The correlation of cognitive flexibility with pain intensity and magnitude of disability in upper extremity illness

Symptomatic Heterotopic Bone Formation after 1,2 ICSRA in Scaphoid Nonunions

Background  We observed several cases of heterotopic bone formation after a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) distal radius vascularized bone graft (VBG) for the treatment of scaphoid nonunion. This adverse event seems underreported. Knowledge about factors associated with the formation of heterotopic bone after VBGs might help reduce this adverse event. Purpose  What factors are associated with resected heterotopic bone formation after 1,2 ICSRA distal radius graft for the treatment of scaphoid nonunion? Patients and Methods  We retrospectively reviewed all patients with a scaphoid nonunion treated with a 1,2 ICSRA distal radius graft between 2008 and 2019 in an urban level 1 trauma center in the Netherlands. We included 42 scaphoid nonunions in 41 people treated with the 1,2 ICSRA graft. We assessed potential correlation with patient, fracture, and treatment demographics. Results  Heterotopic bone developed in 23 VBGs (55% [23/42]), of which 5 (12% [5/42]) were resected. Heterotopic bone was located radially (at the pedicle side) in all participants. Except a longer follow-up time ( p  = 0.028), we found no variables associated with the development of heterotopic bone formation. Conclusion  The location of the heterotopic bone at the pedicle site in all cases suggests a potential association with the periosteal strip. Surgeons might consider not to oversize the periosteal strip as a potential method to prevent heterotopic ossification after VBG. Level of Evidence  Level II, prognostic study.

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.

Outcomes associated with secondary implant removal and arthrolysis in patients with a painful stiff shoulder after proximal humeral fracture fixation

AIMS

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

METHODS

Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively.

RESULTS

A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS.

CONCLUSION

ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157-167.

Pain during physical examination of a healing upper extremity fracture

The evidence that symptom intensity and magnitude of limitations correlate with thoughts and emotions means that subjective signs, such as pain with physical examination, reflect both physical and mental health. During a 1-month evaluation of a rapidly healing upper extremity fracture with no risk of nonunion, 117 people completed measures of adaptiveness to pain and pain during the physical examination. Greater pain during examination correlated with less adaptive responses to pain and older age. This finding raises questions about using tenderness to assess fracture union.Level of evidence: II.

Can Crafted Communication Strategies Allow Musculoskeletal Specialists to Address Health Within the Biopsychosocial Paradigm?

BACKGROUND

Musculoskeletal specialists who attempt to discuss the connection between mental health (thoughts and emotions) and physical health (symptom intensity and activity tolerance) with patients, may fear that they risk offending those patients. In a search for language that creates comfort with difficult conversations, some specialists favor a biomedical framework, such as central sensitization, which posits abnormal central neuron activity. Without addressing the relative accuracy of mind- or brain-based conceptualizations, we addressed crafted and practiced communication strategies as conversation starters that allow specialists to operate within a biopsychosocial framework without harming the relationship with the patient.

QUESTIONS/PURPOSES

We measured (1) patient resonance with various explanations of the mind-body connection, including examples of both mind- and brain-based communication strategies, and (2) factors associated with resonance and emotional reactions to the explanations.

METHODS

In this cross-sectional study, all adult new and returning patients who were literate in English and who attended several musculoskeletal specialty offices were invited to complete questionnaires addressing reactions to one of seven explanations of the mind-body connection assigned using a random number generator. Acknowledging that the relative accuracy of mind-based and nerve- or brain-based strategies are speculative, we developed the following conversation starters: two explanations that were cognitively framed ("the mind is a great story teller"; one positively framed and one negatively framed), two emotionally framed explanations ("stressed or down"; one positively framed and one negatively framed), one mentioning thoughts and emotions in more neutral terms ("mind and body work together … thoughts and emotions affect the way your body experiences pain"), and two biomedical neurophysiology-based explanations ("nerves get stuck in an over-excited state" and "overstimulated nerves"), all crafted with the assistance of a communication scholar. It was unusual for people to decline (although the exact number of those who did was not tracked) and 304 of 308 patients who started the questionnaires completed them and were analyzed. In this sample, 51% (155 of 304) were men, and the mean ± SD age was 49 ± 17 years. Reactions were measured as resonance (a 1 to 5 Likert scale regarding the degree to which the stated concept aligns with their understanding of health and by inference is a comfortable topic of discussion) and self-assessment manikins using circled figurines to measure feelings of happiness (frowning to smiling figures), stimulation/excitement (a relaxed sleepy figure to an energized wide-eyed figure), and security/control (small to large figures). These are commonly used to quantify the appeal and emotive content of a given message. Patients also completed surveys of demographics and mental health. Multilevel multivariable linear regression models were constructed to assess factors associated with resonance, happiness, excitement, and control.

RESULTS

Controlling for potential confounding variables such as demographics and mental health measures, a relatively neutral biopsychosocial explanation ("mind and body work together") had the greatest mean resonance (4.2 ± 0.8 versus 3.8 ± 0.9 for the other explanations; p < 0.01) and the largest regression coefficient for resonance (0.78 [95% confidence interval 0.41 to 1.15]). The next-most-resonant explanations were biomedical ("excitable nerves", "over-excited state"). Biopsychosocial explanations that mention stress, distress, or cognitive bias ("mind is a great storyteller") had lower resonance. People with greater unhealthy cognitive bias regarding pain (more catastrophic thinking) were less comfortable with all the explanations (lower resonance, regression coefficient -0.03 [95% CI -0.06 to -0.01]). Emotional reactions were relatively comparable with the exception that people felt less control and security with specific explanations such as "excitable nerves" and "mind is a great storyteller."

CONCLUSION

Crafted communication strategies allow musculoskeletal specialists to address health within the biopsychosocial paradigm without harming their relationship with the patient.

CLINICAL RELEVANCE

Musculoskeletal specialists may be the first clinicians to notice mental health opportunities. It may be helpful for them to develop and practice effective communication strategies that make mental health a comfortable topic of discussion.

Attitudes Toward Aging Among Patients With Upper Extremity Illness

Background: An adaptive attitude toward aging might limit symptom intensity and magnitude of limitations. This study sought factors associated with attitudes toward aging (measured with the Brief Aging Perceptions Questionnaire [B-APQ]) and studied the relationship of having an age-related disease to magnitude of limitations, pain intensity, patient satisfaction, and patient comfort with completing a questionnaire about attitudes toward aging. We also looked for a subset of questions from B-APQ that maintained the construct validity and internal consistency of B-APQ, without unacceptable flooring or ceiling effects. Methods: A total of 161 upper extremity patients completed the following questionnaires: B-APQ, Patient Health Questionnaire-Short Form, Pain Self-efficacy-Short Form, Pain Catastrophizing Scale-Short Form, Patient-Reported Outcomes Measurement Information System Physical Function-Upper Extremity, pain intensity, satisfaction with the surgeon, and comfort with completing the B-APQ. We created multivariable linear regression models to test for associations. Results: Factors independently associated with less positive perceptions about aging included white race, retired work status, having nonspecific comorbidities, and more catastrophic thinking. Variation in the magnitude of limitations and pain intensity was accounted for by effectiveness of coping strategies rather than attitudes toward aging in particular. A 4-question version of the B-APQ has acceptable performance. Conclusion: Adaptive attitudes toward aging are associated with psychological and social determinants of health. We present a 4-item short form of B-APQ that could be used as a brief measure to assess attitudes toward aging. Interventions to improve adaptiveness to nociception (eg, cognitive behavioral therapy to limit catastrophic thinking) might help with adaptation to age-related changes.

Misperception of Disease Onset in People with Gradual-Onset Disease of the Upper Extremity

BACKGROUND

Misperception that an established, gradual-onset disease such as osteoarthritis started when the symptoms were first noticed might lead to testing and treatment choices that are inconsistent with what matters most to a patient. In the present study, the primary null hypothesis was that there are no factors associated with patient-reported symptom duration (in months). The secondary null hypotheses were that there are no factors independently associated with (1) a sudden versus gradual perception of disease onset, (2) an event or injury-related versus age-related perceived cause of disease onset, and (3) the magnitude of physical limitations.

METHODS

In this cross-sectional study, 121 patients with an atraumatic, established, gradual-onset condition of the upper extremity completed a demographic questionnaire, measures of mental health (symptoms of depression and anxiety, worst-case thinking, and self-efficacy [the ability to adapt and continue with daily activity] when in pain), measurement of the magnitude of upper extremity-specific limitations, and questions about the perceived course and cause of the disease.

RESULTS

The median patient-reported symptom duration was 12 months (interquartile range, 3 to 36 months). Twenty-two patients (18%) perceived their disease as new, and 29 patients (24%) believed that the condition was related to ≥1 event (injury) rather than being time and age-related. In multivariable analysis, patients with Medicare insurance were independently associated with longer reported symptom duration (in months). Greater self-efficacy was associated with longer symptom duration in bivariate, but not multivariable, analysis. No factors were independently associated with a sudden versus gradual onset of symptoms. Hispanic ethnicity and federal, county, or no insurance were independently associated with the perception that the problem was caused by an injury or event.

CONCLUSIONS

Approximately 1 in 5 patients misperceived new symptoms as representing a new disease, often as a type of injury. Misperception of the pathology as new had a limited association with unhealthy thoughts and is likely generally responsive to reorientation. We speculate that gentle, strategic reorientation of misperception can protect patients from choices inconsistent with their values.

Early Psychological and Social Factors Explain the Recovery Trajectory After Distal Radial Fracture

BACKGROUND

This prospective study identified the association of demographic, injury, psychological, and social variables, measured early during recovery, with limitations in function (measured by the Patient-Reported Outcomes Measurement Information System Upper Extremity Physical Function Computer Adaptive Test [PROMIS UE]) at 6 to 9 months after a distal radial fracture. Additionally, we assessed variables associated with the PROMIS UE; the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH); the Patient-Rated Wrist Evaluation (PRWE); and the 3-Level EuroQol 5 Dimensions Index (EQ-5D-3L) over time.

METHODS

A total of 364 adult patients (73% female), with a median age of 65 years (interquartile range, 45.5 to 77 years), who sustained an isolated distal radial fracture completed questionnaires at 3 time periods after the fracture: within 1 week, between 2 and 4 weeks, and between 6 and 9 months. We created a multivariable regression model and a generalized least squares random effects model, accounting for multicollinearity using correlation matrices, the variable inflation factor, and the partial R.

RESULTS

Multiple variables within a week of the injury correlated with 6 to 9-month limitations in bivariate analysis. Being retired (partial R = 0.19; p < 0.001), using opioids after the fracture (partial R = 0.04; p < 0.001), using antidepressants (partial R = 0.11; p < 0.001), greater pain interference (partial R = 0.03; p = 0.001), and greater pain catastrophization (partial R = 0.04; p = 0.002) within 1 week of the injury were strong predictors of greater limitations (PROMIS UE) at 6 to 9 months in multivariable analysis. Longitudinal analysis of variables over time demonstrated greater pain interference, greater fear of movement, lower self-efficacy, older age, and female sex as strong predictors of limitations.

CONCLUSIONS

Recovery from a distal radial fracture is influenced by a series of demographic, psychological, and social variables. Of these factors, being retired, using opioids, using antidepressants, greater pain interference, and greater pain catastrophization within a week of the injury explain the largest amounts of unique variance in self-perceived upper-extremity physical function. Evaluating the impact of change in variables over time underlined the influence of pain interference as well as the influence of fear of movement and self-efficacy (or resiliency) on limitations in physical function and general health. These findings have important implications for identifying individuals who can benefit from behavioral interventions for these psychological factors to optimize recovery.

LEVEL OF EVIDENCE

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

Pain-related psychological issues in hand therapy

STUDY DESIGN

Literature review.

INTRODUCTION

Pain is a subjective experience that results from the modulation of nociception conveyed to the brain via the nervous system. Perception of pain takes place when potential or actual noxious stimuli are appraised as threats of injury. This appraisal is influenced by one's cognitions and emotions based on her/his pain-related experiences, which are processed in the forebrain and limbic areas of the brain. Unarguably, patients' psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, disability, and treatment outcomes. Therefore, hand therapists should address the patient pain experience using a biopsychosocial approach. However, in hand therapy, a biomedical perspective predominates in pain management by focusing solely on tissue healing.

PURPOSE OF THE STUDY

This review aims to raise awareness among hand therapists of the impact of pain-related psychological factors.

METHODS AND RESULTS

This literature review allowed to describe (1) how the neurophysiological mechanisms of pain can be influenced by various psychological factors, (2) several evidence-based interventions that can be integrated into hand therapy to address these psychological issues, and (3) some approaches of psychotherapy for patients with maladaptive pain experiences.

DISCUSSION AND CONCLUSION

Restoration of sensory and motor functions as well as alleviating pain is at the core of hand therapy. Numerous psychological factors including patients' beliefs, cognitions, and emotions alter their pain experience and may impact on their outcomes. Decoding the biopsychosocial components of the patients' pain is thus essential for hand therapists.

Factors associated with the magnitude of limitations during recovery from a fracture of the proximal humerus

Aims

The purpose of this study was to identify factors associated with limitations in function, measured by patient-reported outcome measures (PROMs), six to nine months after a proximal humeral fracture, from a range of demographic, injury, psychological, and social variables measured within a week and two to four weeks after injury.

Patients and Methods

We enrolled 177 adult patients who sustained an isolated proximal humeral fracture into the study and invited them to complete PROMs at their initial outpatient visit within one week of injury, between two and four weeks, and between six to nine months after injury. There were 128 women and 49 men; the mean age was 66 years (sd 16; 18 to 95). In all, 173 patients completed the final assessment. Bivariate analysis was performed followed by multivariable regression analysis accounting for multicollinearity using partial R2, correlation matrices, and variable inflation factor.

Results

Many variables within a week of injury and between two and four weeks after injury correlated with six- to nine-month PROMs in bivariate analysis. Kinesiophobia measured within a week of injury (Tampa Scale for Kinesiophobia-11: partial R2 = 0.14; p = 0.000) and self-efficacy measured between two and four weeks (Pain Self-efficacy Questionnaire-2: partial R2 = 0.266; p < 0.001) were the strongest predictors of limitations (measured by Patient Reported Outcome Measurement Information System Upper Extremity Physical Function Computer Adaptive Test (PROMIS UE)) at six to nine months in multivariable analysis. Similar findings were observed with other types of PROM. Regression models accounted for a substantial amount of variance in all PROMs at both timepoints (e.g. 66% of the overall variance within one week, and 70% within two to four weeks for PROMIS UE at six to nine months).

Conclusion

Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy (developing resilience and more effective coping strategies) within a month. Such factors are modifiable using enhanced communication skills and cognitive behavioural treatments. These findings could be a catalyst for the routine assessment and treatment of psychological and social factors in the management of patients with fractures. Cite this article: Bone Joint J 2019;101-B:715–723.

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.

Psychological Factors Affecting Outcomes After Elective Shoulder Surgery

To optimize outcomes following elective shoulder surgery, it is important to address not only the injury or pathology itself, but also the cognitive and emotional factors that may influence a patient's recovery. Depression, anxiety, catastrophic thinking, distress, somatization, and decreased self-efficacy are among the most common psychological factors associated with adverse perioperative events and poor postoperative outcomes. Such factors may manifest at any point during recovery. Validated questionnaires can be used to measure psychological factors preoperatively, thereby enabling earlier intervention that may mitigate any potential negative effect of these factors on the patient's overall outcome. Orthopaedic surgeons must be sensitive to the influence of stress, distress, and limited coping strategies on patients and should learn how best to mitigate the detrimental effects of these factors on outcomes after elective shoulder surgery.

Ability to Cope with Pain Puts Migraine Surgery Patients in Perspective

BACKGROUND

Candidates for migraine surgery are chronic pain patients with significant disability. Currently, migraine-specific questionnaires are used to evaluate these patients. Analysis tools widely used in evaluation of better understood pain conditions are not typically applied. This is the first study to include a commonly used pain questionnaire, the Pain Self-Efficacy Questionnaire (PSEQ) that is used to determine patients' pain coping abilities and function. It is an important predictor of pain intensity/disability in patients with musculoskeletal pain, as low scores have been associated with poor outcome.

METHODS

Ninety patients were enrolled prospectively and completed the Migraine Headache Index and PSEQ preoperatively and at 12 months postoperatively. Scores were evaluated using paired t tests and Pearson correlation. Representative PSEQ scores for other pain conditions were chosen for score comparison.

RESULTS

All scores improved significantly from baseline (p < 0.01). Mean preoperative pain coping score (PSEQ) was 18.2 ± 11.7, which is extremely poor compared with scores reported for other pain conditions. Improvement of PSEQ score after migraine surgery was higher than seen in other pain conditions after treatment (112 percent). Preoperative PSEQ scores did not influence postoperative outcome.

CONCLUSIONS

The PSEQ successfully demonstrates the extent of debility in migraine surgery patients by putting migraine pain in perspective with other known pain conditions. It further evaluates functional status, rather than improvement in migraine characteristics, which significantly adds to our understanding of outcome. Poor preoperative PSEQ scores do not influence outcome and should not be used to determine eligibility for migraine surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

What Demographic and Clinical Characteristics Correlate With Expectations With Trapeziometacarpal Arthritis?

BACKGROUND

Pretreatment variables have been shown to be associated with the fulfillment of patient expectations, yet in treating thumb trapeziometacarpal osteoarthritis (OA) it remains unclear how patient expectations correlate with the effectiveness of treatment. An increased understanding of the variables that affect patient expectations enables tailored patient education and patient-provider communication.

QUESTIONS/PURPOSES

(1) Is there a correlation between patient demographics and clinical characteristics, and the expectations the patients have when seeking treatment for trapeziometacarpal OA? (2) What factors are independently associated with the total expectations score and frequency of expecting "back to normal" among patients treated for trapeziometacarpal OA?

METHODS

Between March 2011 and October 2013, 89 patients of all 96 eligible patients seeking treatment for trapeziometacarpal OA were approached and agreed to participate in this study. Participants completed a validated expectations survey measuring the number of expectations and the degree of improvement expected. Comparative analysis of demographic and clinical characteristics and multivariate regression analysis against patients' expectations were performed to assess and identify factors that correlate with the number and degree of expectations. Sample size was determined with an a priori power analysis (with 80% power and statistical significance set at p < 0.05), which showed that 88 patients were needed to detect the minimal clinical difference of 12 points in the Michigan Hand Questionnaire; we then increased this by 10% to allow for potential dropouts.

RESULTS

After controlling for potential confounding variables such as age, hand dominance, and work status, the following factors were associated with a higher expectations score: choice of surgery (β = 11.5; 95% CI, 0.7-23.8; p = 0.044), female gender (β = 19.0; 95% CI, 5.3-32.7; p = 0.007), and dominant side affected (β = -41.6; 95% CI, -63.7 to -19.5; p < 0.001). For the frequency of "back to normal" responses, surgical treatment (β = 7.4; 95% CI, 2.3-12.4; p = 0.005) and history of previous injury (β = 8.2; 95% CI, 0.1-16.3; p = 0.047) were independently associated factors after controlling for confounding variables. There were no independent associations with age, marital status, work status, depression or anxiety, or prior contralateral surgery.

CONCLUSIONS

Patients whose dominant side was affected, were female, and chose surgical treatment, had higher total expectations. Patients who reported an antecedent injury and chose surgical treatment more frequently expected a return to normal. With identification of these factors, orthopaedic surgeons can recognize patients who are prone to higher expectations, and, thus, have the opportunity to implement efficient pretreatment education. In addition, identification of specific factors enables a focused measure of the effect of these factors on the fulfillment of expectations.

LEVEL OF EVIDENCE

Level II, prognostic study.