated in the shock room (during 2016 and 2017, Elisabeth-TweeSteden Hospital and Erasmus Medical Centre) will be asked to participate. The inclusion period is 12 months. Participants will complete the Impact of Event Scale-Revised, MINI-plus, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF after inclusion and at 3, 6, 9, and 12 months after injury. The NEO-Five Factor Inventory and the State-Trait Anxiety Inventory-Trait are completed after inclusion only. Repeated measures of latent class analysis and linear mixed models will be used to examine the research aims.

Results

This project was funded in August 2015 by ZonMw. The results of the focus group study are expected in the first trimester of 2018. With regard to the observational study, recruitment is currently underway. Data collection will be completed in November 2018. The first results will be expected in the first trimester of 2019.

Conclusions

This is the first multi-method study in trauma patients that examines patients’ experiences (qualitative design) as well as psychological disorders (observational prospective). This study will contribute to necessary information on psychological consequences after injury. Moreover, it provides knowledge about which patients to include in future psychological intervention research. Finally, awareness in clinicians about the psychological consequences can be created, so they are able to act more effectively to provide patient-oriented care.

Trial Registration

Netherlands Trial Registry NTR6258; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6258 (Archived by WebCite at http://www.webcitation.org/6xSCiO1bS)

Incidence, Intensity, and Impact of Pain in Recently Discharged Adult Trauma Patients: An Exploratory Study

The long-term implications of pain following injury are well known; however, the immediate posthospitalization incidence and impact of pain is less understood. Inadequate pain relief during this time can delay return to work, leading to psychological stress and chronic pain. This exploratory study aimed to identify the incidence, intensity, and impact of injury-related pain in recently discharged adult trauma patients. During July to December 2014, 82 recently discharged adult trauma patients completed a questionnaire about their injury-related pain experience approximately 2 weeks posthospital discharge from a Level 1 trauma center. The questionnaire was developed using the Brief Pain Inventory, assessing severity, and impact of pain through a score from 0 to 10. The average age of participants was 52 years, the median Injury Severity Score was 6, and almost all (n = 80, 98%) experienced a blunt injury. The majority of participants reported pain since discharge (n = 80, 98%), with 65 (81%) still experiencing pain on the day of data collection. Normal work was most affected by pain, with an average score of 6.6 of 10, closely followed by effect on general activity (6.1 of 10) and enjoyment of life (5.7 of 10). The highest pain severity was reported by those with injuries from road trauma, with low Injury Severity Scores, who were female, and did not speak English at home. Pain in the recently discharged adult trauma patient is common, intense and interferes with quality of life. Identification of barriers to effective pain management and interventions to address these barriers are required.

Incidence and Predictors of Opioid Prescription at Discharge After Traumatic Injury

Importance

In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored.

Objective

To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort.

Design, Setting, and Participants

Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016.

Exposures

Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors.

Main Outcomes and Measures

Prescription of opioid analgesics at discharge.

Results

Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge.

Conclusions and Relevance

The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

Comorbid mild traumatic brain injury increases pain symptoms in patients suffering from an isolated limb fracture

OBJECTIVES

This study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group).

PATIENTS AND METHODS

All subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed.

RESULTS

A total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49days, SD: 34.9), compared to the control group (p<0.0001; mean difference 2.8, 95% confidence interval 1.8-4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation.

CONCLUSIONS

Results suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.

Association Between Opioid Intake and Disability After Surgical Management of Ankle Fractures

BACKGROUND

Opioid-centric pain management strategies have created an epidemic of prescription opioid abuse. This study assesses whether opioid intake is associated with disability, satisfaction with treatment, and pain at the time of suture removal and at 5 to 8 months after suture removal following open reduction and internal fixation of ankle fractures.

METHODS

We enrolled 102 adult patients in the study at the time of suture removal, 59 of whom were available for follow-up at 5 to 8 months. At the time of suture removal, we recorded opioid use; trauma-related factors; and scores on measures of disability, pain, and treatment satisfaction. Patients who were available for follow-up completed the disability, pain, and treatment satisfaction measures at 5 to 8 months and their opioid use at that time was recorded.

RESULTS

No association was found between opioid intake and disability at the time of suture removal. No association was found between opioid intake and satisfaction with treatment or satisfaction with pain management at the time of suture removal. At 5 to 8 months after suture removal, no variables were associated with opioid intake. The psychologic measures of pain anxiety and catastrophic thinking were the factors most consistently associated with disability, treatment satisfaction, satisfaction with pain management, pain at rest, and pain with activity at both of the time points.

CONCLUSION

Patients with ankle fractures may be able to use fewer opioids than are currently prescribed and experience levels of disability and treatment satisfaction comparable with those of patients who take greater amounts of opioids, independent of injury characteristics.

LEVEL OF EVIDENCE

Prognostic level II.

A Hybrid Web-Based and In-Person Self-Management Intervention to Prevent Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): Protocol for a Pilot Single-Blind Randomized Controlled Trial

Background

Acute pain frequently transitions to chronic pain after major lower extremity trauma (ET). Several modifiable psychological risk and protective factors have been found to contribute to, or prevent, chronic pain development. Some empirical evidence has shown that interventions, including cognitive and behavioral strategies that promote pain self-management, could prevent chronic pain. However, the efficacy of such interventions has never been demonstrated in ET patients. We have designed a self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma).

Objective

This pilot randomized controlled trial (RCT) aims to evaluate the feasibility and research methods of the intervention, as well as the potential effects of iPACT-E-Trauma, on pain intensity and pain interference with daily activities.

Methods

A 2-arm single-blind pilot RCT will be conducted. Participants will receive the iPACT-E-Trauma intervention (experimental group) or an educational pamphlet (control group) combined with usual care. Data will be collected at baseline, during iPACT-E-Trauma delivery, as well as at 3 and 6 months post-injury. Primary outcomes are pain intensity and pain interference with daily living activities at 6 months post-injury. Secondary outcomes are pain self-efficacy, pain acceptance, pain catastrophizing, pain-related fear, anxiety and depression symptoms, health care service utilization, and return to work.

Results

Fifty-three patients were recruited at the time of manuscript preparation. Comprehensive data analyses will be initiated in July 2017. Study results are expected to be available in 2018.

Conclusions

Chronic pain is an important problem after major lower ET. However, no preventive intervention has yet been successfully proven in these patients. This study will focus on developing a feasible intervention to prevent acute to chronic pain transition in the context of ET. Findings will allow for the refinement of iPACT-E-Trauma and methodological parameters in prevision of a full-scale multi-site RCT.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6rR8G2vMs)

The effect of depressive symptoms on social support one year following traumatic injury

BACKGROUND

Depression is a common mental health outcome after traumatic injury, negatively impacting physical outcomes and increasing the cost of care. Research shows that the presence and quality of support is a leading protective factor against depression post-injury; however, research is vague on the directional effects of both factors over the course of recovery.

METHODS

130 patients admitted to a Level I Trauma Center were recruited to a prospective study examining overall outcomes one-year after injury. Effects of social support and depression at baseline and 12-months post-injury were examined using correlational and cross-lagged path model analyses. Additional follow-up analyses were conducted for depression on specific types of social support.

RESULTS

Findings replicated previous research suggesting depression and social support were inversely related. Initial depression at time of traumatic injury was predictive of social support 12-months after their injury, but initial social support levels did not significantly predict depression at 12-months. Additionally, initial depression significantly predicted attachment, social integration, reassurance of worth, and guidance 12-months later.

LIMITATIONS

Findings of the analyses are limited by lack of experimentation and inability to control for other related variables.

CONCLUSIONS

Findings of the present study support the notion that initial depression predicts poorer social support in recovery, in lieu of prevailing theory (i.e., initial support buffers against later depression) in a sample of trauma patients. These findings highlight the need for medical staff to target specific factors during inpatient stay, such as addressing depressive symptoms and preparing family members and caregivers prior to discharge.

Prevalence of Depression and Posttraumatic Stress Disorder After Acute Orthopaedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to systematically assess the existing literature and to derive a pooled estimate of the prevalence of depression and posttraumatic stress disorder (PTSD) in adult patients after acute orthopaedic trauma.

DATA SOURCES

A comprehensive search of databases, including MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials databases was conducted through June 2015.

STUDY SELECTION

We included studies that assessed the prevalence of depression or PTSD in patients who experienced acute orthopaedic trauma to the appendicular skeleton or pelvis. Studies with a sample size of ≤10 were excluded.

DATA EXTRACTION

Two authors independently extracted data from the selected studies and the data collected were compared with verify agreement.

DATA SYNTHESIS

Twenty-seven studies and 7109 subjects were included in the analysis. Using a random-effects model, the weighted pooled prevalence of depression was 32.6% (95% CI, 25.0%-41.2%) and the weighted pooled prevalence of PTSD was 26.6% (95% CI, 19.0%-35.9%). Six studies evaluated the prevalence of both depression and PTSD in patients with acute orthopaedic injuries. The weighted pooled prevalence of both depression and PTSD for those patients was 16.8% (95% CI, 9.0%-29.4%).

CONCLUSIONS

Nearly one-third of patients suffer from depression and more than one-quarter of patients suffer from PTSD after an acute orthopaedic injury suggesting that strategies to address both the mental and physical rehabilitation after an orthopaedic injury should be considered to optimize patient recovery.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute Pain Characteristics in Patients with and without Chronic Pain following Lower Extremity Injury

Many patients with injuries to lower extremities report chronic pain. High pain intensity at time of admission for injury is a risk factor for chronic pain, but it is not clear whether specific acute pain patterns following injury influence the development of chronic pain. To examine the relationship between the pain trajectory, the mean pain score, and the frequency of pain documentation during the immediate hospitalization following injury, with the report of chronic pain. This was a descriptive, retrospective cohort study of adults admitted with lower extremity fractures to an academic urban trauma center. Participants, 6-45 months postinjury, rated their current pain, worst pain, and average pain over the last 3 months. Pain scores from hospitalization associated with the injury were obtained through a retrospective chart review. The pain trajectory, mean pain score, and frequency of pain documentation was compared between patients with and without chronic pain. A total of 129 patients were enrolled in this study and 78% reported chronic pain at the site of injury. The mean pain score (5.1 vs. 4.2) and first pain score (5.6 vs. 3.4) were higher for patients with chronic pain compared to patients with no chronic pain. Consistent with other studies, high pain intensity at time of injury was associated with chronic pain. The findings contribute valuable information about acute pain characteristics associated with chronic pain and provide insight into the importance of early and adequate acute pain treatment.

Clinical Significance of Pain at Hospital Discharge Following Traumatic Orthopedic Injury: General Health, Depression, and PTSD Outcomes at 1 Year

OBJECTIVES

The purpose of this study was to determine whether pain at hospital discharge is associated with general health and depression and posttraumatic stress disorder (PTSD) at 1 year following traumatic orthopedic injury.

MATERIALS AND METHODS

This study prospectively enrolled 213 patients, 19 to 86 years of age, admitted to an academic level 1 trauma center for surgical treatment of a traumatic lower-extremity or upper-extremity orthopedic injury. Pain at hospital discharge was measured with the Brief Pain Inventory. At 1-year follow-up, physical and mental health was assessed with the SF-12 and depressive and PTSD symptoms with the 9-item Patient Health Questionnaire (PHQ-9) and PTSD Checklist-Civilian Version (PCL-C), respectively. Cut-off scores of 10 on the PHQ-9 and 44 on the PCL-C classified patients as having depression or PTSD.

RESULTS

A total of 133 patients (62%) completed follow-up at 1 year. Responders and nonresponders did not differ significantly on baseline characteristics. Multivariable regression found that increased pain at discharge was significantly associated with depression (odds ratio=3.3; P<0.001) and PTSD (odds ratio=1.4; P=0.03) at 1 year, after controlling for age, education, injury severity score, and either depressive or PTSD symptoms at hospital discharge. Early postoperative pain was not a significant risk factor for long-term physical and mental health.

DISCUSSION

Findings highlight the importance of early screening for uncontrolled postoperative pain to identify patients at high risk for poor psychological outcomes and who could benefit from more aggressive pain management. Results suggest early interventions are needed to address pain severity in patients with orthopedic trauma.

Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 1)

BACKGROUND

Several studies have been conducted over the last decade that describe the issue of pain and prognostic factors of acute to chronic pain transition post extremity trauma (ET). However, no thorough interventions to prevent chronic pain development in ET patients have yet been proposed.

OBJECTIVES

This first part of a series of two articles aimed to provide a comprehensive analysis of literature on the epidemiology of pain post-ET, the impact of persistent pain on ET patients and the relevant biological transformations involved in acute to chronic pain transition. The second article will focus on risk and protective factors relating to chronic pain that could potentially assist in the development of preventive interventions.

METHODS

A narrative review of the literature was undertaken. Databases were searched to identify relevant studies and seminal works on the topics of interest.

RESULTS

The review revealed that acute pain converts to chronic pain in up to 86% of ET patients. Analysis of study findings also indicated that chronic pain interferes with activities of daily living and capacity to work. Weak associations between chronic pain and anxiety as well as depression have been demonstrated. Anxiety and depression have been identified as important predictors of chronic pain post-ET. Neuro-immunological transformations, genetics and an emotional shift in the brain circuitry involved in nociception have been shown to contribute to the transition towards chronic pain.

CONCLUSIONS

This narrative review supports the view that acute to chronic pain transition is a prevalent and significant issue post-ET. It also provides information about patients who present a higher risk of chronic pain and features that should be integrated in preventive interventions as well as methodological considerations pertaining to the evaluation of such interventions.

Factors Associated With Met Expectations in Patients With Hand and Upper Extremity Disorders: A Pilot Study

PURPOSE

The degree to which patients' expectations are met during an office visit consistently correlates with patients' satisfaction, whereas the relationship between previsit expectations and satisfaction varies.

OBJECTIVE

The aim of this pilot study was to preliminarily assess the relationship of psychosocial factors, pain intensity, and magnitude of disability to previsit expectations, met expectations, and satisfaction with medical care in patients with hand and upper extremity conditions in a surgical outpatient clinic.

METHODS

A cohort of 85 outpatients with upper extremity illnesses indicated their previsit expectations (Patients Intention Questionnaire), degree to which these expectations were met (Expectations Met Questionnaire), level of depressive symptoms (Patient Health Questionnaire-2), confidence about the ability to achieve one's goals in spite of pain (Pain Self-Efficacy Questionnaire), pain intensity (Numerical Rating Scale for pain), disability (Disabilities of the Arm Shoulder and Hand, short version; QuickDASH), and satisfaction with the medical visit (Medical Interview Satisfaction Scale).

RESULTS

Higher previsit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and fewer years of education. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, fewer years of education, and more pain compared to those in the high-met expectations category. Fewer years of education and higher pain intensity predicted higher previsit expectations and explained 19% of variance.

CONCLUSION

Psychosocial factors affect both previsit expectations and met expectations during an outpatient visit to a hand surgeon. Met expectations, but not previsit expectations, affect satisfaction.

LEVEL OF EVIDENCE

Prognostic, level II.

Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2)

BACKGROUND

The first part of this series of 2 articles revealed that chronic pain is an important issue post extremity trauma (ET) involving permanent biological transformations. Interventions aimed at preventing chronic pain in ET patients are therefore required.

OBJECTIVE

To conduct a comprehensive analysis of literature on risk and protective factors for chronic pain post-ET to guide the development of relevant preventive interventions.

METHODS

A narrative review of the literature was undertaken. Databases were searched to identify studies on chronic pain prognostic factors in ET patients.

RESULTS

Demographic, injury-related and psychological factors were shown to either contribute to or limit acute to chronic pain transition. High-intensity acute pain hasconsistently been identified as an important chronic pain risk factor. Other significant documented risk factors include: female gender, older age, less than college education, lower limb injury, symptoms of anxiety and depression and pain catastrophizing. Pain self-efficacy and pain acceptance have been shown to protect individuals against chronic pain.

CONCLUSIONS

This narrative review highlights factors placing ET patients at higher risk of chronic pain or protecting them against this problem. Determining how these factors could be addressed in preventive interventions is the next step before undertaking their development.

Pain, Functional Scores, and Radiographic Severity of Illness Influence the Perception of Time Spent With the Physician by Patients Presenting for Initial Evaluation of Knee Osteoarthritis

BACKGROUND

Patient satisfaction has become a significant factor in reimbursement schedules for physicians. A matter of debate is whether the patient's perception of time spent with the physician improves patient satisfaction. We sought to determine whether patient-physican time correlates with patient satisfaction and which factors are associated with patient perception of time.

METHODS

A total of 73 patients who presented for an initial evaluation of knee osteoarthritis were evaluated by the same orthopedic surgeon at an outpatient clinic in New Orleans, LA. Each encounter was timed with a stopwatch. After the physician encounter, patients were asked to fill out a questionnaire assessing their perception of time spent with the physician, subjective pain, satisfaction with the visit, and understanding of the diagnosis and treatment plan. Patients were also asked to complete 4 functionality surveys. Radiographs of the patients' knees were taken and quantified using Kellgren-Lawrence and Ahlbäck grading scales.

RESULTS

We noted no relationship between patient satisfaction and patients' perception of time spent with the physician. Patients perceived their time with the physician to be an average of 6.5 minutes more than the actual time. However, patients who reported higher subjective pain scores (>7 on a 10-point scale) misestimated their time with the physician by nearly 96%, while patients with lower subjective pain scores (<7 on a 10-point scale) misestimated their time with the physician by only 54% (P<0.007). We discovered similar findings in patients with worse Kellgren-Lawrence radiographic scores as well as worse Oxford Knee Scores and Knee injury and Osteoarthritis Outcome Scores. The actual time spent was not different among patients.

CONCLUSION

Patients with greater subjective pain and worse functional status and patients with worse radiographic severity of knee osteoarthritis perceived greater time spent with the physician. However, no relationship between these variables and patient satisfaction scores was seen.

Characteristics of Patients with Lower Extremity Trauma with Improved and Not Improved Pain During Hospitalization: A Pilot Study

Up to 62% of patients report chronic pain at the injury site 6-12 months after blunt trauma, with pain from lower extremity fractures exceeding that from other sites. High pain intensity at time of injury is a risk factor for chronic pain, but it is not clear what patient characteristics influence the pain intensity level during the immediate hospitalization following injury. The purpose of this pilot study was to determine the feasibility of collecting pain scores from medical records to calculate pain trajectories and to determine whether it is possible to examine patient characteristics by classifying them into those whose pain improved and those whose pain did not improve. This descriptive study retrospectively reviewed medical records of 18 randomly chosen patients admitted to an academic trauma center. Patient characteristics and pain scores were collected form electronic and handwritten medical records. The pain trajectories calculated from routinely collected pain scores during the inpatient stay showed that for 44% of patients the pain improved during the hospitalization, for 39% the pain remained the same, and for 17% the pain worsened. The variables age, smoking, weight, abbreviated injury scores, length of hospital stay, mean pain score, and opioid equianalgesic dose differed based on pain trajectory. While patient characteristics differed based on pain trajectory, any significant effects seen from individual tests should be considered tentative, given the number of analyses conducted on this data set. However, feasibility and significance of conducting a larger study has been established.

Psychosocial Factors Predict Pain and Physical Health After Lower Extremity Trauma

BACKGROUND

There has been increasing evidence to support the importance of psychosocial factors to poor outcomes after trauma. However, little is known about the contribution of pain catastrophizing and fear of movement to persistent pain and disability.

QUESTIONS/PURPOSES

Therefore, we aimed to determine whether (1) high pain catastrophizing scores are independently associated with pain intensity or pain interference; (2) high fear of movement scores are independently associated with decreased physical health; and (3) depressive symptoms are independently associated with pain intensity, pain interference, or physical health at 1 year after accounting for patient characteristics of age and education.

METHODS

Of 207 eligible patients, we prospectively enrolled 134 patients admitted to a Level I trauma center for surgical treatment of a fracture to the lower extremity. Sixty percent of patients (80 of 134) had an isolated lower extremity injury and the remainder sustained additional minor injury to the head/spine, abdomen/thorax, or upper extremity. Pain catastrophizing was measured with the Pain Catastrophizing Scale, fear of movement with the Tampa Scale for Kinesiophobia, and depressive symptoms with the Patient Health Questionnaire. Pain and physical health outcomes were assessed with the Brief Pain Inventory and the SF-12, respectively. Assessments were completed at 4 weeks and 1 year after hospitalization. Multiple variable hierarchical linear regression analyses were used to address study hypotheses. One hundred ten patients (82%) completed the 1-year followup.

RESULTS

Pain catastrophizing at 4 weeks was associated with pain intensity (β = 0.67; p < 0.001) and pain interference (β = 0.38; p = 0.03) at 1 year. No association was found between fear of movement and physical health (β = 0.15; p = 0.34). Depressive symptoms at 4 weeks were associated with pain intensity (β = 0.49; p < 0.001), pain interference (β = 0.51; p < 0.001), and physical health (β = -0.32; p = 0.01) at 1 year.

CONCLUSIONS

Catastrophizing behavior patterns and depressive symptoms are associated with more severe pain and worse function after traumatic lower extremity injury. Cognitive and behavioral strategies that have proven effective for chronic pain populations may be beneficial for trauma patients. Future research is needed to determine whether the early identification and treatment of subgroups of at-risk patients based on catastrophizing behavior or depressive symptoms can improve long-term outcomes.

LEVEL OF EVIDENCE

Level I, prognostic study.

The effect of feedback regarding coping strategies and illness behavior on hand surgery patient satisfaction and communication: a randomized controlled trial

BACKGROUND

Patients and surgeons can feel uncomfortable discussing coping strategies, psychological distress, and stressful circumstances. It has been suggested that patient-reported outcome measures (PROMs) facilitate the discussion of factors associated with increased symptoms and disability. This study assessed the effect of providing feedback to patients regarding their coping strategy and illness behavior on patient satisfaction and patient-physician communication in orthopedic surgery.

METHODS

In a prospective study, 136 orthopedic patients were randomly assigned to either receive feedback about the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference computer-adaptive test (CAT) prior to the visit with the hand surgeon or not. The primary outcome was patient satisfaction with the consultation and secondary outcomes involved patient-physician communication. Bivariate and multivariable analyses were performed to determine the influence of the feedback on patient satisfaction and communication.

RESULTS

There was no significant difference in patient satisfaction between patients who received feedback and patients who did not (P = 0.70). Feedback was associated with more frequent discussion of coping strategies (P = 0.045) in bivariate analysis but was not independently associated: in multivariable analysis, only PROMIS Pain Interference CAT and age were identified as independent predictors (odds ratio (OR) 1.1; 95 % confidence interval (CI) 1.0-1.1, P = 0.013, and OR 0.97, 95 % CI 0.94-0.99, P = 0.032, respectively). No factors were associated with discussion of stressors. Discussion of circumstances was independently associated with increased PROMIS Pain Interference CAT, marital status, and work status.

CONCLUSION

We found that feedback regarding coping strategies and illness behavior using the PROMIS Pain Interference CAT did not affect patient satisfaction. Although feedback was associated with increased discussion of illness behavior in bivariate analysis, less effective coping strategies and personal factors (age, marital status, and work status) were more important factors.

Do previsit expectations correlate with satisfaction of new patients presenting for evaluation with an orthopaedic surgical practice?

BACKGROUND

Patient satisfaction is associated with increased compliance, improved treatment outcomes, and decreased risk of litigation. Factors such as patient understanding and psychological well-being are recognized influences on satisfaction. Less is known about the relationship between previsit expectations and satisfaction.

QUESTIONS/PURPOSES

(1) Are there correlations among previsit expectations, met expectations, and patient satisfaction? (2) What are the categories of expectations, and which one(s) correlate with satisfaction?

METHODS

Eighty-six new patients presenting to a hand surgery practice of a tertiary referral hospital with 70% direct primary care referrals, mostly with elective concerns, indicated their previsit expectations (Patient Intention Questionnaire [PIQ]). Immediately after the visit, the same patients rated the degree to which their previsit expectations were met (Expectation Met Questionnaire [EMQ]) and their satisfaction level (Medical Interview Satisfaction Scale). These tools have been used in primary care office settings and claim good psychometric properties, and although they have not been strictly validated for responsiveness and other test parameters, they have good face validity. We then conducted a multivariable backward linear regression to determine whether (1) scores on the PIQ; and (2) scores on the EMQ are associated with satisfaction.

RESULTS

Satisfaction correlated with met expectations (r=0.36; p<0.001) but not with previsit expectations (r=-0.01, p=0.94). We identified five primary categories of previsit expectations that accounted for 50% of the variance in PIQ: (1) "Information and Explanation"; (2) "Emotional and Understanding"; (3) "Emotional Problems"; (4) "Diagnostics"; and (5) "Comforting". The only category of met expectations that correlated with satisfaction was Information and Explanation (r=0.43; p<0.001).

CONCLUSIONS

Among patients seeing a hand surgeon, met expectations correlate with satisfaction. In particular, patients with met expectations regarding information and explanation were more satisfied with their visit. Efforts to determine the most effective methods for conveying unexpected information warrant investigation.

LEVEL OF EVIDENCE

Level II, prognostic study.

An integrative review of self-efficacy and patient recovery post acute injury

AIM

To present an integrative literature review examining the relationship between self-efficacy and patient recovery post acute injury.

BACKGROUND

Self-efficacy is a belief in one's ability to perform a set of actions; the greater a person's confidence, the more likely they will initiate and continue activity that will produce a positive outcome in terms of recovery. Increasingly, research indicates that application of self-efficacy theory into clinical practice is likely to promote recovery in the rehabilitation setting. This review examines self-efficacy in the post acute injury group.

DESIGN

Integrative literature review.

DATA SOURCES

A database search was conducted in PSYCHINFO, MEDLINE and CINAHL between 1990-2012.

REVIEW METHODS

Whittemore and Knafl's theoretical framework was used to guide the review in conjunction with a critical appraisal template. Findings from studies were extracted, critically examined and grouped into key themes under factors (interventions) and outcomes relating to self-efficacy.

RESULTS

Eighteen articles met the inclusion criteria. Level of education may be a significant factor related to self-efficacy. Educational, physical and psychological interventions to improve self-efficacy emerged, but few interventions led to significantly enhanced self-efficacy. Self-efficacy was found to influence outcomes, including pain and disability, adherence to discharge instructions, locomotion recovery and quality of life.

CONCLUSION

Interventions addressing the connection between physical and psychological health with respect to mood, emotion, stress, fear and anxiety to improve the psychological response to acute injury may enhance self-efficacy and patient recovery.