The Influence of Psychological Factors on the Michigan Hand Questionnaire

Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: A systematic review and network meta-analysis

AIM

This network meta-analysis aims to compare functional outcomes and complications between conservative treatment and surgery for distal radius fractures in patients aged 60 years and over.

METHODS

We searched the PubMed, EMBASE, and Web of Science databases for randomized controlled trials (RCTs) assessing the effect of conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. Primary outcomes included grip strength and overall complications. Secondary outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, wrist range of motion and forearm rotation, and radiographic assessment. All continuous outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and binary outcomes were assessed using odds ratio (OR) with 95% CIs. The surface under the cumulative ranking curve (SUCRA) was used to determine a hierarchy of treatments. Cluster analysis was performed for grouping treatments based on the SUCRA values of primary outcomes.

RESULTS

Fourteen RCTs were included to compare conservative treatment, volar lockedplate (VLP), K-wires fixation, and external-fixation. VLP outperformed conservative treatment for 1-year and minimum 2-year grip strength (SMD; 0.28 [0.07 to 0.48] and 0.27 [0.02 to 0.53], respectively). VLP yielded the optimal grip strength at 1-year and minimum 2-year follow-up (SUCRA; 89.8% and 86.7%, respectively). In a subgroup analysis of patients aged 60 to 80 years old, VLP outperformed conservative treatment in DASH and PRWE scores (SMD, 0.33 [0.10, 0.56] and 0.23 [0.01, 0.45], respectively). In addition, VLP had the fewest complications (SUCRA = 84.3%). Cluster analysis suggested that VLP and K-wire fixation were more effective treatment groups.

CONCLUSION

Evidence to date demonstrates that VLP provides measurable benefits in grip strength and fewer complications to those 60 years of age and over, and that benefit is not reflected in current practice guidelines. There is a subgroup of patients where K-wire fixation outcomes are similar to those of VLP; defining this subgroup may yield substantial societal benefits.

Single Digit Index Finger Amputation-To Replant or Not?

Background: Single index finger replantation is often listed as a contraindication due to its hindrance of hand function when replanted. Recent studies demonstrate comparable subjective and global functional outcomes for index flexor zone II finger replants versus revision amputations. We therefore sought to identify current opinions of plastic surgery trainees and staff treating single index finger zone II amputations including influential patient and injury characteristics. Methods: With the approval of the Canadian Society of Plastic Surgery, a 17-question survey was sent via email to all listed members on 3 separate occasions. Participation was voluntary and survey responses were compiled and analyzed using SPSS statistical software. Results: Survey response rate was 38.5%. When asked whether the surgeon would replant a single index digit, flexor zone II, sharp amputation, 55.3% of respondents chose "yes," while 44.7% responded "no." Staff (51.5%) were less likely to replant a single index digit amputation. Likelihood of replant dropped substantially in crush (12.4%) and avulsion (17.1%) injury. Smoking was the most likely patient characteristic to change a surgeon's decision (61.9%). Poor range of motion (77.5%) and patient satisfaction (72.5%) were the most frequently listed reasons not to replant. Conclusion: Among Canadian plastic surgeons, there exists disagreement in how single index flexor zone II amputations should be managed. In review of the literature, these notions and previous teaching around replants highlight many inherent surgeon biases with regard to the merit and value of single digit replantation.

Rasch Analysis of the Michigan Hand Questionnaire

OBJECTIVES

The Michigan Hand Questionnaire (MHQ) is a commonly used evaluation for hand problems, but previous work reports conflicting evidence regarding the subscale structures. Rasch analysis uses probabilistic modeling of items and responses: if scale items can be fit to the Rasch model, it provides evidence of construct validity and interval-level measurement for precise statistical estimates. We conducted Rasch analysis on the MHQ to evaluate model fit, unidimensionality of the subscales, bias across person factors, and conversion to interval metrics.

METHODS

We conducted a secondary Rasch analysis of MHQ data from 924 persons with thumb basal joint osteoarthritis using the RUMM2030 software. Modeling was based on responses for the most affected hand and person factors including age, sex, type of work, whether the dominant side was the most affected, and surgical status. The analysis plan followed the published recommendations for examinations of person and item fit, with iterative adjustments as required.

RESULTS

A total of 11 of the 37 items required rescoring to create orderly progression of scoring thresholds. Only the overall hand function and pain subscales could be fit to the Rasch model, demonstrating unidimensionality and good reliability of fit estimates. Dividing the activities of daily living subscale into unilateral and bilateral activities also allowed unilateral activities to fit the model. Persistent misfitting in other subscales suggested local dependency and response bias across multiple person factors.

CONCLUSIONS

This Rasch analysis of the MHQ raises concerns regarding the validity and fundamental measurement properties of this widely used outcome evaluation when used as a summary score.

Mental Health in Patients Undergoing Orthopaedic Surgery: Diagnosis, Management, and Outcomes

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Mental health and psychosocial factors play a critical role in clinical outcomes in orthopaedic surgery.

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The biopsychosocial model of disease defines health as a product of physiology, psychology, and social factors and, traditionally, has not been as emphasized in the care of musculoskeletal disease.

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Improvement in postoperative outcomes and patient satisfaction is incumbent upon the screening, recognition, assessment, and possible referral of patients with high-risk psychosocial factors both before and after the surgical procedure.

Pain during physical examination of a healing upper extremity fracture

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

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

INTRODUCTION

Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8-12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks.

MATERIALS AND METHODS

In a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization.

RESULTS

Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons' decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28-6.81, p  =  0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as 'other') (OR 2.64; 95% CI 1.31-5.33, p  =  0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18-19.52, p  =  0.01 versus Europe) were more likely to recommend continued immobilization.

CONCLUSION

Adoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.

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).

Psychological factors are more strongly associated with pain than radiographic severity in non-invasively treated first carpometacarpal osteoarthritis

BACKGROUND

The aim of this study was to investigate to what extent psychological factors are related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint.

METHODS

We included patients (n = 255) at the start of non-invasive treatment for osteoarthritis of the first carpometacarpal joint who completed the Michigan Hand Outcome Questionnaire. Psychological distress, pain catastrophizing behavior and illness perception was measured. X-rays were scored on presence of scaphotrapeziotrapezoid osteoarthritis. We used hierarchical linear regression analysis to determine to what extent pain levels could be explained by patient characteristics, X-ray scores, and psychological factors.

RESULTS

Patient characteristics and X-ray scores accounted for only 6% of the variation in pre-treatment pain levels. After adding the psychological factors to our model, 47% of the variance could be explained.

CONCLUSIONS

Our results show that psychological factors are more strongly related to pain levels prior to non-invasive treatment in patients with osteoarthritis of the first carpometacarpal joint than patient characteristics and X-ray scores, which implies the important role of these factors in the reporting of symptoms. More research is needed to determine whether psychological factors will also affect treatment outcomes for patients treated non-invasively for osteoarthritis of the first carpometacarpal joint.IMPLICATIONS FOR REHABILITATIONPain is the most important complaint for patients with osteoarthritis of the first carpometacarpal joint.Psychological factors are strongly associated with pain levels prior to treatment.Pain catastrophizing behavior appears to be a promising target for complementary treatment in patients with osteoarthritis of the first carpometacarpal joint.

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

BACKGROUND

Health systems and payers use patient-reported outcome measures (PROMs) to inform quality improvement and value-based payment models. Although it is known that psychosocial factors and priming influence PROMs, we sought to determine the effect of having patients complete functional tasks before completing the PROM questionnaire, which has not been extensively evaluated.

QUESTIONS/PURPOSES

(1) Will QuickDASH scores change after patients complete the tasks on the questionnaire compared with baseline QuickDASH scores? (2) Will the change in QuickDASH score in an intervention (task completion) group be different than that of a control group? (3) Will a higher proportion of patients in the intervention group than those in the control group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points?

METHODS

During a 2-month period, 140 patients presented at our clinic with a hand or upper-extremity problem. We approached patients who spoke and read English and were 18 years old or older. One hundred thirty-two (94%) patients met the inclusion criteria and agreed to participate (mean ± SD age, 52 ± 17 years; 60 men [45%], 72 women [55%]; 112 in the intervention group [85%] and 20 in the control group [15%]). First, all patients who completed the QuickDASH PROM (at baseline) were recruited for participation. Intervention patients completed the functional tasks on the QuickDASH and completed a followup QuickDASH. Control patients were recruited and enrolled after the intervention group completed the study. Participants in the control group completed the QuickDASH at baseline and a followup QuickDASH 5 minutes after (the time required to complete the functional tasks). Paired and unpaired t-tests were used to evaluate the null hypotheses that (1) QuickDASH scores for the intervention group would not change after the tasks on the instrument were completed and (2) the change in QuickDASH score in the intervention group would not be different than that of the control group (p < 0.05). To evaluate the clinical importance of the change in score after tasks were completed, we recorded the number of patients with a change greater than an MCID of 14 points on the QuickDASH. Fisher's exact test was used to evaluate the difference between groups in those reaching an MCID of 14.

RESULTS

In the intervention group, the QuickDASH score decreased after the intervention (39 ± 24 versus 25 ± 19; mean difference, -14 points [95% CI, 12 to 16]; p < 0.001). The change in QuickDASH scores was greater in the intervention group than that in the control group (-14 ± 11 versus -2 ± 9 [95% CI, -17 to -7]; p < 0.001). A larger proportion of patients in the intervention group than in the control group demonstrated an improvement in QuickDASH scores greater than the 14-point MCID ([43 of 112 [38%] versus two of 20 [10%]; odds ratio, 5.4 [95% CI, 1 to 24%]; p = 0.019).

CONCLUSIONS

Reported disability can be reduced, thereby improving PROMs, if patients complete QuickDASH tasks before completing the questionnaire. Modifiable factors that influence PROM scores and the context in which scores are measured should be analyzed before PROMs are broadly implemented into reimbursement models and quality measures for orthopaedic surgery. Standardizing PROM administration can limit the influence of context, such as task completion, on outcome scores and should be used in value-based payment models.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Hand Function in Apert Syndrome

Background:

The Michigan Hand Questionnaire is widely used to assess hand outcomes in congenital hand deformities. The purpose of the present study is to compare Apert syndrome hand outcomes according to Upton hand type and age stratification with age-matched unaffected controls.

Methods:

The Brief Michigan Hand Questionnaire was administered to 39 Apert patients after completion of the digit separation surgical regimen, and 140 age-matched unaffected controls. Patients were divided into 3 groups according to age. In group 1 (from 4 months to 7 years of age), responses were provided by parents of Apert patients, and in group 2 (from 8 to 17 years of age), patients responded with assistance from their parents, and in group 3 (18 years of age or older), responses were provided by the patients themselves. Groups were substratified according to Upton hand type (type I, II, and III). Comparisons were made among groups, subgroups, and controls.

Results:

Comparisons of hand types for intragroups 1, 2, and 3, did not demonstrate any statistically significant differences (P > 0.05) between hand outcomes according to Upton hand type, regardless of patient age. Comparisons between Apert patients and their age-matched controls demonstrated statistically significant differences (P < 0.05), as the control group had higher outcome scores.

Conclusions:

Similar hand outcomes scores were achieved by all Apert patients regardless of hand type. Following completion of the digit separation regimen, Apert patients presented hand outcome scores that were lower than those of the patients in the normative control group.

Does resiliency mediate the association of psychological adaptability with disability and pain in patients with an upper extremity injury or illness?

OBJECTIVE

Symptom intensity and magnitude of limitations are highly variable for a given nociception and pathophysiology. As psychological determinants are of great influence to physical wellbeing, we assessed the influence of the protective factor measured and labelled as resilience in upper extremity illness.

METHODS

One hundred and six patients completed a survey of demographics, the Brief Resilience Scale (BRS), the Psychological Adaptation Scale (PAS), an 11-point ordinal measure of pain intensity, and the PROMIS Physical Function (PROMIS PF) Computer Adaptive Test (CAT). Measures of pain intensity and PROMIS PF were repeated 3 months later. We created mediation models using structural equation modeling (SEM) to assess the mediation effect of BRS on the association of PAS and other confounding variables with disability and pain at initial assessment and 3 months later.

RESULTS

Resiliency does not mediate the association of psychological adaptability with physical limitations and pain intensity at baseline (P = .89 and .82 respectively) or 3 months after enrollment (P = .65 and .72 respectively).

CONCLUSIONS

Positive and protective factors promote beneficial resilience mechanisms that strengthen coping responses to pain and disability. In future studies we should either include more patients to improve power and provide more information about the health benefits of resilience or focus more on mood and self-efficacy on symptoms and limitations in patients with musculoskeletal illness.

LEVEL OF EVIDENCE

Prospective, longitudinal cohort study; Level II.