Psychological factors contributing to perceptions pain intensity after acute orthopaedic injury

Association of First Metatarsal Phalangeal Joint Fusion for Hallux Rigidus With Patient-Reported Pain and Mental Health Outcomes in Patients Taking Psychotropic Medications

Background:

Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients.

Methods:

A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50).

Results:

Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) (P ≤ .0001 and P ≤ .0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P = .006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P = .037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P = .228). There were no observed differences in operative time (P = .219), tourniquet time (P = .359), nor time to full weightbearing (P = .512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups.

Conclusion:

In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications.

Level of Evidence:

Level III, retrospective comparative study.

Risk Factors for Prolonged Opioid Use After Open Treatment of Distal Radius Fractures

BACKGROUND

The objective of this study was to evaluate factors associated with postoperative opioid use after open treatment of distal radius fractures.

METHODS

The Humana insurance claims database was queried for open treatment of distal radius fractures by Current Procedural Terminology codes. The search was further refined to identify patients who filled an opioid prescription within 6 weeks after their surgery. The study's outcomes were: (1) limited postoperative opioid use, defined as filling a prescription once in the 6-week to 6-month period after surgery; and (2) persistent postoperative opioid use, defined as filling a prescription more than once in the 6-week to 6-month period after surgery. Logistic regression models were performed to identify factors associated with limited and persistent postoperative opioid use. Subgroup analyses were performed among opioid-naïve patients and those with open fractures.

RESULTS

This study identified 9141 of 19 220 total patients with limited and persistent opioid use. Significant risk factors included nonhome discharge, inpatient surgical setting, long-term pain, tobacco abuse, and age less than 65 years. Of note, both preoperative opioid use within 1 month before surgery (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.2-2.9) and preoperative opioid use between 1 and 6 months before surgery (OR, 4.0; 95% CI, 3.7-4.4) were significantly associated with persistent postoperative opioid use.

CONCLUSIONS

This study has identified numerous risk factors associated with postoperative opioid use after open treatment of distal radius fractures. Understanding these risk factors is the first step toward reducing postoperative opioid use.

Integrated Practice Units: What Are They and How Can They Be Applied to Orthopaedic Trauma?

Musculoskeletal professionals are looking for opportunities to provide integrated patient-centered models of care. Integrated practice units (IPUs) are structurally and functionally organized around the patient's medical condition over a full cycle of care with a comprehensive range of services delivered by dedicated multidisciplinary teams. Although IPUs have been developed for chronic orthopaedic conditions, such as hip and knee osteoarthritis, relatively little has been explored in relation to orthopaedic trauma. Development of novel IPUs for managing musculoskeletal injuries may help surgeons to better contend with the substantial burden associated with these conditions on the quality of life of individual patients and society at large. This review explores the challenges and unmet needs unique to orthopaedic trauma that could be bridged by high-value, integrated patient-centered models of care. It also provides a framework for the design and implementation of IPUs and the rationale of this framework in 3 major populations: ambulatory trauma, fragility fractures, and complex polytrauma. To conclude, in this review, we consider the mechanism and impact of alternative payment models in this setting.

Opioid Consumption Rate Following Foot and Ankle Surgery

BACKGROUND

The rapid increase in the consumption of prescription opioids has become one of the leading medical, economic, and sociological burdens in North America. In the United States, orthopedic surgery is the fourth leading specialty in the number of opioids prescribed, and the largest among all operative specialties. There is insufficient evidence to guide surgeons about appropriate opioid prescription amounts after orthopedic foot and ankle (F&A) procedures. The aim of this study was to determine the opioid consumption rate after foot and ankle procedures and identify risk factors associated with higher use.

METHODS

A total of 535 patients who underwent foot and/or ankle surgery between August 2016 and March 2018 were included in the study. Each patient received a preoperative discussion about postoperative pain and expectations alongside a standardized handout. At the 2-week postoperative visit, the patients self-reported the amount of consumed opioids. Prescription details, number of opioid pills consumed, refill requests, pain-issue-related telephone calls, and additional physician/emergency department visits were documented. Patient demographics, comorbidities, use of regional anesthesia, hospitalization, surgery type/severity, and preoperative opioid use were collected. A total of 244 patients had a sufficiently complete data set for inclusion in the final cohort. Subjects had a mean age of 50 years (±16.3) and a body mass index (BMI) of 29 (±6.1). Sixty-six (27%) patients underwent a soft tissue procedure alone and 178 (73%) underwent a bony procedure.

RESULTS

On average, patients consumed 46.6% of the prescribed pills following a bony procedure and 42.4% after a soft tissue procedure, which resulted in a total of 4496 leftover pills. BMI, procedure type (bony vs soft tissue)/severity, and number of opioids prescribed were positively correlated with elevated consumption rates (P = .008, P < .001, P < .001, P < .001, respectively).

CONCLUSION

BMI, procedure type, and higher initial pill dispensation correlated with a larger number of consumed pills during the postoperative period. On average, patients took 42.4% of the prescribed opioid after soft tissue procedures and 46.6% after bony procedures, resulting in a significant number of unused pills. Future guidelines are necessary to improve postoperative pain management to prevent narcotic overprescription and minimize the downstream potential for unprescribed community opioid access.

LEVEL OF EVIDENCE

Level III, retrospective case series, analytic.

Psychosocial predictors in the transition from acute to chronic pain: a systematic review

Chronic non-cancer pain (CNCP) is a major health problem which psychosocial factors have significant implications in. There is a gap in regards to evidence for the prevention of chronicity specifically addressing psychological and social domains. Four databases were searched with terms related to "psychosocial", "acute pain", and "chronic pain". A total of 1,389 studies were identified in which titles, abstracts, and full texts were assessed for inclusion criteria. A data template was used to capture pertinent details, and overall themes and patterns were organized according to type of pain examined and psychosocial variables measured. Of the 18 articles that met inclusion criteria, fifteen (83%) of the articles reported an association between psychosocial factors and chronicity. A total of 5 of the studies (29%) demonstrated that depression was a possible predictor and 6 (35%) of the studies found fear-avoidance to be associated with chronicity. This review provides evidence that psychosocial factors are associated with chronicity within CNCP. These results suggest a need for targeting psychosocial predictors in prevention and early intervention through clinical guidelines and a national strategy to support a cultural change in pain care.

Should high-power posing be integrated in physical therapy?

[Purpose] Postural assessment and correction is a common approach in patient management to decrease symptoms and improve function for patients. The purpose of this study was to determine the effects of high-power posing on muscle strength and pain threshold. [Subjects and Methods] Thirty-one subjects, 16 females and 15 males, mean age 28.9 (SD 10.8) years old, were recruited through a convenience sampling on the university campus. The research design was a randomized controlled trial. In the experimental group, the subjects were instructed to stand in a high-power posture. In the control group, the subjects were instructed to stand in a low-power posture. Grip strength and pain threshold measurements were conducted before and after the postural intervention. [Results] The grip strength changed by −3.4 (−3.7, 0.3) % and 1.7 (−3.6, 5.3) % for the experimental and control groups, respectively. The pain threshold changed by 0.6 (−9.9, 10.4) % and 15.1 (−9.3, 24.4) % for the experimental and control groups, respectively. However, both changes were not significant as all the 95% CIs included 0. [Conclusions] The data did not show significant benefits of high-power posing in increasing grip strength and pain threshold compared to low-power posing.

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.

Who is healthy? Aspects to consider when including healthy volunteers in QST--based studies-a consensus statement by the EUROPAIN and NEUROPAIN consortia

Clinical and human experimental pain studies often include so-called "healthy" controls in investigations of sensory abnormalities, using quantitative sensory testing (QST) as an outcome measure. However, the criteria for what is considered "healthy" vary among the different studies and between study centers and investigators, partly explaining the high variability of the results. Therefore, several aspects should be considered during inclusion of healthy volunteers in QST-based trials to have homogenous groups of healthy controls with less variability between human experimental studies, so that results are less likely to be false negative or false positive because of subject-related factors. The EUROPAIN and NEUROPAIN consortia aimed to define factors influencing the variability in selection of healthy subjects in QST-based studies before the start of both projects and to give recommendations how to minimize it based on the current literature and expertise of the participants. The present suggestions for inclusion criteria of healthy volunteers into QST-based trials describe a 2-level approach including standardized questionnaires enabling the collection of relevant information on sociodemographic data, medical history, current health status, coping strategies in dealing with pain, and the motivation of the volunteer to participate in the study. These suggestions are believed to help researchers interpret their results in comparison with others and improve the quality of clinical studies including healthy volunteers as controls or in human experimental pain studies. They aim to reduce any confounding factors. Furthermore, the acquired information will allow post hoc analyses of variance for different potential influencing factors.

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.

Orthopaedic trauma patients and depression: a prospective cohort

OBJECTIVES

This study prospectively followed a cohort of orthopaedic trauma patients to identify risk factors that contribute to depression in patients with skeletal injuries.

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

PATIENTS

One hundred ten orthopaedic trauma patients admitted as inpatients.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Patient Health Questionnaire (PHQ-9) scores.

RESULTS

One hundred ten patients were enrolled at the time of injury in which 22 patients had moderate-to-major depression and 36 patients had mild depression. Forty-eight patients completed the follow-up surveys that were taken, on average, 9 months after the date of injury. Factors that were significant for mild depression (PHQ-9 >4) at the time of injury included a history of illegal drug use (P = 0.037) and a lower Duke Social Support and Stress Scale (DUSOCS) support score (P = 0.002). The duke social support and stress scale score had a negative Pearson correlation coefficient with PHQ-9 (n = -0.18, P = 0.03). Factors that were significant for moderate-to-major depression (PHQ-9 >9) at the time of injury were a history of a psychiatric diagnosis (P = 0.0009) and unemployment at injury (P = 0.039). Both a history of psychiatric diagnosis and an elevated PHQ-9 score at the time of injury were predictors of having depression at 9 months (P = 0.02 and P = 0.001, respectively). Also, patients with Medicaid insurance had a significant increase in their depression scores at 9 months (P = 0.02).

CONCLUSION

Depression was quite prevalent in our patient sample. A previous psychiatric diagnosis predisposed patients to depression. The socioeconomic status was also a predictive factor for increased depression scores at 9 months. Patients with a higher feeling of support from friends and family had an inverse correlation for depression. Employment also seems to have a protective effect against depression. Surprisingly, the severity of injury did not affect the depression score. Targeted consultation with a mental health care provider may obviate any morbidity that is associated with depression in an injured patient.

LEVEL OF EVIDENCE

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

Anxiety sensitivity and alexithymia as mediators of postconcussion syndrome following mild traumatic brain injury

OBJECTIVE

To examine the influence of anxiety sensitivity (AS) and alexithymia as potential mediators for the development of psychological distress and postconcussion syndrome after mild traumatic brain injury (mTBI).

PARTICIPANTS

Sixty-one patients with mTBI assessed at a mean of 2.38 weeks after injury and demographically matched healthy controls (n = 61).

MEASURES

Twenty-item Toronto Alexithymia Scale, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, and Rivermead Post Concussion Questionnaire.

RESULTS

The mTBI group reported significantly higher levels of AS, alexithymia, psychological distress, and postconcussion (PC) symptom scores than controls. High AS and alexithymia in the mTBI group were associated with a greater number of PC symptoms and higher levels of psychological distress than patients scoring low on these measures and controls. In the mTBI group, a combination of AS and low mood explained 52.6% of the variance in PC symptom reporting. A combination of trait-anxiety, alexithymia, and PC symptoms explained 77.2% of the variance in levels of mood.

CONCLUSION

A combination of low mood and high AS may act as a psychological diathesis for the development of persisting PC symptoms. Early identification could provide a focus for early intervention to prevent the development of postconcussion syndrome after mTBI.