How much are upper or lower extremity disabilities associated with general health status in the elderly?

Comparison of gender differences in health-related quality of life between patients with hand disease and those with other musculoskeletal disorders of the knee and lumbar spine

BACKGROUND

Musculoskeletal diseases are a major public health concern among older adults. There has been an increase in the number of studies on pain between men and women, such as knee and lumbar pain. However, there is a dearth of research on pain between men and women in hand disease. This study compared health-related quality of life (HRQOL) between patients with musculoskeletal disorders of the hand and those with disorders of the knee and the lumbar spine.

METHODS

From 2014 to 2018, 5595 adult patients completed a questionnaire on HRQOL. Among these patients, we identified patients with hand disease (n = 1038), knee disease (n = 680), and lumbar spine disease (n = 2021) resulting in a total sample of 3739 patients (1749 men and 1992 women). Patients' responses to the EuroQol (EQ-5D), the Short Form 12-item Survey (SF-12), and three visual analogue scales (VAS), as different measures of the HRQOL, were evaluated.

RESULTS

It was found that the EQ-5D index was lowest in the lumbar spine patients, followed by knee and hand patients. The VAS scores were negatively affected in all groups. The EQ-5D index was significantly lower in women than in men only in the hand disease group. Multivariate analysis revealed that for the EQ-5D index, age, gender, and VAS scores for job and activities of daily living were explanatory factors in the hand disease group. Gender was not a significant predictor in the other groups.

CONCLUSIONS

This study demonstrated that pain negatively affected HRQOL, and gender differences in HRQOL were found only in patients with hand disease. Gender differences in HRQOL in patients with hand disease warrant appropriate clinical attention.

What Factors Are Associated With Disability After Upper Extremity Injuries? A Systematic Review

BACKGROUND

Psychosocial factors are key determinants of health after upper extremity injuries. However, a systematic review is needed to understand which psychosocial factors are most consistently associated with disability and how the language, conceptualization, and types of measures used to assess disability impact these associations in upper extremity injuries.

QUESTIONS/PURPOSES

(1) What factors are most consistently associated with disability after upper extremity injuries in adults? (2) What are the trends in types of outcome measures and conceptualization of disability in patients' upper extremity injuries?

METHODS

We searched multiple electronic databases (PubMED, OVIDSP, PsycInfo, Google Scholar, ISI Web of Science) between January 1, 1996, and December 31, 2016, using terms related to the "upper extremity", "outcome measurement", and "impairment, psychological, social or symptomatic" variables. We included all studies involving adult patients with any musculoskeletal injury and excluded those that did not use patient-reported outcome measures. We identified and screened 9339 studies. Of these, we retained 41 studies that involved conditions ranging from fractures to soft tissue injuries in various regions of the arm. We conducted quality assessment using a 10-item validated checklist and a five-tier strength of evidence assessment. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria and registered the review before performing our search (PROSPERO: CRD42017054048). None of the authors received any funding to perform this work.

RESULTS

Disability after upper extremity injury was most consistently associated with depression (21 cohorts), catastrophic thinking (13 cohorts), anxiety (11 cohorts), pain self-efficacy (eight cohorts), and pain interference (seven cohorts). Social and demographic factors were also associated with disability. Measures of impairment such as ROM and injury severity were least associated with disability. There has been a gradual increase in use of region or condition-specific patient-reported outcome measures and measures of psychological, social, and symptomatic factors over a period since the introduction of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) around 2000. Approximately 17% of studies (n = 454 of 2628) had instances of unclear, conflicting, or inappropriate terminology and 11% of studies (n = 257 of 2628) involved misrepresentations of outcome measures related to disability.

CONCLUSIONS

Psychologic and social factors are most consistently associated with disability than factors related to impairment. Further research involving the assessment of depression, anxiety, and coping strategies in cohorts with specific injuries may support decision-making regarding the provision of emotional support and psychologic therapies during recovery. Using the WHO ICF framework to conceptualize disability is key in increasing strength of evidence and allowing accurate comparisons of research in this field.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Preoperative Pain Sensitization Is Associated With Postoperative Pillar Pain After Open Carpal Tunnel Release

BACKGROUND

Postoperative pillar pain (deep-seated wrist pain worsened by leaning on the heel of the hand) sometimes occurs after carpal tunnel release (CTR), leading to weakness in the hand and delayed return to work. Increased pain sensitivity has been found to be associated with worse symptoms and poorer treatment response in a number of chronic musculoskeletal conditions, but few studies have investigated the association of pain sensitization with pillar pain after CTR.

QUESTIONS/PURPOSES

(1) Is preoperative pain sensitization in patients with carpal tunnel syndrome (CTS) associated with increased severity of pillar pain after open CTR? (2) What other demographic, electrophysiological, or preoperative clinical characteristics are associated with pillar pain after CTR?

METHODS

Over a 35-month period, one surgeon performed 162 open carpal tunnel releases. Patients were eligible if they had sufficient cognitive and language function to provide informed consent and completed a self-reported questionnaire; they were not eligible if they had nerve entrapment other than CTR or if the surgery was covered by workers compensation insurance. Based on these criteria, 148 (91%) were approached for this study. Of those, 17 (9%) were lost to followup before 12 months, leaving 131 for analysis. Their mean age was 54 years (range, 32-78 years), and 81% (106 of 131) were women; 34% (45 of 131) had less than a high school education. We preoperatively measured pain sensitization by assessing the patients' pressure pain thresholds by stimulating pressure-induced pain in the pain-free volar forearm and administering a self-reported Pain Sensitivity Questionnaire minor subscale, an instrument that assesses pain intensity in daily life situations. We evaluated postoperative pillar pain using the "table test" (having the patient lean on a table with their weight on their hands placed on the table's edge with elbows straight) with an 11-point ordinal scale at 3, 6, and 12 months after their surgical procedures. We conducted bivariate and multivariable analyses to determine whether the patients' clinical, demographic, and pain sensitization factors were associated with their postoperative pillar pain severity after CTR.

RESULTS

After controlling for relevant confounding variables such as age, education level, and functional states, we found that increased pillar pain severity was associated with the pressure pain threshold (β = -1.02 [-1.43 to -0.61], partial R = 11%, p = 0.021) and Pain Sensitivity Questionnaire minor (β = 1.22 [0.73-1.71], partial R = 17%, p = 0.013) at 3 months, but by 6 months, only Pain Sensitivity Questionnaire minor (β = 0.92 [0.63-1.21], partial R = 13%, p = 0.018) remained an associated variable for pillar pain. Additionally, gender (women) was associated with increased pain severity at 3 (β = 0.78 [0.52-1.04], partial R = 9%, p = 0.023) and 6 months (β = 0.72 [0.41-1.01], partial R = 8%, p = 0.027). At 3 months, pressure pain threshold, Pain Sensitivity Questionnaire minor, and gender (women) collectively accounted for 37% of the variance in pillar pain severity; at 6 months, Pain Sensitivity Questionnaire minor and gender (women) accounted for 21% of the variance, but no relationship between those factors and pillar pain was observed at 12 months.

CONCLUSIONS

Gender (women) and preoperative pain sensitization measured by pressure pain threshold and self-reported Pain Sensitivity Questionnaire were associated with pillar pain severity up to 3 and 6 months after CTR, respectively. However, the influence of pain sensitization on pillar pain was diminished at 6 months and it did not show persistent effects beyond 12 months. Pain sensitization seems to be more important in the context of recovery from surgical intervention (in the presence of a pain condition) than in healthy states, and clinicians should understand the role of pain sensitization in the postoperative management of CTS. Future research may be needed to determine if therapeutic interventions to reduce sensitization will decrease the risk of pillar pain.

LEVEL OF EVIDENCE

Level III, prognostic study.

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting

BACKGROUND

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability .

METHODS

Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes.

RESULTS

MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury.

CONCLUSIONS

Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.

Limb Differences in the Therapeutic Effects of Complex Decongestive Therapy on Edema, Quality of Life, and Satisfaction in Lymphedema Patients

Objective

To investigate the changing patterns of edema, quality of life (QOL), and patient-satisfaction after complex decongestive therapy (CDT) in three trajectories: arm lymphedema (AL), secondary leg lymphedema (LL) and primary leg lymphedema (PL).

Methods

Candidates for AL (n=35), LL (n=35) and PL (n=14) were identified from prospective databases. The patients were treated with CDT for 2 weeks, and lymphedema volume was measured before and immediately following the therapy. Patients then self-administered home therapy for 3 months and presented for a follow-up visit. The Korean version of Short Form-36 (SF-36) was used to assess QOL, and we administered a study-specific satisfaction survey.

Results

There was no significant difference in the volume reductions between the 3 groups. There were no significant differences in all of the measures between PL and LL. Overall initial QOL was significantly lower in patients with LL than in patients with AL. SF-36 scores post-CDT did not differ significantly between AL and LL. Clinically significant differences were noted between AL and LL in the mean values of the satisfaction survey.

Conclusion

AL, LL, and PL may have different longitudinal courses. We suggest that lower extremity lymphedema patients present more favorable outcomes after CDT with respect to QOL and satisfaction than upper extremity lymphedema patients. Clinicians should approach patients with different therapeutic considerations specific to each type or region of lymphedema before using CDT in clinical practice.

Association Between Lower Extremity Performance and Health-Related Quality of Life in Elderly Mexican Americans

OBJECTIVE

To examine the longitudinal association between levels of lower extremity performance (LEP) and health-related quality of life (HRQoL) in older Mexican Americans aged 72 years or older participating in the Hispanic Established Population for the Epidemiological Study of the Elderly (2000-2006).

METHOD

LEP was measured in 621 non-institutionalized participants with the Short Physical Performance Battery (SPPB). Participants were divided into high (SPPB score 10-12), intermediate (SPPB score 7-9), and low (SPPB score 0-6) groups based on LEP. HRQoL was assessed using the Medical Outcomes Study Short Form (SF-36), which includes a Physical Composite Scale (PCS) and a Mental Composite Scale (MCS).

RESULTS

Participants in the high LEP group had slower rates of decline in the PCS, and those in the intermediate LEP group had slower rates of decline in the MCS score over time.

DISCUSSION

Increased LEP was associated with slower rates of decline in physical and mental HRQoL in older Mexican Americans.

Cross cultural adaptation and validation of a Spanish version of the Lower Limb Functional Index

BACKGROUND

The Lower Limb Functional Index (LLFI) is a relatively recently published regional outcome measure. The development article showed the LLFI had robust and valid clinimetric properties with sound psychometric and practical characteristics when compared to the Lower Limb Extremity Scale (LEFS) criterion standard.

OBJECTIVE

The purpose of this study was cross cultural adaptation and validation of the LLFI Spanish-version (LLFI-Sp) in a Spanish population.

METHODS

A two stage observational study was conducted. The LLFI was initially cross-culturally adapted to Spanish through double forward and single backward translation; then subsequently validated for the psychometric characteristics of validity, internal consistency, reliability, error score and factor structure. Participants (n = 136) with various lower limb conditions of >12 weeks duration completed the LLFI-Sp, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the Euroqol Health Questionnaire 5 Dimensions (EQ-5D-3 L). The full sample was employed to determine internal consistency, concurrent criterion validity, construct validity and factor structure; a subgroup (n = 45) determined reliability at seven days concurrently completing a global rating of change scale.

RESULTS

The LLFI-Sp demonstrated high but not excessive internal consistency (α = 0.91) and high reliability (ICC = 0.96). The factor structure was one-dimensional which supported the construct validity. Criterion validity with the WOMAC was strong (r = 0.77) and with the EQ-5D-3 L fair and inversely correlated (r = -0.62). The study limitations included the lack of longitudinal data and the determination of responsiveness.

CONCLUSIONS

The LLFI-Sp supports the findings of the original English version as being a valid lower limb regional outcome measure. It demonstrated similar psychometric properties for internal consistency, validity, reliability, error score and factor structure.

Clinical evaluation of upper limb function: Patient's impairment, disability and health-related quality of life

Musculoskeletal disorders substantially impacts physical activity, mental state, and quality of life (QOL). Generally, comprehensive assessment of upper limb function requires measures of impairment or disability as well as health-related quality of life. A growing number of outcome instrument have been introduced to evaluate upper limb function and disability, and these measures can be categorized as patient- or clinician-based, and as condition specific or general health-related QOL evaluations. The upper limb outcome instruments reviewed in this article assess different aspect of upper limb conditions, and the measures are affected by differences in cultural, psychological, and gender aspect of illness perception and behavior. Therefore, physician should select/interpret the outcome instruments addressing their primary purpose of research. Information about regional instruments for upper limb condition and health-related QOL in upper limb disorder may help us in decision-making for treatment priority or in interpretation of the treatment outcomes.

Evaluation of factors influencing grip strength in elderly koreans

Objectives

Grip strength has been used as a measure of function in various health-related conditions. Although grip strength is known to be affected by both physical and psychological factors, few studies have looked at those factors comprehensively in a population-based cohort regarding elderly Koreans. The aim of this study was to evaluate potential factors influencing grip strength in elderly Koreans.

Methods

We evaluated dominant hand grip strengths in 143 men and 123 women older than 65 years who participated in a population-based cohort study, the Korean Longitudinal Study on Health and Aging (KLoSHA). Individuals who had a history of surgery for musculoskeletal disease or trauma in the upper extremity were excluded. Factors assessed for potential association with grip strength were; 1) demographics such as age and gender, 2) body constructs such as height, body mass index (BMI), and bone mineral density (BMD), 3) upper extremity functional status using disabilities of the arm, shoulder and hand (DASH) scores, and 4) mental health status using a depression scale and the short form-36 (SF36) mental health score. Multivariate analyses were performed in order to identify factors independently associated with grip strength.

Results

Grip strengths of dominant hands in elderly Koreans were found to generally decrease with aging, and were significantly different between men and women, as expected. Multivariate analyses indicated that grip strength was independently associated with age, height and BMI in men (R² = 21.3%), and age and height (R² = 19.7%) in women. BMD, upper extremity functional status, or mental health status were not found to be associated with grip strength.

Conclusions

This study demonstrates that in elderly Koreans, grip strength is mainly influenced by age and height in both men and women, and additionally by BMI in men. BMD or self-reported physical or mental health status was not found to influence grip strength in elderly Koreans. This information may be helpful in future studies using grip strength as a measure of function in elderly Koreans.