Relative Prevalence of Anxiety and Depression in Patients With Upper Extremity Conditions

The presence of cognitive impairments in the acute phase of traumatic upper limb injuries: A cross-sectional observational study

OBJECTIVES

The purpose of this study was to investigate the association between cognitive impairments and traumatic upper limb injuries of the acute phase.

MATERIAL AND METHODS

A cross-sectional observational study was conducted with three groups: a nerve-injury group, a without nerve injury group, and a control group (uninjured participants). Demographic characteristics (e.g. age, sex, body mass index, and education) and traumatic characteristics (duration since injury, injury side, pain, light touch sensation, hand motor function) were recorded. Short-term memory and executive functions were assessed using Rey Auditory and Verbal Learning Test (RAVLT) and Stroop Color and Word Test (SCWT, including SIECT and SIECN), respectively.

RESULTS

The study comprised 43 participants in the nerve-injury group, 30 participants in the group without nerve injury, and 104 participants in the control group. Generalized linear model was applied to explore the difference of cognitive functions among three groups with impactors. Significantly poorer performance on the RAVLT was observed in the nerve-injury group compared to the other two groups, and lower score of SIECT in nerve-injury group was lower compared to the control group. However, there was no significant difference of SIECN among three groups. In addition, traumatic characteristics did not significantly impact RAVLT and SIECT (p > 0.05) in all injured participants.

CONCLUSION

Traumatic nerve injury to the upper limb appears to be associated with both short-term memory and executive function impairment, whereas musculoskeletal injuries without nerve damage showed no cognitive impairment. Therefore, it is important to monitor cognitive function following upper limb nerve injuries.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains

PURPOSE

Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain.

METHODS

This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy.

RESULTS

Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10.

CONCLUSIONS

It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study

BACKGROUND

Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study.

METHODS

This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts.

RESULTS

Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P <0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P <0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P =0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement.

CONCLUSION

We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement.

LEVEL OF EVIDENCE

II.

Pain Interference Prior to and 1 Year After Surgery for Adult Traumatic Brachial Plexus Injury

PURPOSE

Pain after brachial plexus injury (BPI) can be severely debilitating and is poorly understood. We hypothesized that pain interference (PI) ("the extent to which pain hinders engagement in life") would be predicted by depression, anxiety, severity of pain symptoms, and poorer preoperative muscle function.

METHODS

Among patients in a prospective multicenter BPI cohort study, 37 completed Patient-Reported Outcomes Measurement Information System (PROMIS) PI questionnaires before and 1 year after surgery. At both times, participants completed anxiety and depression questionnaires and BPI-specific measures of pain symptoms, physical limitations, and emotional recovery. Surgeon-graded muscle testing, injury severity, age at the time of injury, body mass index, and time from injury to surgery were included. We performed a bivariate analysis of predictors for preoperative and 1-year PROMIS PI followed by multivariable regression modeling using stepwise selection and Bayesian Information Criterion to select covariates.

RESULTS

Before surgery, the mean PROMIS PI score was 60.8 ± 11.0, with moderate correlations between PROMIS PI and depression, as well as between PROMIS PI and functional limitations. At 1 year after surgery, the mean PROMIS PI score was 59.7 ± 9.5. There was no difference in preoperative and 1-year PROMIS PI. There were strong correlations between PROMIS PI and pain symptoms, functional limitations, and emotional aspects of recovery at the 1-year follow-up that remained significant in multivariable regression. There were no notable associations between muscle testing and PI.

CONCLUSIONS

Pain interference remained substantial and elevated in BPI patients 1 year after surgery. We noted strong associations between PI and pain symptoms, functional limitations, and emotional aspects of recovery. These findings demonstrate the persistence of pain as a feature throughout life after BPI and that its treatment should be considered a priority alongside efforts to improve extremity function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognosis IV.

Anxiety, Depression, and Quality of Sleep Vary in Their Correlation to Postoperative Outcomes of Rotator Cuff Repair: A Prospective Study

Background/Objectives: Recent studies imply that psychological factors and sleep quality play a role in the outcomes of surgical procedures, including in orthopedic surgery. The aim of the present study is to evaluate possible correlations between preoperative depression, anxiety, and quality of sleep and functional 6-month postoperative scores in patients having undergone rotator cuff repair (RCR). Methods: All patients included in the study performed the Hospital Anxiety and Depression Scale (HADS) and Pittsburgh Sleep Quality Index (PSQI) questionnaires preoperatively and 36-item Short-Form Health Survey (SF-36), Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and PSQI questionnaires at the six-month postoperative follow-up. A total of 47 patients were included in the analysis. Results: Statistically significant differences between preoperative anxious and not-anxious groups were found in the postoperative SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores and PSQI score. The correlation of the preoperative depression score to postoperative outcome measures revealed a strong positive correlation between the preoperative HADS-D score and the 6-month PCS, MCS, and OSS scores. The correlation of preoperative sleep quality to postoperative outcome measures revealed a strong positive correlation between the preoperative PSQI score and 6-month MCS score. Conclusions: Anxious patients had worse postoperative RCR outcomes. Depression may be influenced by factors related to RC pathology; however, there were no statistically significant correlations. Sleep quality generally improves postoperatively, and no significant association was found between bad preoperative sleepers and worse outcomes.

Cannabis Abuse Is Associated With Greater Medical Complications, Emergency Department Visits, and Readmissions Following Open Reduction and Internal Fixation for Distal Radius Fractures

BACKGROUND

Despite increased legalization, little is known about the influence of cannabis use disorder (CUD) following open reduction and internal fixation (ORIF) for distal radius fractures (DRFs). The aims were to determine whether CUD patients undergoing ORIF for DRF have increased: (1) medical complications; and (2) health care utilization (emergency department [ED] visits and readmission rates).

METHODS

Patients were identified from an insurance database from 2010 to 2020 using Current Procedural Terminology codes: 25607, 25608, and 25609. Patients with a history of CUD were 1:5 ratio matched to controls by age, sex, tobacco use, alcohol abuse, opioid dependence, and comorbidities. This yielded 13,405 patients with (n = 2,297) and without (n = 11,108) CUD. Outcomes were to compare 90-day medical complications, ED visits, and readmissions. Multivariable logistic regression models computed the odds ratios of CUD on dependent variables. P values less than .005 were significant.

RESULTS

The incidence of CUD among patients aged 20 to 69 years undergoing ORIF increased from 4.0% to 8.0% from 2010 to 2020 (P < .001). Cannabis use disorder patients incurred significantly higher rates and odds of developing 90-day medical complications (15.24% vs 5.76%), including pneumoniae (3.66% vs 1.67%), cerebrovascular accidents (1.04% vs 0.32%), pulmonary emboli (0.57% vs 0.16%), respiratory failures (1.00% vs 0.48%), and surgical site infections (1.70% vs 1.04%; all P < .004). Emergency department visits (2.53% vs 1.14%) and readmission rates (5.79% vs 4.29%) within 90 days were higher among cannabis abusers.

CONCLUSIONS

With a greater number of states legalizing cannabis, hand surgeons should be cognizant of the association with increased 90-day complications and health care utilization parameters.

Patient-Reported Mental Health Outcomes After Single-Digit Non-thumb Traumatic Amputation in Adults

Background

Though traumatic digital amputations are common, outcomes data are scarce. The FRANCHISE study clarified functional outcomes after digital amputation, but little information is available regarding mental health outcomes. The aims of this study were to document patient-reported mental health outcomes after traumatic digital amputation, elucidate the relationship between mental health and functional outcomes, and determine which patient/injury attributes conferred risk of unfavorable mental health outcomes.

Methods

This was a descriptive, retrospective study of 77 patients with history of single digit, non-thumb traumatic amputation. Eligible patients completed Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity, Pain Interference, Anger, Anxiety, and Depression computer adaptive tests, and a short questionnaire recorded handedness, demographics, and worker's compensation status.

Results

Correlation across the 3 PROMIS mental health domains (Anger, Anxiety, Depression) was uniformly strong and statistically significant. Correlation between the PROMIS mental health and functional (Upper Extremity and Pain Interference) scores was statistically significant but much weaker. Multivariable analysis revealed younger age and a worker's compensation claim had independent statistically significant predictive value for worse PROMIS Anger, Anxiety, and Depression scores. Female sex was also found to independently predict PROMIS Anxiety.

Conclusions

By identifying patients at increased risk for feelings of anger, anxiety, and depression after digital amputation, anticipatory counseling can be provided. Anger, anxiety, and depression are very likely to coexist in the same patient; when responding to a patient who exhibits 1 element of this triad, the surgeon should be aware that the other 2 elements are likely to be present, even if not obvious.

Risk Factors and Outcomes in Carpal Tunnel Syndrome Following Distal Radius Open Reduction Internal Fixation

PURPOSE

Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS.

METHODS

A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores.

RESULTS

Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46).

CONCLUSIONS

In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Evaluation of Preoperative Factors Affecting Midterm Patient-Reported Outcomes Following Ligament Reconstruction Tendon Interposition: A Prognostic Study

PURPOSE

The aim of this study was to evaluate the prognostic value of preoperative patient-reported outcomes as predictors of functional improvement following ligament reconstruction tendon interposition. We hypothesized that high levels of preoperative pain interference (PI) and upper-extremity disability are associated with lower magnitudes of functional improvement ≥1 year after surgery on the shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) (primary outcome) and Patient-Reported Outcomes Measurement Information System Upper Extremity (UE) Computer Adaptive Test (CAT) (UE CAT) v1.2 (secondary outcome).

METHODS

Adult patients who underwent ligament reconstruction tendon interposition between February 2014 and April 2018 at an academic tertiary institution were considered for inclusion in this longitudinal cohort study. Patient-reported outcomes were collected at baseline and ≥1 year after surgery. Univariate and multivariable linear regression analyses were performed to identify factors associated with the magnitude of functional improvement on the QuickDASH and UE CAT.

RESULTS

Among 93 included participants, the mean age was 61 ± 7 years, and 75 (81%) were women. At 2.5 ± 1.0 years after surgery, the QuickDASH and UE CAT improved by a mean of 24.5 ± 20.9 and 9.9 ± 10.7 points, respectively. In the primary multivariable model, a greater preoperative QuickDASH (indicative of lower function; coefficient, 0.8; 95% confidence interval [CI], 0.6 to 0.9) and lower preoperative Performance of Patient-Reported Outcomes Measurement Information System PI CAT (eg, less pain interference; coefficient, -0.7; 95% CI, -1.2 to -0.2) were associated with greater QuickDASH improvement independent of potential confounders. In the secondary multivariable model, lower preoperative UE CAT (indicative of worse function; coefficient, -0.9; 95% CI, -1.1 to -0.7) and lower preoperative Patient-Reported Outcomes Measurement Information System PI CAT (coefficient, -0.3; 95% CI, -0.6 to -0.1) were associated with greater UE CAT improvement.

CONCLUSIONS

Preoperative patient-reported outcomes may be useful in understanding the degree of improvement that certain patient populations can expect from ligament reconstruction tendon interposition. Those with lower baseline (preoperative) upper-extremity function and PI are expected to derive the greatest functional improvement in the midterm.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Association of Anxiety and Depressive Symptoms in Patients with Adhesive Capsulitis

Objective  The present study aimed to assess the association between anxiety and depression symptoms in patients with adhesive capsulitis. Methods  This was a cross-sectional study carried out in a single center from a tertiary hospital with patients presenting with secondary adhesive capsulitis. The control group did not have shoulder disease, thyroid disease, anxiety, and/or depression. The instrument used was the Hospital Anxiety and Depression Scale (HADS). An analysis of covariance compared HADS scores between groups. The significance level was 5%. Results  The final sample consisted of 17 patients (case group) and 27 (control group). The Shapiro-Wilk test revealed normal distribution ( p  > 0.05). A HADS score > 0.70 (Cronbach alpha) was reliable and presented good internal consistency. Patients with adhesive capsulitis reported "doubtful" (average/standard deviation = 8.88/4.50) "anxious symptoms" ( p  = 0.019) but no "depressive symptoms" (average/standard deviation = 6.41/3.69), despite p  = 0.015. Conclusion  There is a "doubtful" positive association between anxiety symptoms and adhesive capsulitis but a negative association with depressive symptoms.

Time to Reconsider Occupation Induced De Quervain's Tenosynovitis: An Updated Review of Risk Factors

De Quervain's tenosynovitis (DQT) is described to be an attritional and degenerative process, triggered by stenosing inflammation of the tendon sheath in the first dorsal compartment of the wrist. Understanding and targeting the risk factors associated with DQT will help clinicians and patients to reduce its prevalence. This review aims to evaluate the current literature surrounding the risk factors which were divided into the anatomical, patient, and occupational factors associated with the condition. The two main anatomical variations associated with DQT are subcomparmentalization and multiple tendon slips of the abductor pollicus longus (APL) and extensor pollicus brevis (EPB) tendons. DQT is more common in females and is often noted in pregnancy and the postpartum period. When considering occupational factors, work-related activity has not been shown to be a direct cause of DQT, despite leading organisations supporting the converse.

Symptom cluster profiles following traumatic orthopaedic injuries

BACKGROUND

Millions of Americans experience traumatic orthopaedic injuries (TOIs) annually. Post-injury symptoms of acute stress disorder (ASD), anxiety, depression, pain, and sleep disturbance are common. Symptoms often present in clusters. Symptom cluster profiles phenotypically characterize TOI survivors' experiences with clustered symptoms. Expression of brain-derived neurotrophic factor (BDNF) may contribute to the biological underpinnings of symptom cluster profile membership.

METHODS

We recruited hospitalized TOI survivors within 72 hours of injury. We measured symptoms of ASD with the Acute Stress Disorder Scale and symptoms of anxiety, depression, pain, and sleep disturbance with Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. We measured serum BDNF concentrations with enzyme-linked immunosorbent assay (ELISA) and identified rs6265 genotypes with TaqMan real-time PCR. We performed latent profile analysis to identify the symptom cluster profiles. We identified the variables associated with symptom cluster profile membership with unadjusted and adjusted multinomial logistic regression.

RESULTS

We identified 4 symptom cluster profiles characterized by symptom severity that we labelled Physical Symptoms Only, and Mild, Moderate, and Severe Psychological Distress. Age, self-identified Black race, resilience, and serum BDNF concentrations were associated with lower odds, and female sex with higher odds, of being in the Psychological Distress clusters. Clinical characteristics and rs6265 genotypes were not associated with symptom cluster profile membership.

CONCLUSION

TOI survivors experience distinct symptom cluster profiles. Sociodemographic characteristics and serum BDNF concentrations, not clinical characteristics, were associated with symptom cluster profile membership. These findings support comprehensive symptom screening and treatment for all TOI survivors and further evaluating BDNF as a biomarker of post-injury symptom burden.

The Psychological and Somatic Consequences of Digital Amputation

Major limb amputation is a devastating potential outcome of trauma, tumor, or disease. Much has been written about the physical, functional, economic, and psychological consequences of major limb loss. In contradistinction, considerably less has been written concerning the consequences of "minor" limb loss, specifically single partial digit amputations. Are minor limb (partial single digit) amputations associated with symptoms of psychological disorder similar to those reported for major limb amputations?

Methods

We conducted a clinical research study through interview and examination of 25 adult patients (average age: 45 years) who had suffered a single partial digit amputation to determine if symptoms of depression, anxiety, anger, or posttraumatic stress disorder newly occurred, and if such symptoms correlated with the surgical outcome. Questionnaires for Quick-DASH, Michigan Hand Score, and Diagnostic and Statistical Manual of Mental Disorders-5 Psychological Profile testing were completed.

Results

All but one of the patients suffered from psychological symptoms for a minimum of 3 months. Symptom resolution time averaged 6 months for seven of the 25 patients. For 18 of the 25 patients, both psychological disturbance and neuroma pain were ongoing. The Psychological Profile scores suggesting pathology were inversely related to the scores on the Quick-Dash and Michigan Hand (somatic) questionnaires indicating wellness (P < 0.03).

Conclusions

(1) Even minor partial amputations of single digits can trigger significant psychological disturbance; the study hypothesis is validated. (2) Psychological and somatic outcomes are directly correlative. (3) Mitigating neuroma pain and verbally offering psychological support services early in the postamputation period should improve the clinical outcome of digital amputations.

PROMIS Depression and Anxiety in shoulder surgery patients

AIMS

The purpose of this study was to assess the prevalence of depression and anxiety symptoms in patients undergoing shoulder surgery using the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Depression and Anxiety computer adaptive tests, and to determine the factors associated with more severe symptoms. Additionally, we sought to determine whether PROMIS Depression and Anxiety were associated with functional outcomes after shoulder surgery.

METHODS

This was a retrospective analysis of 293 patients from an urban population who underwent elective shoulder surgery from 2015 to 2018. Survey questionnaires included preoperative and two-year postoperative data. Bivariate analysis was used to identify associations and multivariable analysis was used to control for confounding variables.

RESULTS

Mean two-year PROMIS Depression and Anxiety scores significantly improved from preoperative scores, with a greater improvement observed in PROMIS Anxiety. Worse PROMIS Depression and Anxiety scores were also significantly correlated with worse PROMIS Physical Function (PF) and American Shoulder and Elbow Surgeons scores (ASES). After controlling for confounding variables, worse PROMIS Depression was an independent predictor of worse PROMIS PF, while worse PROMIS Anxiety was an independent predictor of worse PROMIS PF and ASES scores.

CONCLUSION

Mean two-year PROMIS Depression and Anxiety scores improved after elective shoulder surgery and several patient characteristics were associated with these scores. Worse functional outcomes were associated with worse PROMIS Depression and Anxiety; however, more severe two-year PROMIS Anxiety was the strongest predictor of worse functional outcomes. Cite this article: Bone Joint J 2022;104-B(4):479-485.

Is psychological distress associated with carpal tunnel syndrome symptoms and nerve conduction study findings? A case-control study from Syria

BACKGROUND

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the median nerve at the wrist which causes severe symptoms. However, psychological aspects can affect patients' perception of this pain and can cause similar pain in some instances. This study aims to determine the association between symptoms severity, functional status, and nerve conduction studies (NCS) of adult patients with CTS and their anger, anxiety, and depression status.

METHODS

This case-control study was conducted in clinics in Damascus, Syria. Controls were frequency matched by gender and age from a general clinic. Interviews based on questionnaires were used that included the Boston Carpal Tunnel Questionnaire (BCTQ-A), Hospital Anxiety and Depression Scale (HADS), Dimensions of Anger Reactions Scale-5 (DAR-5), and NCS.

RESULTS

Overall, 242 patients (121 cases) were included in this study. Cases with CTS had significantly higher anxiety and depression when compared to controls, but not higher anger. Cases with higher anxiety, depression, and anger had significantly more CTS symptoms and less functional status. Anxiety was also higher in cases with normal NCS in the case group. When using regression, anxiety and depression remained significantly associated with having CTS.

CONCLUSION

Anxiety and depression are more prominent with CTS. Furthermore, having anxiety and depression were associated with more CTS symptoms in the hand. Having anger was also associated with more CTS symptoms among cases. These findings emphasize the importance of psychological aspects when having hand pain or CTS symptoms as these patients might have these symptoms despite having normal NCS.

Depression Is Transiently Increased in Patients Undergoing Two-Stage Revision Arthroplasty

BACKGROUND

The implications of two-stage revision on mental health are poorly understood. The purpose of this study is to determine (1) whether patients undergoing two-stage revision total hip and knee arthroplasty for prosthetic joint infection were more likely to get Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores consistent with major depressive disorder (MDD) than those undergoing aseptic revision and (2) whether these symptoms resolved after the procedure.

METHODS

Records of all 366 patients that underwent revision total hip or knee arthroplasty from January 1, 2015, - June 20, 2019, were reviewed. Forty-two patients were excluded for missing PROMIS Depression scores or incomplete treatment. Preoperative (<3 months), early postoperative (2-8 weeks), and final postoperative (6-18 months) Depression scores were collected. Patients crossing the PROMIS Depression threshold equivalent to a Patient Health Questionnaire-9 score ≥10, indicative of MDD, were evaluated.

RESULTS

More two-stage revision patients developed Depression scores indicative of MDD perioperatively than the aseptic cohort (20.0% vs 6.5%, P = .01). Two-stage revision patients had higher (worse) median Depression scores preoperatively (54.8 vs 51.3, P = .04) and at early follow-up (54.3 vs 49.9, P = .01), but not at final follow-up (50.4 vs 49.1, P = .39). Across all patients, Depression scores improved by 2.4 points at early follow-up (95% confidence interval:1.1-3.7; P < .001) and 3 points at final follow-up (95% confidence interval:1.5-4.5; P < .001; minimal clinically important difference 3.0).

CONCLUSIONS

Twenty percent of two-stage revision arthroplasty patients, compared to <7% of aseptic revision patients, developed PROMIS Depression scores consistent with MDD during treatment. At final follow-up, a clinically significant improvement in Depression scores from baseline was evident in both cohorts.

The relationship between depression, anxiety, and pain interference with therapy referral and utilization among patients with hand conditions

INTRODUCTION

Patients with upper extremity conditions may also experience symptoms of depression, anxiety, and pain that limit functional recovery.

PURPOSE OF THE STUDY

This study examined the impact of mental health and pain symptoms on referral rates to therapy and utilization of therapy services to achieve functional recovery among patients with common hand conditions.

STUDY DESIGN

This is a retrospective cohort study of patients from one orthopedic center.

METHODS

Data extraction provided demographics, the International Classification of Diseases, 10th revision diagnoses, therapy referral, therapy visit counts, treatment goal attainment, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, Anxiety, and Pain Interference scores. The chi-square test, t-test, and logistic regression analyses assessed associations between baseline PROMIS depression, anxiety, and pain interference to therapy referral, the number of therapy visits, and goal attainment.

RESULTS

Forty-nine percent (172/351) of patients were referred to hand therapy. There was no relationship between three baseline PROMIS scores based on physician referral (t-test P values .32-.67) and no association between PROMIS scores and therapy utilization or goal attainment (Pearson correlation (r): 0.002 to 0.020, P > .05). Referral to therapy was most strongly associated with having a traumatic condition (P < .01). Patients with high depression, anxiety, and pain interference scores on average required one more therapy visit to achieve treatment goals (average visits: 3.7 vs 3.1; 4.1 vs 2.7; 3.4 vs 2.3, respectively). Fewer patients with high depression scores (50%) achieved their long-term goals than patients with low depression scores (69%, P = .20).

CONCLUSIONS

Patients' baseline level of depressive symptoms and anxiety do not predict referrals to hand therapy by orthopedic hand surgeons. There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. Therapists may address mental health needs in treatment plans. Future studies should examine if nonreferred patients with depressive symptoms achieve maximal functional recovery.

Depression, Anxiety, and Alcohol Use Among LGBTQ+ People During the COVID-19 Pandemic

Objectives. To describe disparities in depression, anxiety, and problem drinking by sexual orientation, sexual behavior, and gender identity during the COVID-19 pandemic. Methods. Data were collected May 21 to July 15, 2020, from 3245 adults living in 5 major US metropolitan areas (Atlanta, Georgia; Chicago, Illinois; New Orleans, Louisiana; New York, New York; and Los Angeles, California). Participants were characterized as cisgender straight or LGBTQ+ (i.e., lesbian, gay, bisexual, and transgender people, and men who have sex with men, and women who have sex with women not identifying as lesbian, gay, bisexual, or transgender). Results. Cisgender straight participants had the lowest levels of depression, anxiety, and problem drinking compared with all other sexual orientation, sexual behavior, and gender identity groups, and, in general, LGBTQ+ participants were more likely to report that these health problems were "more than usual" during the COVID-19 pandemic. Conclusions. LGBTQ+ communities experienced worse mental health and problem drinking than their cisgender straight counterparts during the COVID-19 pandemic. Future research should assess the impact of the pandemic on health inequities. Policymakers should consider resources to support LGBTQ+ mental health and substance use prevention in COVID-19 recovery efforts.

Association of Depression and Anxiety With Expectations and Satisfaction in Foot and Ankle Surgery

INTRODUCTION

Mental health diagnoses involving depression or anxiety are common and can have a dramatic effect on patients with musculoskeletal pathologies. In orthopaedics, depression/anxiety (D/A) is associated with worse postoperative patient-reported outcomes. However, few studies have assessed the effect of D/A on expectations and satisfaction in foot and ankle patients.

METHODS

Adult patients undergoing elective foot and ankle surgery were prospectively enrolled. Preoperatively, patients completed the eight-item Patient Health Questionnaire Depression Scale, Generalized Anxiety Disorder Screener-7, Foot and Ankle Outcome Score (FAOS), and Expectations Survey. At 2 years postoperatively, surveys including satisfaction, improvement, and fulfillment of expectations were administered. Fulfillment of expectations (fulfillment proportion) and FAOS scores were compared between patients with D/A and non-D/A patients.

RESULTS

Of 340 patients initially surveyed, 271 (80%) completed 2-year postoperative expectations surveys. One in five patients had D/A symptoms. Preoperatively, D/A patients had greater expectations of surgery (P = 0.015). After adjusting for measured confounders, the average 2-year postoperative fulfillment proportion was not significantly lower among D/A compared with non-D/A (0.86 versus 0.78, P = 0.2284). Although FAOS scores improved postoperatively for both groups, D/A patients had significantly lower preoperative and postoperative FAOS scores for domains of symptoms, activity, and quality of life (P < 0.05 for all). D/A patients reported less improvement (P = 0.036) and less satisfaction (P = 0.005) and were less likely willing to recommend surgery to others (P = 0.011).

DISCUSSION

Patients with D/A symptoms had higher preoperative expectations of surgery. Although D/A patients had statistically similar rates of fulfillment of expectations compared with non-D/A patients, they had markedly lower FAOS scores for domains of symptoms, activity, and quality of life. D/A patients also perceived less improvement and were more often dissatisfied with their outcomes. These findings should not dissuade providers from treating these patients surgically but rather emphasize the importance of careful patient selection and preoperative expectation management.

LEVEL OF EVIDENCE

Level III; retrospective review of prospective cohort study.

Predictors of households at risk for food insecurity in the United States during the COVID-19 pandemic

OBJECTIVE

To examine associations between sociodemographic and mental health characteristics with household risk for food insecurity during the COVID-19 outbreak.

DESIGN

Cross-sectional online survey analysed using univariable tests and a multivariable logistic regression model.

SETTING

The United States during the week of 30 March 2020.

PARTICIPANTS

A convenience sample of 1965 American adults using Amazon's Mechanical Turk platform. Participants reporting household food insecurity prior to the pandemic were excluded from analyses.

RESULTS

One thousand two hundred and fifty participants reported household food security before the COVID-19 outbreak. Among this subset, 41 % were identified as at risk for food insecurity after COVID-19, 55 % were women and 73 % were white. On a multivariable analysis, race, income, relationship status, living situation, anxiety and depression were significantly associated with an incident risk for food insecurity. Black, Asian and Hispanic/Latino respondents, respondents with an annual income <$100 000 and those living with children or others were significantly more likely to be newly at risk for food insecurity. Individuals at risk for food insecurity were 2·60 (95 % CI 1·91, 3·55) times more likely to screen positively for anxiety and 1·71 (95 % CI 1·21, 2·42) times more likely to screen positively for depression.

CONCLUSIONS

An increased risk for food insecurity during the COVID-19 pandemic is common, and certain populations are particularly vulnerable. There are strong associations between being at risk for food insecurity and anxiety/depression. Interventions to increase access to healthful foods, especially among minority and low-income individuals, and ease the socioemotional effects of the outbreak are crucial to relieving the economic stress of this pandemic.

Relative Prevalence of and Factors Associated with Anxiety and Depression in Degenerative Triangular Fibrocartilage Complex Lesion Patients - a Casecontrol Study

Triangular fibrocartilage complex (TFCC) lesions are a common cause of ulnar wrist pain. Data, including mental status assessment, were prospectively collected from patients who underwent arthroscopy. The HADS was used to assess the prevalence of depression and anxiety. Patients with degenerative TFCC lesions were at an increased risk of anxiety and depression. Early screening for anxiety and depression in degenerative TFCC lesions patients should be recommended.

Impact of Biofeedback in the Treatment of Nonspecific Persistent Wrist and Forearm Pain in Adolescents

PURPOSE

Biofeedback is a self-regulation technique in which patients learn to control what were once thought to be involuntary bodily processes. The goal of this study was to examine a sample of adolescents with persistent, nonspecific wrist and forearm pain to assess whether biofeedback can improve symptoms. A secondary goal was to identify any shared characteristics.

METHODS

This is a retrospective case series of patients seen by an upper-extremity surgeon and a biofeedback expert at a pediatric hospital from 2011 through 2017. Data collected included Multidimensional Anxiety Scale for Children (MASC) and Children's Depression Inventory (CDI) scores, pain intensity, frequency, and duration; as well as self-report of depression, anxiety, self-harm, and/or suicidal ideation. Additional data included biological sex, brace or orthosis wear, history of injury, prior medical or surgical treatments, and the presence of paresthesias. Biofeedback sessions were held every 1 to 2 weeks, for typically 5 sessions.

RESULTS

Sixteen patients met inclusion criteria; 9 completed biofeedback. Eight patients were female (88%) and 1 was male (11%). The dominant extremity was affected in 8 patients (89%). Seven of the 9 patients who completed biofeedback had improvement or resolution of symptoms (78%). Both patients who completed biofeedback but did not have improvement in pain underwent surgery before biofeedback referral. Three patients reported paresthesias; each had an elevated CDI and MASC score (33%). Six patients did not report paresthesias, and one patient had similar elevated CDI and MASC scores CONCLUSIONS: More females than males were seen and referred to biofeedback in this study group. There appears to be an association between underlying anxiety or depression and the report of paresthesias. Biofeedback is an available nonsurgical treatment modality for persistent wrist and forearm pain that should be considered in appropriate patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Is the Patient-Reported Outcome Measurement Information System Feasible in Bundled Payment for Care Improvement Total Knee Arthroplasty Patients?

BACKGROUND

Several bundled payment plans, like the Bundled Payment for Care Improvement (BPCI) initiative for total joint arthroplasty, have been introduced to decrease costs and improve clinical care. Measuring clinical outcomes with efficient, standardized methodologies is essential to determine the relative value of total joint arthroplasty care. We investigated feasibility and responsiveness of the recently developed Patient-Reported Outcomes Measurement Information System (PROMIS) in total knee arthroplasty (TKA) patients.

METHODS

We included patients with preoperative and 1-year PROMIS Physical Function (PF), Pain Interference (PI), and Depression (DEP) scores who received unilateral primary TKA. Burden was assessed using the number of questions and time required for PROMIS completion. The minimum clinically important difference was defined as 5. Floor/ceiling effects were noted if more than 15% of patients responded with the lowest/highest possible score, respectively. Wilcoxon rank-sum test was used to compare categorical data. Analysis of variance was used for PROMIS comparisons.

RESULTS

In total, 172 knees (54 BPCI) were included. Floor effects were identified for DEP at baseline (non-BPCI) and follow-up (both groups), and for PI at follow-up only (BPCI). Patients required 140 seconds and 16 questions to answer all 3 PROMIS domains. Sixty-seven percent, 60%, and 44% of knees achieved minimum clinically important difference in PI, PF, and DEP scores respectively, with no significant difference between groups. The BPCI cohort was older (P < .001) with a higher American Society of Anesthesiologists score (P = .028). There were no significant differences in scores between BPCI and non-BPCI patients.

CONCLUSION

PROMIS is feasible and time-efficient in BPCI patients undergoing primary TKA. There were no significant differences in outcomes between BPCI and non-BPCI knees.

LEVEL OF EVIDENCE

Level III.

Prevalence and association of anxiety and depression among orthopaedic trauma inpatients: a retrospective analysis of 1994 cases

Background

Patients with traumatic injuries are often accompanied by emotional disorders, which seriously impede functional gains. The objective of this study was to identify the prevalence and risk factors associated with underlying anxiety and depression in orthopaedic trauma patients.

Methods

From July 2015 to December 2017, all orthopaedic trauma patients were included in the retrospective study. Patients with conditions that might affect cognitive impairment were excluded from the study. Basic demographic data were collected. All patients were screened for emotional disorders on admission using a simple questionnaire called “Huaxi Emotional-Distress Index” (HEI). Bivariate analyses and logistic regression were used to identify the factors associated with a HEI score of > 8.

Results

One hundred and sixty-two patients (8.1%) had a HEI score of > 8. About 1.0% of enrolled patients had severe emotional disorders (HEI score ≥ 17). The reasons caused by emotional disorders in patients with orthopaedic trauma were a higher Injury Severity Score (ISS), a higher visual analogue score (VAS) and type of surgery. On logistic regression, marital status was a protective factor for emotional disorders, while VAS and ISS were the risk factors for emotional disorders.

Conclusions

Although a significantly low percentage of orthopaedic trauma patients in our setting have emotional disorders, traumatic orthopaedic surgeons still need to pay attention to the risk of emotional disorders and integrate effective screening tools into clinical practice to screen for these factors and stratify emotional disorders. Appropriate targeted psychological intervention and treatment should be adopted according to the stratification of emotional disorders.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review

BACKGROUND

The Patient-Reported Outcomes Measurement Information SystemⓇ (PROMISⓇ) is a dynamic system of psychometrically sound patient-reported outcome (PRO) measures. There has been a recent increase in the use of PROMIS measures, yet little has been written about the reporting of these measures in the field of orthopedics. The purpose of this study was to conduct a systematic review to determine the uptake of PROMIS measures across orthopedics and to identify the type of PROMIS measures and domains that are most commonly used in orthopedic research and practice.

METHODS

We searched PubMed, Embase, and Scopus using keywords and database-specific subject headings to capture orthopedic studies reporting PROMIS measures through November 2018. Our inclusion criteria were use of PROMIS measures as an outcome or used to describe a population of patients in an orthopedic setting in patients ≥ 18 years of age. We excluded non-quantitative studies, reviews, and case reports.

RESULTS

Our final search yielded 88 studies published from 2013 through 2018, with 57% (50 studies) published in 2018 alone. By body region, 28% (25 studies) reported PROMIS measures in the upper extremity (shoulder, elbow, hand), 36% (32 studies) reported PROMIS measures in the lower extremity (hip, knee, ankle, foot), 19% (17 studies) reported PROMIS measures in the spine, 10% (9 studies) reported PROMIS measures in trauma patients, and 6% (5 studies) reported PROMIS measures in general orthopedic patients. The majority of studies reported between one and three PROMIS domains (82%, 73 studies). The PROMIS Computerized Adaptive Test (CAT) approach was most commonly used (81%, 72 studies). The most frequently reported PROMIS domains were physical function (81%, 71 studies) and pain interference (61%, 54 studies).

CONCLUSION

Our review found an increase in the reporting of PROMIS measures over the recent years. Utilization of PROMIS measures in orthopedic populations is clinically appropriate and can facilitate communication of outcomes across different provider types and with reduced respondent burden.

REGISTRATION

The protocol for this systematic review was designed in accordance with the PRISMA guidelines and is registered with the PROSPERO database (CRD42018088260).

Determinants of anxiety and depression in patients with cubital tunnel syndrome

BACKGROUND

The aim of this cross-sectional study to assess the proportions of anxiety and depression in patients with CuTS, and to explore the associated demographic and clinical features.

METHODS

From May 2011 to January 2017, 246 patients diagnosed with CuTS were recruited. The Hospital Anxiety and Depression Scale was used to assess the proportions of depression and anxiety. Patient demographic and clinical data were collected. Univariate analysis and multivariate regression were carried out to identify the variables that were independently associated with anxiety and depression.

RESULTS

The proportions of depression and anxiety were 17.9% (n = 44) and 14.2% (n = 35), respectively. Five patients had both possible/probable anxiety and depression. Logistic regression analysis revealed that diabetes mellitus was independently associated with depression; and the modified McGowan grade was independently associated with anxiety.

CONCLUSIONS

In patients with CuTS, the proportions of depression and anxiety were 17.9% and 14.2%, respectively. Early screening for anxiety and depression is beneficial for patients with CuTS.

High Levels of Stress Due to the SARS-CoV-2 Pandemic among Parents of Children with and without Chronic Conditions across the USA

BACKGROUND

The 2020 SARS-CoV-2 pandemic led to community-wide measures affecting parents and children such as school/daycare closures, job losses, and interruptions in medical care for children with chronic diseases. This is the first study to describe the level of stress and mental health of parents of either healthy children or children with chronic conditions, during the 2020 pandemic.

METHODS

A representative sample of US parents was recruited from 10-17 April 2020. Parents completed online questionnaires about the past 7 days, including the Perceived Stress Scale, Resilient Coping Scale, Self-Efficacy Scale, Kansas Marital Satisfaction Scale, Parental Stress Scale, PROMIS Anxiety and Depression scales and various other pandemic-related stress questions Results: Levels of stressors (e.g., job loss, school closures, etc.) were high during this time (e.g., 79% of children attended home/online school) and parents reported being moderately to highly stressed. Rates of clinical anxiety (44.6%) and depression (42.2%) were high. Parents of children with chronic conditions reported higher levels of stress and worse mental health, but did not differ from other parents in dealing with stress or interruptions in work, child schooling, and marital satisfaction.

DISCUSSION

The COVID-19 pandemic has introduced unprecedented levels of stress for parents, especially those of children with chronic conditions. Mental health effects are expected to continue for months/years and preparation is needed to meet an increasing demand for mental health care.

The impact of preoperative pain-related psychological factors on pain intensity post-surgery in Jordan

This study aimed to investigate the impact of preoperative psychological factors on postoperative pain. We included 300 postoperative patients who underwent open reduction and internal fixation surgery. Pain Scale, Pain Catastrophizing Scale, and Depression, Anxiety, and Stress Scale were completed by patients preoperatively and at 24 hours after surgery. Clinical characteristics were obtained from medical records. Data were analyzed using multiple linear regression. Postoperative pain was predicted by pain catastrophizing and anxiety symptoms. High preoperative catastrophizing and anxiety levels were associated with increased pain postoperatively. However, the relationships between preoperative depressive and stress symptoms and postoperative pain were not significant.

Understanding PROMIS

Patient reported outcomes (PROs) are becoming increasingly emphasized in health care. Some medical and orthopedic specialties have 1 or 2 primary PROs that are used across the discipline, whereas hand surgery has multiple PROs. The multitude of PROs gives hand surgeons flexibility because each provides slightly different information, but the number of options can present a daunting task when choosing which to use. The latest generation of PROs leverages computer adaptive testing and includes assessments of physical, mental, and social health. The Patient-Reported Outcomes Measurement Information System was funded by the National Institutes of Health to include a comprehensive set of health instruments that are not disease-specific; it has undergone several forms of validation and has been found to be comparable across medical specialties. This article discusses the details of the Patient-Reported Outcomes Measurement Information System, how it compares with other outcomes instruments, and how it can be used in practice.

The Prognostic Value of Preoperative Patient-Reported Function and Psychological Characteristics on Early Outcomes Following Trapeziectomy With Ligament Reconstruction Tendon Interposition for Treatment of Thumb Carpometacarpal Osteoarthritis

PURPOSE

Biopsychosocial factors are associated with patient-reported upper extremity disability; however, their impact on postoperative outcomes remains less clear. Our purpose was to test the hypothesis that high levels of preoperative patient-reported upper extremity and psychological disability are associated with lower magnitudes of improvement following trapeziectomy with ligament reconstruction tendon interposition (LRTI).

METHODS

Adult patients undergoing LRTI by fellowship-trained hand surgeons between February 2014 and March 2017 were considered for inclusion. Patient-reported outcomes were collected by tablet computer, including the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) Computer Adaptive Test (CAT), PROMIS Depression CAT, and PROMIS Anxiety CAT. Univariate and multivariable linear regression analyses were performed to identify factors associated with QuickDASH improvement.

RESULTS

Of 119 included patients, the mean age was 62.7 ± 7.2 years and 74% were women. At a mean of 14 weeks after surgery, the QuickDASH improved by a mean of -10 ± 20 points. The QuickDASH improvement was significantly greater for patients with preoperative QuickDASH scores greater than the median (score change, -19 ± 20) versus those at or below the median (-2 ± 16), and for patients with preoperative PI CAT scores greater than the median (-17 ± 21) versus at or below the median (-4 ± 17). No differences were observed between groups when Anxiety or Depression CAT baseline scores were similarly dichotomized. Multivariable modelling revealed that higher preoperative QuickDASH scores were associated with greater improvement on the QuickDASH; however, no association was observed for preoperative PI CAT, Depression CAT, and Anxiety CAT scores.

CONCLUSIONS

Patients with higher levels of preoperative upper extremity disability experienced more improvement in the early postoperative period following LRTI. Baseline pain interference, depression, and anxiety were not associated with early outcomes. These findings may be useful when identifying patients who may experience the most functional improvement in the immediate postoperative period following LRTI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Disproportionate positive feedback facilitates sense of agency and performance for a reaching movement task with a virtual hand

This study investigated the generalized effects of positive feedback (PF) versus negative feedback (NF) during training on performance and sense of agency for a reach-to-touch task with a virtual hand. Virtual reality (VR) is increasingly employed for rehabilitation after neuromuscular traumas such as stroke and spinal cord injury. However, VR methods still need to be optimized for greater effectiveness and engagement to increase rates of clinical retention. In this study, we observed that training with disproportionate PF subsequently produced greater reaching performance (minimizing path length) and greater agency (perception of control) than with disproportionate NF. During PF training, there was also progressive increase in agency, but conversely a decrease in performance. Thus, the increase in performance after training may not be due to positively bolstered learning, but rather priming higher confidence reflected in greater agency. Agency was positively measured as compression in perceived time-intervals between the action of touch to a sound consequence, as standard with intentional binding paradigms. Positive feedback desirably increased agency (~180 msec) and reduced path length (1.8 cm) compared to negative feedback, which itself showed insignificant, or neutral, effects. Future investigations into optimizing virtual reality paradigms for neuromotor rehabilitation should consider agency as a driving factor for performance. These studies may serve to optimize how feedback is better presented with performance results for complex motor learning. Investigators should also ponder how personal characteristics, both cognitive and physical, may further affect sensitivity to feedback and the rate of neuromotor rehabilitation.

Development and Usability Testing of a Web-Based and Therapist-Assisted Coping Skills Program for Managing Psychosocial Problems in Individuals With Hand and Upper Limb Injuries: Mixed Methods Study

Background

Ineffective coping has been linked to prolonged pain, distress, anxiety, and depression after a hand and upper limb injury. Evidence shows that interventions based on cognitive behavioral therapy (CBT) may be effective in improving treatment outcomes, but traditional psychological interventions are resource intensive and unrealistic in busy hand therapy practices. Developing web-based, evidence-based psychological interventions specifically for hand therapy may be feasible in clinical practice and at home with reduced training and travel costs. Hand Therapy Online Coping Skills (HOCOS) is a program developed to supplement traditional hand therapy with therapist-assisted coping skills training based on principles from CBT and the Technology Acceptance Model.

Objective

This study aimed to describe the development and assess the usability of HOCOS to support hand therapists in the management of psychosocial problems.

Methods

The ADDIE model (Analysis, Design, Development, Implementation, and Evaluation) of system design was applied to create HOCOS. The usability testing of HOCOS involved a 2-stage process. In the first step, heuristic testing with information and communications technology (ICT) experts was completed using two sets of heuristics: Monkman heuristics and the Health Literacy Online (HLO) checklist. The second step involved user testing with hand therapists performing a series of online and face-to-face activities, completing 12 tasks on the website using the think-aloud protocol, completing the system usability scale (SUS) questionnaire, and a semistructured feedback interview in 2 iterative cycles. Descriptive statistics and content analyses were used to organize the data.

Results

In total, 4 ICT experts and 12 therapists completed usability testing. The heuristic evaluation revealed 15 of 35 violations on the HLO checklist and 5 of 11 violations on the Monkman heuristics. Initially, hand therapists found 5 tasks to be difficult but were able to complete all 12 tasks after the second cycle of testing. The cognitive interview findings were organized into 6 themes: task performance, navigation, design esthetics, content, functionality and features, and desire for future use. Usability issues identified were addressed in two iterative cycles. There was good agreement on all items of the SUS. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients.

Conclusions

We describe the development and usability testing of HOCOS; a new web-based psychosocial intervention for individuals with a hand and upper limb injuries. HOCOS targets psychosocial problems linked to prolonged pain and disability by increasing access to therapist-guided coping skills training. We actively involved target users in the development and usability evaluation of the website. The final website was modified to meet the needs and preferences of the participants.

Is the Patient-Reported Outcome Measurement Information System Feasible in Bundled Payment for Care Improvement in Total Hip Arthroplasty Patients?

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) is increasingly used to assess patient health. The Bundled Payment for Care Improvement (BPCI) initiative for total hip arthroplasty (THA) was introduced to decrease costs and improve clinical care. We investigated differences between BPCI and non-BPCI THA patients and their PROMIS scores, along with its feasibility and responsiveness in these populations.

METHODS

We included all consecutive patients receiving unilateral primary THA who also had preoperative and one-year postoperative PROMIS physical function (PF), PROMIS pain interference (PI), and PROMIS depression (DEP) scores. Demographics and PROMIS scores were compared. Test burden was assessed using the number of questions and time required for PROMIS completion. The minimum clinically important difference was defined as 5. Floor and ceiling effects were noted if more than 15% of patients responded with the lowest or highest possible score, respectively. Wilcoxon rank-sum test was used to compare categorical data. ANOVA was used for PROMIS comparisons.

RESULTS

290 hips (86 BPCI, 30%) were included. The BPCI cohort was older (P < .001) with a higher American Society of Anesthesiologists physical status classification system (P = .0045). There were significant differences in baseline scores of PF and DEP between BPCI and non-BPCI (P = .046 and P = .048, respectively). Both groups showed significant improvement at follow-up in all scores (all P < .001). Significantly more non-BPCI patients achieved minimum clinically important difference at follow-up in PI and PF (P = .047 and P = .023, respectively). Floor effects were identified for DEP at baseline and follow-up and for PI at follow-up only.

CONCLUSION

PROMIS is feasible and time-efficient in BPCI patients undergoing primary THA. There were significant differences between BPCI and non-BPCI hips.

LEVEL OF EVIDENCE

Level III.

Illness Perceptions of Patients With First Carpometacarpal Osteoarthritis, Carpal Tunnel Syndrome, Dupuytren Contracture, or Trigger Finger

PURPOSE

Previous studies indicate that patients with a more negative perception of their illness tend to respond less favorably to treatment, but little is known about whether illness perceptions differ based on the type of hand or wrist conditions. Therefore, we compared illness perceptions between patients scheduled to undergo surgery for 4 illnesses in hand surgery: carpometacarpal osteoarthritis (CMC OA), Dupuytren disease, carpal tunnel syndrome (CTS), and trigger finger syndrome (TFS). We hypothesized there would be differences in illness perception between these patient groups.

METHODS

Before surgery, patients were asked to complete the Brief Illness Perception Questionnaire (Brief-IPQ) as part of routine outcome measurement in a specialized hand and wrist surgery clinic. The Brief-IPQ is a validated questionnaire to rapidly assess the cognitive and emotional representation of illness. Differences in illness perception between the 4 diagnostic groups, corrected for age, sex, hand dominance, and work type, were examined. Cohen D effect sizes were calculated for the between-group differences.

RESULTS

We included 514 patients in the analyses: 87 with CMC OA, 146 with Dupuytren disease, 129 with CTS, and 152 with TFS. On a scale ranging from 0 (most positive perception) to 80 (most negative perception) the Brief-IPQ sum scores for these subgroups were 42.0, 28.2, 38.8, and 33.3, respectively. Corrected for age, sex, hand dominance, and work type, patients with Dupuytren disease had a more positive perception of their illness than patients with CMC OA and CTS. Compared with CMC OA patients, the effect sizes for Dupuytren, CTS, and TFS patients were, respectively, 1.28, 0.32, and 0.81.

CONCLUSIONS

In these patients with various hand/wrist disorders, differences were found in their preoperative perceptions of illness. Interventions that directly target negative illness perceptions might improve treatment outcomes for CMC OA and CTS.

CLINICAL RELEVANCE

These differences should be considered during preoperative medical consultations and/or when investigating surgical outcomes.

The Association Between Symptoms of Depression and Office Visits in Patients With Nontraumatic Upper-Extremity Illness

PURPOSE

Because psychological and social factors increase symptoms and limitations, it is possible that they are also related to higher use of care.

METHODS

We used a database of an academic outpatient orthopedic department in which patient-reported outcome measures were routinely collected and identified 3,620 patients with de Quervain tendinopathy, ganglion, trapeziometacarpal arthritis, trigger digit, or carpal tunnel syndrome who remained in care at least 3 months. At every office visit, patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (CAT), PROMIS Pain Interference CAT, and PROMIS Depression CAT. We conducted multivariable Poisson regression analysis of factors associated with the total number of office visits, accounting for PROMIS scores at the first office visit, age, surgical treatment, sex, diagnosis, and clinician team.

RESULTS

Operative treatment had the greatest influence on the number of office visits. Other variables associated with the number of visits were female sex, younger age, higher PROMIS Depression scores, and higher Pain Interference scores.

CONCLUSIONS

Treatment choice had the greatest influence on the number of subsequent visits for atraumatic conditions. The fact that the total number of office visits is associated with greater symptoms of depression and greater pain interference, independent of treatment choice, suggests a relation between mental health and resource use.

CLINICAL RELEVANCE

Quality improvement efforts and future research might address whether adding strategies to decrease symptoms of depression and optimize coping strategies (to reduce pain interference) might improve upper-extremity health more efficiently than standard treatment alone.

Establishing "Normal" Patient-Reported Outcomes Measurement Information System Physical Function and Pain Interference Scores: A True Reference Score According to Adults Free of Joint Pain and Disability

Numerous recent studies have demonstrated the validity and efficiency of the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) forms in patients undergoing orthopaedic surgical procedures. It is assumed that a score of 50 in each domain represents the health state of a “reference” population, but this threshold has not been definitively proven. In order to truly assess whether a given orthopaedic intervention is successful, the comparative scores of healthy individuals must be known for any given health domain measured. Therefore, the purpose of this study was to determine baseline scores for the PROMIS general physical function (PROMIS-PF), pain interference (PROMIS-PI), and upper-extremity physical function (PROMIS-UE) domains in physically healthy, asymptomatic adult individuals. We hypothesized that, in individuals <40 years old, the mean PROMIS-PF and PROMIS-UE scores would be >50 and PROMIS-PI scores would be <50. We further hypothesized that these scores would be impacted by participant age.

Impact of Patient Demographic Factors on Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, Pain Interference, and Depression Computer Adaptive Testing Scores in Patients Undergoing Shoulder and Elbow Surgery

Background:

There has been a growing emphasis in orthopaedics on providing patient-centered care. The US National Institutes of Health launched the Patient-Reported Outcomes Measurement Information System (PROMIS) initiative that incorporates patient-reported outcome measures across a number of medical domains. The relationship between PROMIS domains and the impact of patient demographic factors in those undergoing upper extremity surgery remains unclear.

Purpose/Hypothesis:

The goal of this study was to investigate the correlation between physical function, pain interference, and depression in patients undergoing shoulder and elbow surgery as measured by PROMIS computer adaptive testing (CAT) forms and to determine the impact of patient demographic factors. We hypothesized that there would be a significant negative correlation between physical function and both pain interference and depression in this patient population.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

All patients who underwent elective shoulder or elbow surgery by 3 shoulder, elbow, and/or sports medicine fellowship–trained orthopaedic surgeons were included in the study. Preoperative PROMIS–Upper Extremity (PROMIS-UE), PROMIS–Pain Interference (PROMIS-PI), and PROMIS-Depression (PROMIS-D) CAT scores were analyzed. Pearson correlations were calculated between PROMIS domains as well as between PROMIS outcomes with patient demographic factors.

Results:

Preoperative PROMIS CAT scores for all 3 domains were collected and analyzed from 172 unique patients (516 individual CAT forms) with shoulder and elbow injuries. A negative correlation of moderate strength was found between the PROMIS-UE and PROMIS-PI (R = –0.61; P < .001), and a negligible correlation was found between the PROMIS-UE and PROMIS-D (R = –0.28; P < .001). When stratified by patient demographic factors, the correlation between the PROMIS-UE and PROMIS-PI was stronger in female patients compared with male patients (R = –0.77 vs –0.46, respectively; P < .001 for both), stronger in black patients compared with white patients (R = –0.72 vs –0.56, respectively; P < .001 for both), and highest in current tobacco users (R = –0.80; P < .001).

Conclusion:

Before shoulder and elbow surgery, patients demonstrated impairments in physical function and pain interference as measured by CAT forms, with a moderate negative correlation between baseline upper extremity physical function and pain interference scores. In certain subpopulations, such as female patients, black patients, and current tobacco users, the correlations between these tested domains were stronger than in other groups.

Preoperative Anxiety Effect on Patient-Reported Outcomes Following Foot and Ankle Surgery

BACKGROUND

Preoperative emotional distress has been shown to negatively influence joint arthroplasty and spine surgery, but limited data exist for foot and ankle outcomes. Emotional distress can be captured through modern tools like the Patient-Reported Outcomes Instrument Measurement System (PROMIS) anxiety domain. We hypothesized that patients with greater preoperative PROMIS anxiety scores would report greater pain and less function after foot and ankle surgery than patients with lower preoperative anxiety levels.

METHODS

Elective foot and ankle surgeries from May 2016 to December 2017 were retrospectively identified. PROMIS anxiety, pain interference (PI), and physical function (PF) scores were collected before and after surgery. Patients were grouped based on preoperative PROMIS scores greater or less than 59.4. A cutoff of PROMIS anxiety above 59.4 was selected as the threshold that corresponds to traditional measures of anxiety.

RESULTS

Compared to patients with less preoperative anxiety (average: 47.2, n=146), patients with higher preoperative anxiety (average: 63.9, n=59) had greater preoperative pain (PROMIS PI: 63.5 vs 59.1, P < .001) and lower physical function (PROMIS PF: 37.9 vs 42.0, P = .001). Postoperatively, patients with higher preoperative anxiety had more residual pain and greater functional disability as compared to patients with less preoperative emotional distress (PROMIS PI: 58.6 vs 52.9, P < .001; PROMIS PF: 39.8 vs 44.4, P < .001; respectively).

CONCLUSION

Our evidence showed that preoperative emotional anxiety predicted worse pain and function at early operative follow-up. Measures of preoperative anxiety could be useful in identifying patients at risk for poorer operative outcomes, but continued study is necessary.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anxiety and depression in patients with suspected carpal tunnel syndrome - A case controlled study

PURPOSE

Carpal tunnel syndrome (CTS) is a common entrapment neuropathy causing significant, and often disabling, pain. We aimed to establish the prevalence of anxiety and depressive symptoms in patients who were referred with suspected CTS and identify potential determinants.

METHODS

All patients underwent nerve conduction studies (NCS) and were classified into mild, moderate, severe, and no CTS groups. Volunteers, without symptoms or signs of CTS, formed the control group. Anxiety and depressive symptoms were assessed via the Hospital Anxiety and Depression Scale.

RESULTS

Ninety-one patients and 41 controls were recruited. Following NCS the patients were classified as follows: mild CTS (n = 20), moderate CTS (n = 21), severe CTS (n = 11), and no CTS (n = 31). CTS patients had significantly higher depression scores compared to controls but not anxiety scores. Patients experiencing pain and itchiness had significantly higher anxiety scores compared to those who did not. Patients who reported symptoms suggestive of CTS but did not meet the electrodiagnostic criteria for a diagnosis had significantly higher anxiety and depression scores compared to CTS patients and controls.

CONCLUSIONS

Patients suffering with CTS may be at an increased risk of depression. Experiencing pain in CTS may further increase the likelihood of experiencing mental health difficulties. Poor mental health can give rise to functional symptoms, similar to those seen in CTS, demonstrating the need for electrophysiological testing before considering surgical intervention.

Dispelling the Myth of Work-Related de Quervain's Tenosynovitis

De Quervain's Tenosynovitis (DQT) is a common condition characterized by pain about the dorsal-radial aspect of the wrist, just proximal to the radial styloid. The condition is precipitated by a thickened first dorsal compartment and its tendons. The impression that DQT is caused from work-related injury is misdirected, as no study has established an association between hand usage at work or trauma with DQT. Physicians should exercise caution when discussing the causes and natural history of DQT with symptomatic patients.

PROMIS Physical and Emotional Health Scores Are Worse in Musculoskeletal Patients Presenting to Physiatrists than to Other Orthopedic Specialists

BACKGROUND

Physiatrists' unique training in person-centered biopsychosocial management of complex problems may influence musculoskeletal patients' expectations and self- and/or physician-referral patterns to physiatrists. Consequently, average patient complexity and need for multi-disciplinary services may be increased in physiatric patients.

OBJECTIVE

To compare musculoskeletal patients' self-reported physical and emotional health according to provider specialty. Researchers tested the null hypothesis that there is no significant difference in Patient-Reported Outcomes Measurement Information System (PROMIS) scores between patients who present to physiatrists in comparison to other musculoskeletal specialists.

DESIGN

Cross-sectional study.

SETTING

Orthopedic department of a tertiary academic medical center.

PATIENTS

Participants included 31 791 new adult patients (mean age 52.6 ± 16.2 years) who presented for initial elective evaluation of a musculoskeletal problem by an orthopedic surgeon or sports medicine trained emergency medicine, family medicine, pediatric, or physiatric physician.

METHODS

Patients completed the PROMIS computer adaptive test (CAT) Physical Function, Pain Interference, Anxiety, and Depression domains at department check-in prior to the physician encounter. Score differences by provider type were assessed using Wilcoxon rank-sum tests.

MAIN OUTCOME MEASUREMENTS

Mean PROMIS score in each domain subdivided by physiatric, surgical, and other nonsurgical provider type.

RESULTS

In total, 2081 patients presented to physiatrists, 28 267 presented to surgeons, and 1443 presented to other nonsurgical providers. For each respective provider type, average PROMIS scores were Physical Function 38.9 ± 8.2, 41.5 ± 9.5, and 43.5 ± 8.2; Pain Interference 62.6 ± 7.2, 60.9 ± 7.7, and 59.2 ± 6.8; Anxiety 54.5 ± 10.4, 51.9 ± 10.6, and 49.8 ± 9.8; and Depression 49.3 ± 10.4, 47.0 ± 10.0, and 44.2 ± 8.7. Physiatric patients had significantly worse average scores for all domains compared to surgical (P < .001) and other nonsurgical patients (P < .001).

CONCLUSIONS

Average PROMIS Physical Function, Pain Interference, Anxiety, and Depression scores were worse in musculoskeletal patients who presented to physiatrists in comparison to surgical or other nonsurgical providers. This suggests that some patients who choose to see or are referred to see physiatrists may have more or be more willing to endorse having biopsychosocial impairments.

LEVEL OF EVIDENCE

III.

Feasibility of PROMIS CAT Administration in the Ambulatory Sports Medicine Clinic With Respect to Cost and Patient Compliance: A Single-Surgeon Experience

Background:

Pay-for-performance reimbursement models are becoming increasingly popular, but the implementation of a routine patient-reported outcome (PRO) collection system places additional burden on both the patient and the provider. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed in an effort to make PRO collection more practical and efficient, but providers may be reluctant to embrace a transition to a PROMIS-based clinical outcome registry.

Hypothesis:

PROMIS can be successfully incorporated into daily clinical practice, with an overall patient compliance rate of 80%.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

As part of routine practice, all patients presenting to a single surgeon’s sports medicine clinic for an appointment were asked to complete a series of PROMIS computerized adaptive tests (CATs), including PROMIS Physical Function, Physical Function–Upper Extremity, Pain Interference, and Depression subscales. Overall compliance was calculated by dividing the number of survey sets completed by the number of eligible clinic visits. Compliance rates were further assessed by patient age, type of clinic visit, and location of injury. Costs associated with this system of routine PRO collection were categorized as start-up or maintenance costs.

Results:

From August 7, 2017, to December 8, 2017, there were 581 patients (1109 clinic encounters) who met inclusion criteria for the study. Of the 1109 clinic encounters, there was an overall compliance rate of 91.3% (1013/1109 visits during which the patient completed the entire PROMIS survey set). Overall, the full survey set consisted of a mean 15.3 questions and took a mean of 2.6 minutes to complete. Patients who were aged ≥62 years had a significantly lower compliance rate (81.8%; P < .0001) than each of the younger patient quartiles. When analyzing patients by the most common locations of injury (elbow, shoulder, hip, knee), the compliance rate for completing PROMIS was significantly higher for the hip than for the shoulder (95.1% vs 88.9%, respectively; P = .02). The cost of establishing a PROMIS-based registry using our project design and workflow was estimated at $2045, whereas the monthly maintenance cost was $1000.

Conclusion:

The routine electronic collection of PROMIS scores in the ambulatory orthopaedic clinic resulted in a compliance rate of over 90%, although older patients were generally less compliant than younger patients. Our system of data collection is practical and efficient in a high-volume orthopaedic clinic and places minimal financial burden on the provider.