The correlation of phrases and feelings with disability

The association between pain self-efficacy and patient-reported outcome measures for hand disorders: a cross-sectional study

Introduction

Multiple psychological factors influence the functioning of patients with hand disorders. Pain self-efficacy is a positive psychological factor, which concerns an individual's confidence to function despite experiencing pain. This study aimed to analyse the association between pain self-efficacy and a patient-reported outcome measure (PROM) for hand and wrist disorders.

Methods

Cross-sectional data from patient records were collected prior to hand therapy to analyse the correlation between pain self-efficacy and a PROM for hand and wrist disorders. The assessment tools consisted of the Dutch translations of the Pain Self-Efficacy Questionnaire Short Form (PSEQ-2) and the Patient Rated Wrist Hand Evaluation (PRWHE).

Results

The findings were reported for the entire sample of 185 respondents (61% women). The PSEQ-2 and the PRWHE were strongly and significantly correlated, which signifies that a higher pain self-efficacy was associated with less pain and disability as measured by the PRWHE. Within a multivariable regression model which accounted for confounding variables, pain self-efficacy independently predicted 28% of the PRWHE scores.

Conclusions

A strong association between the Dutch PSEQ-2 and the PRWHE was found in this sample of hand therapy patients. This study was limited by the use of retrospective data and by the lack of validation of the Dutch PSEQ-2. The findings were consistent with existing research which reported similar correlations between upper extremity PROM scores and pain self-efficacy. The positively worded PSEQ presents a chance to routinely assess pain self-efficacy as a key psychological factor while also affirming a positive coping strategy.

Patient symptom exaggeration is associated with communication effectiveness and trust

Objective

Patients might exaggerate their symptoms in an attempt to align the clinician's views with their own. A person who sees potential benefit in symptom exaggeration might also experience less trust, more difficulty communicating, and lower satisfaction with their clinician. We asked if there was an association between patient rating of communication effectiveness, patient satisfaction, and patient trust with symptom exaggeration?

Methods

One hundred and thirty-two patients in four orthopaedic offices completed surveys including demographics, Communication-Effectiveness-Questionnaire (CEQ-6), Negative-Pain-Thoughts-Questionnaire (NPTQ-4), a Guttman-style satisfaction question, PROMIS Depression, and Stanford Trust in Physician. Patients were randomly assigned to answer three questions about symptom exaggeration for two scenarios: 1) their own exaggeration during the just-completed visit or 2) the average person's tendency to exaggerate.

Results

In multivariable analysis, lower ratings of communication effectiveness were associated with greater symptom exaggeration (p=0.002), while an annual household income>$100,000 (p=0.033) was associated with higher ratings. Higher rating of satisfaction was associated with lower education attained (p=0.004). Greater trust was associated with lower personal exaggeration (p=0.002).

Conclusion

The relationship between greater exaggeration and lower ratings of communication effectiveness and trust suggests that symptom descriptions that seem more intense or diffuse than expected may indicate opportunities for more effective communication and trust.

Innovation

Patient experience can be improved by training clinicians to identify symptom exaggeration as a signal that the patient does not feel heard and understood and a cue to return to communication strategies that build trust.

It's Not About The Biceps

In the biomedical paradigm all symptoms and limitations are ascribed to discrete pathophysiology. However, a biopsychosocial health model that accounts for the important influence of mind-set and circumstances on illness may be preferable in the vast majority of cases. Some of the shortcomings of the biomedical model include an overreliance on tests and treatments. One major issue of the biomedical model is the raging epidemic of opioid misuse and opioid related overdose deaths as previously reported in North America. Emblematic of these issues is a 56-year-old male that had surgery for a rupture of the distal biceps in our clinic with psychosocial aspects of the illness that were underappreciated by the care team and had disastrous opioidcentric attempts at pain control leading to threats to hospital staff, and finally resulting in forcible removal by hospital security from the ward and national police from the hospital. One might argue that there is no higher priority than rejecting the biomedical model, understanding illness is its full complexity, and learning from the world's mistakes so that we don't repeat them.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

BACKGROUND

Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking.

QUESTIONS/PURPOSES

(1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures?

METHODS

Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made.

RESULTS

Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138).

CONCLUSIONS

Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

LEVEL OF EVIDENCE

Level III, diagnostic study.