Self-reported upper extremity health status correlates with depression

Influence of psychological factors on grip strength

PURPOSE

Grip strength is widely used to assess upper-extremity function. Although grip strength is a quantitative measure of function, grip strength is a reflection of both physical impairment as well as subjective, psychological factors. We investigated the determinants of grip strength with the hypothesis that psychological factors are associated with diminished grip strength.

METHODS

One hundred thirty-four patients with an isolated, discrete upper-extremity condition had grip strength measurements, and, as part of one of several prospective clinical studies, during the same visit they completed 2 or more of the following surveys: the Center for Epidemiologic Studies-Depression (CES-D) scale, Pain Anxiety Symptoms Scale, and Pain Catastrophizing Scale. Univariate and multivariable statistical analysis sought determinants of absolute grip strength and grip strength as a percentage of the opposite, uninvolved limb.

RESULTS

Determinants of absolute grip strength included gender and grip strength of the uninvolved limb. The association between CES-D score and absolute grip strength was near significant but very weak. Multivariable regression analysis produced a best-fit model that retained grip strength of the uninvolved limb and CES-D scores. When grip strength of the involved limb was evaluated as a percentage of grip strength of the uninvolved limb, CES-D score was a weak but significant predictor, and patients recovering from a fracture of the distal radius had weaker grip strength than did patients with nontraumatic conditions.

CONCLUSIONS

Depression scores were minimally associated with diminished grip strength. Psychological factors appear to affect disability (patient-reported health status) more than they affect performance-based measures of function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Long-term outcomes of arthroscopic acromioplasty for chronic shoulder impingement syndrome: a prospective cohort study with a minimum of 12 years' follow-up

PURPOSE

The purpose of this study was to evaluate long-term outcomes of arthroscopic acromioplasty for shoulder impingement syndrome.

METHODS

This was a prospective cohort study of 31 shoulders (24 men) that underwent arthroscopic acromioplasty for shoulder impingement syndrome during 1992 and 1993. The mean age at surgery was 49 years (range, 33 to 68 years). A group of 29 shoulders (22 men) operated on consecutively with open acromioplasty from 1985 through 1991 served as controls. The patients were evaluated with the University of California, Los Angeles (UCLA) score (range, 0 to 35 points) at baseline and at 2 follow-up times performed at a mean of 1 and 13 years after surgery, respectively. At the second follow-up, the Disabilities of the Arm, Shoulder and Hand score, the Short Form-36 bodily pain score, and the EQ-5D health utility index also were obtained.

RESULTS

After arthroscopic acromioplasty, the mean improvement in UCLA score from baseline to long-term follow-up was 13 points (95% confidence interval, 11 to 15 points), and the scores indicated an excellent or good result in 77% of shoulders. The mean UCLA score was 32 points (SD, 5 points) for the patients treated with arthroscopic acromioplasty and 28 points (SD, 8 points) for those treated with open acromioplasty; the mean difference was 4.3 points (95% confidence interval, 0.4 to 8.2 points; P = .03). In a mixed-model analysis adjusting for age, sex, duration of symptoms, preoperative UCLA score, dominance of operated side, rotator cuff status at surgery, and time since surgery, the rate of change from baseline in UCLA score over time was significantly better after arthroscopic surgery than after open surgery.

CONCLUSIONS

Good results of arthroscopic acromioplasty were maintained at 12 to 14 years after surgery with excellent or good results shown in 77% of shoulders, and the long-term outcomes were superior to those after open acromioplasty.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Psychological differences between patients that elect operative or nonoperative treatment for trapeziometacarpal joint arthrosis

Among 44 consecutive patients electing operative treatment of trapeziometacarpal arthrosis, three age- and gender-matched controls that presented during the same time period but had not yet requested operative treatment were selected from billing records. Each patient and control was mailed a survey that included an upper extremity-specific health status measure (Disabilities of the Arm, Shoulder, and Hand questionnaire; DASH) and a set of questionnaires evaluating psychological factors including the Pain Anxiety Symptoms Scale (PASS), the Pain Catastrophizing Scale (PCS) and the Center for the Epidemiological Study of Depression (CES-D) instrument. Seventy-two patients (45%; 31 that elected operative and 41 nonoperative care) returned a completed questionnaire with usable data. Older age was the only significant predictor of choice for nonoperative treatment among survey responders. Arm-specific disability (DASH) correlated with the CES-D, PASS, and PCS scores, and the influence of radiographic severity was near significant (p = 0.06). Stepwise multiple linear regression resulted in a model including the CES-D and PCS scores and accounting for 51% of the variability in DASH scores for patients from both cohorts. For both the operative and nonoperative cohorts, a model including CES-D alone accounted for 50% of the variability in DASH scores (p < 0.01). This study suggests that depression, pain anxiety, and pain catastrophizing are strong correlates of arm-specific disability but do not predict election of operative treatment in patients with trapeziometacarpal arthrosis.

Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial

PURPOSE

We tested the hypothesis that there is no difference in disability, pain, and grip strength 1 and 6 months after corticosteroid and lidocaine injection compared with lidocaine injection alone (placebo).

METHODS

Sixty-four patients were randomly assigned to dexamethasone (n = 31) or placebo (n = 33) injection. At enrollment, disability (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire), pain on a visual analog scale, grip strength, depression (the Center for Epidemiologic Studies Depression Scale; CESD), and ineffective coping skills (the Pain Catastrophizing Scale; PCS) were comparable between treatment groups. At 1 and 6 months, DASH, pain, and grip strength measures were repeated. Univariate and multivariate analyses were used to determine predictors of disability. Analysis was by intention to treat.

RESULTS

One month after injection, DASH scores averaged 24 versus 27 points (dexamethasone vs placebo), pain 3.7 versus 4.3 cm, and grip strength 83% versus 87%. At 6 months, DASH scores averaged 18 versus 13 points, pain 2.4 versus 1.7 cm, and grip strength 98% versus 97%. CESD and PCS scores correlated with disability as measured by the DASH questionnaire. The best multivariate models included CESD at 1 month and PCS scores at 6 months and explained the majority of variability in DASH scores.

CONCLUSIONS

Corticosteroid injection did not affect the apparently self-limited course of lateral elbow pain. In secondary analyses in a subset of patients, perceived disability associated with lateral elbow pain correlated with depression and ineffective coping skills.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger

PURPOSE

This study was designed to test the null hypothesis that there is no difference in resolution of triggering 3 months after injection with either a soluble (dexamethasone) or insoluble (triamcinolone) corticosteroid for idiopathic trigger finger.

METHODS

Eighty-four patients were enrolled in a prospective randomized controlled trial comparing dexamethasone and triamcinolone injection for idiopathic trigger finger. Sixty-seven patients completed the 6-week follow-up (35 triamcinolone arm, 32 dexamethasone arm), and 72 patients completed the 3-month follow-up (41 triamcinolone arm, 31 dexamethasone arm). Outcome measures included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, trigger finger grading according to Quinnell, and satisfaction on a visual analog scale. To preserve autonomy, patients were permitted additional injections and operative treatment at any time. Twenty-five patients requested a second injection (10 triamcinolone arm, 15 dexamethasone arm), and 21 elected operative treatment (10 triamcinolone arm, 11 dexamethasone arm) during the study period. The analysis was according to intention to treat principles.

RESULTS

Six weeks after injection, absence of triggering was documented in 22 of 35 patients in the triamcinolone cohort and in 12 of 32 patients in the dexamethasone cohort. The rates 3 months after injection were 27 of 41 in the triamcinolone cohort and 22 of 31 in the dexamethasone cohort. The triamcinolone cohort had significantly better satisfaction and Quinnell grades than did the dexamethasone cohort at the 6-week follow-up but not at the 3-month follow-up. There were no significant differences between Disabilities of the Arm, Shoulder, and Hand scores at the 6-week follow-up and the 3-month follow-up. After the close of the study, there were 8 recurrences among patients with documented absence of triggering in the triamcinolone cohort and 1 in the dexamethasone cohort.

CONCLUSIONS

Although there were no differences 3 months after injection, our data suggest that triamcinolone may have a more rapid but ultimately less durable effect on idiopathic trigger finger than does dexamethasone.

Predictors of wrist function and health status after operative treatment of fractures of the distal radius

PURPOSE

To identify the most important determinants of physician-based and patient-based scoring systems for the wrist and upper extremity after operative treatment of a fracture of the distal radius, with the hypothesis that pain is the strongest determinant of both types of scores.

METHODS

Eighty-four patients were evaluated a minimum of 6 months after operative fixation of an unstable distal radius fracture using 2 physician-based evaluation instruments (the Mayo Wrist Score and the Gartland and Werley Score) and an upper extremity-specific health status questionnaire (Disabilities of the Arm, Shoulder, and Hand; DASH). Multivariate analysis of variance and multiple linear regression modeling were used to identify the degree to which various factors affect variability in the scores derived with these measures.

RESULTS

The physician-based scoring systems showed moderate correlation with each other and with DASH scores. The results of multiple linear regression modeling were as follows (percent variability accounted for by the best fit model/model with top factor alone): Mayo: 54% grip and flexion arc/47% grip alone; Gartland and Werley: 70% pain, flexion arc, radiocarpal arthritis, and duration of follow-up/53% pain alone; DASH: 71% pain, forearm arc, and type of fracture/65% pain alone.

CONCLUSIONS

At early follow-up, pain dominates the patient's perception of function after recovery from an operatively treated distal radius fracture as measured by the DASH score and the physician-based rating according to the system of Gartland and Werley. The Mayo Wrist Score is determined primarily by grip strength rather than pain. Because perception of pain and strength of grip have been shown to be influenced by psychosocial factors in some individuals, both patient-based and physician-based measures of wrist function may be vulnerable to illness behavior.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Attitudes of hand surgeons, hand surgery patients, and the general public regarding psychologic influences on illness

PURPOSE

Psychologic influences on illness are well recognized but infrequently addressed in the interactions of hand surgeons and patients. This study assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population.

METHODS

An 8-question survey regarding participant's attitudes toward psychologic influences on illness was given to the general public (people waiting in an airport), patients presenting to a hand surgery practice, and members of the American Society for Surgery of the Hand.

RESULTS

A total of 474 surgeons, 85 patients, and 42 public participants completed the survey. There were no notable differences between patients and the general public, but the surgeons' attitudes were markedly different from both patients and the general public with respect to 4 items: the surgeons underestimated the openness of patients and the general public to discussing psychologic influences and willingness to see a psychologist or psychiatrist; and they were more supportive than the general public or patients regarding the opinion that the placebo effect reflects the strong influence of psychologic factors in healing and that psychologic stress often is expressed as a physical complaint. The distribution of patient responses showed 2 subgroups with respect to the idea that psychologic stress often is expressed as a physical complaint and with regard to willingness to see a mental heath professional, reflecting that a subset of patients with a hand illness may be resistant to these concepts.

CONCLUSIONS

Hand surgery patients and the general public are not as aware of the psychologic influences on illness as are hand surgeons, but they are more willing to consider and discuss psychologic factors-and even psychologic treatment-than their surgeons realize. Surgeons' views may be colored by a few negative interactions with challenging patients, but a dialogue with our patients regarding the influence of psychologic issues on illness will be well received by most patients and may facilitate recovery.