Management of intolerance to casting the upper extremities in claustrophobic patients

A Preliminary Investigation of Cast Anxiety in General Orthopaedic Practice

Background

Anxiety following casting is an unrecognised complication that results in frequent visits to fracture clinic in the UK. There is a paucity of research regarding this complication. Failure to recognise Cast Anxiety (CA) leads to increased visits, frequent cast changes and possible failure of treatment despite no objective problems with the cast. Prior research has suggested a possible link between CA and claustrophobia but lacks statistical evidence. The Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-V) categorizes claustrophobia as a Specific Phobia (SP) and questionnaires for both claustrophobia and SP exist. As such, the main purpose of this study is to examine the statistical correlation between the SP Questionnaire and the Claustrophobia Questionnaire to identify if a link exists between CA and claustrophobia. The secondary goal is to develop a screening questionnaire to identify those at high risk of CA, the significance of which lies in possible prevention of failure of surgical treatment and frequent visits to fracture clinic.

Methods

Self-report questionnaires were distributed to patients attending fracture clinic and accident emergency for review/ cast application/ problems with the cast over a one month period, no preference between upper or lower limb casts. This group completed both self-report questionnaires (N=157). From this group, patients were identified as having CA if they required frequent cast changes and frequent visits to fracture clinic despite no objective problems with the cast, or had themselves described feelings of anxiety/ claustrophobia. Follow up interviews with patients identified as having CA were undertaken. On the basis of the data gathered, a screening questionnaire was developed and distributed to a second group of patients with the same inclusion and exclusion criteria (N=50).

Results

A correlation between the two questionnaires was found: N= 157, r= 0.522, P<0.001. Three themes were identified as encompassing CA: Anxiety, Cognition and Physiological responses and Behaviour, evidencing an anxiety based disorder. The screening questionnaire identified over 80% of patients suffering from CA when scoring > 20/26. *Any patient scoring = 20/26 should be considered high risk of CA.

Conclusion

Based on this data, CA fits the criteria of an anxiety based condition. The modified screening tool permits early identification of individuals at high risk of CA. Usage of the screening tool is encouraged prior to casting and for future research modifications. Early identification will allow consideration of an alternative treatment option, anticipatory conversation and could prevent the failure of treatment.